GIFT OF 
 Harry East Miller 
 
 BIOLOGY 
 LIBRARY 
 
HANDBOOK 
 
 FOR THE 
 
 HOSPITAL CORPS OF THE U. S. ARMY 
 
 AND 
 
 STATE MILITARY FORCES 
 
 BY 
 
 CHARLES S.MART 
 
 Deputy Surgeon-General, U. S. A. 
 
 APPROVED BY THE SURGEON -GENERAL OF THE ARMY 
 
 NEW YORK 
 
 WILLIAM WOOD AND COMPANY 
 
 1898 
 
Utf 
 S 
 J 
 
 BIOLOGY 
 LIBRARY 
 
 COPYRIGHT, 1898 
 ^ILLIAM WOOD AND COMPANY 
 
 6 
 
Surgeon General George M. Sternberg, U. S. Army. 
 
 GENERAL : When Congress authorized the organization 
 of a Hospital Corps for the Army, 1 wrote and published a 
 Handbook for the Corps with the view of assisting its mem- 
 bers in raising their qualifications to the higher standard 
 required of them than of the detailed men previously on 
 duty with the Medical Department. That the book 
 answered its purpose is shown by the Examination papers 
 filed by the candidates for the positions of Steward and 
 Acting Hospital Steward. 
 
 I have the honor to submit this revised edition in the 
 hope that it may prove of equal benefit to the men who 
 enlist for service under present war conditions. 
 
 Remaining with the highest respect, 
 
 Your obedient servant, 
 
 CHARLES SMART, 
 
 I)eputy Surgeon General. 
 WASHINGTON, D.'C., April 30, 1898. 
 
 M81843 
 
TABLE OF CONTENTS. 
 
 [ TJie paragraphic index at the end should be consulted when a special 
 subject is under consideration or inquiry. ] 
 
 PAKT I. 
 HOSPITALS AND HOSPITAL DUTIES. 
 
 PAGE 
 
 CHAPTER I. THE POST HOSPITAL AND THE HOSPITAL 
 CORPS. Routine duties ; reports and papers ; etc. , . .1 
 
 CHAPTER II. ACTIVE SERVICE IN THE FIELD. Consolida- 
 tion for field service; division field hospitals; ambulance 
 companies and first aid stations. Service on the march and 
 on the bttle-field ; during retreat ; reorganization after dis- 
 asters. Articles of the Geneva Convention. Reports and 
 papers, 16 
 
 CHAPTER J] I. SANITARY CARE OF CAMPS. Selection of 
 sites ; prevention of camp diseases ; quarters ; general 
 police and sanitary government, 39 
 
 CHAPTER IV. GENERAL HOSPITAL SERVICE. Base and 
 general hospitals ; their construction, water-supply, sewer- 
 age, personnel, administration, etc., 70 
 
 PART II. 
 
 ANATOMY AND PHYSIOLOGY. 
 
 CHAPTER I. THE LOCOMOTOR SYSTEM. The bones, joints, 
 
 and muscles, 89 
 
 CHAPTER II. THE SYSTEM OF ORGANIC LIFE. The blood 
 
Vi TABLE OF CONTENTS. 
 
 PAGE 
 
 and its circulation ; digestion and absorption ; excretion 
 by the lungs, skin, and kidneys ; animal heat, . . . 105 
 CHAPTER III. THE ADMINISTRATIVE SYSTEM. The brain, 
 
 spinal cord, nerves, ganglia, and organs of the senses, . 144 
 
 PAET III. 
 
 THE SPECIAL DUTIES OF THE HOSPITAL CORPS. 
 
 CHAPTER I. MANAGEMENT OF ACCIDENTS. First aid and 
 transportation to hospital ; preparations for surgical opera- 
 tions ; anaesthetics ; cleanliness ; diet ; temperature ; bed- 
 sores ; characteristics of urine, etc. , 155 
 
 CHAPTER II. SHOCK, REACTION, AND INFLAMMATION. 
 Shock, reaction, inflammatory congestion, and sympto- 
 matic fever ; treatment by rest, position, cold, heat, warm- 
 water dressings, poultices, leeching, cupping, counter- 
 irritation, and general measures. Chronic inflammations ; 
 treatment, 176 
 
 CHAPTER III. SPECIAL INFLAMMATIONS. Burns ; scalds of 
 the throat ; frostbite ; chilblains ; contusions ; sprains ; 
 abscesses ; gumboils and minor surgery of the teeth ; boils ; 
 carbuncles ; whitlows ; corns ; bunions ; blisters on the 
 feet, and chafings, ........ 188 
 
 CHAPTER IV. WOUNDS. Incised; lacerated; contused; 
 gunshot. First aid in shock and bleeding, and the field 
 dressing of gunshot injuries. Infected wounds; erysip- 
 elas and gangrene ; arrow wounds ; dissection wounds, 
 etc. Glanders 203 
 
 CHAPTER V. HEMORRHAGE. Capillary, venous, and ar- 
 terial ; means of arresting 219 
 
 CHAPTER VI. WOUNDS OF THE HEAD, NECK, AND 
 TRUNK, . 227 
 
TABLE OF CONTENTS. Vll 
 
 PAGE 
 
 CHAPTER VII. CONDITIONS CAUSING INSENSIBILITY. Con- 
 cussion, compression, and congestion of the brain ; apo- 
 plexy ; sunstroke; epileptic stupor; convulsions; alco- 
 holic stupor; opium narcotism; insensibility from cold, 
 from asphyxia, and from heat exhaustion, . . . 232 
 
 CHAPTER VIII. ARTIFICIAL RESPIRATION, and the cases in 
 which it should be used, 241 
 
 CHAPTER IX. FOREIGN BODIES. In the eye, nose, ear, 
 
 trachea, pharynx, stomach, etc., ..... 248 
 
 CHAPTER X. FRACTURES, their symptoms and treatment; 
 of the skull, lower jaw, spine, ribs, collar-bone, shoulder- 
 blade, arm, forearm, hand and fingers, pelvis, thigh, and 
 leg, 253 
 
 CHAPTER XI. DISLOCATIONS, their symptoms and treat- 
 ment ; of the lower jaw, collar-bone, shoulder-joint, elbow, 
 wrist, fingers, hip, kneecap, knee-joint, ankle, and foot, 272 
 
 CHAPTER XII. MANAGEMENT OF CASES OF POISONING, 286 
 
 CHAPTER XIII. DISINFECTANTS AND THE MANAGEMENT OF 
 INFECTIOUS DISEASES. Itch, small-pox, cow-pox, chicken- 
 pox, scarlet fever, rose rash, measles, German measles, 
 typhoid fever, dysentery, cholera, and yellow fever, . . 300 
 
 CHAPTER XIV. PHARMACY. Outlines of course of instruc- 
 tion, .312 
 
 CHAPTER XV. ELEMENTS OF COOKERY, . . . .313 
 ANALYTICAL INDEX TO PARAGRAPH NUMBERS, . . .319 
 
PART v A i ;* / l\\ 
 
 HOSPITALS AND HOSPITAL DUTIES. 
 
 1. A hospital is the shelter or quarters provided for the 
 sick and wounded of a command ; but in an enlarged sense 
 it includes the provision made for the cure of the disabled, 
 with no special reference to the shelter or building that may 
 be used. When a hospital is attached to a stationary com- 
 mand it is a 2>ost hospital; if it accompany the command on 
 an expedition or campaign, it is a field hospital ; if it be de- 
 tached from the command, and particularly if it receive the 
 sick and wounded of any command, it is a yeneral hospital. 
 
 CHAPTER I. 
 
 THE POST HOSPITAL, AND THE HOSPITAL CORPS. 
 
 2. The regulation post hospital building at permanent 
 military posts is of brick, arranged for 12, 24, or 36 beds, 
 heated by hot water, and ventilated through brick flues and 
 galvanized iron ducts ; but as a matter of fact the building 
 may be any kind of a shelter extemporized or utilized for 
 the care of the sick and wounded. 
 
 3. The service of the post hospital is performed by mem- 
 bers of the Hospital Corps enlisted for, and permanently 
 attached to, the Medical Department. Enlisted men who 
 have served one year in the line may be transferred to the 
 Hospital Corps as privates. Married men are not accepted 
 as recruits, nor transferred from the line for service in the 
 corps. Candidates for enlistment should apply to a post 
 
3 THE HOSPITAL CORPS. 
 
 medical officer or to a recruiting officer. Applicants who 
 have graduated in pharmacy, who have been licensed by 
 State boards of phariaacy, or who have had training as nurses 
 in civil, hospitals should present certificates of their special 
 qualifications. SjUglijt physical defects which, under exist- 
 ing orders, would, disqualify for the line, do not disqualify 
 for enlistment in the corps, provided they are not of such 
 a character as would interfere with the full performance of 
 the duties of a sanitary soldier in garrison or in the field. 
 
 4. If the candidate is accepted he is forwarded to a com- 
 pany or detachment of the corps for instruction in military 
 discipline, nursing, first aid, drill, cooking, pharmacy, 
 clerical work, field work, and the care and management of 
 animals. The order of exercises of a company of instruc- 
 tion requires the early morning hours of every day except 
 Sunday to be occupied with policing or cleaning up the hos- 
 pital and the surrounding grounds, after which on every 
 day except Saturday and Sunday half an hour is devoted to 
 calisthenics and from three quarters of an hour to an hour 
 each to study and litter drill ; in addition to this the junior 
 section has an hour on pharmacy on each of four days of 
 the week, with elementary cooking on the fifth day, while 
 the senior section at the same hour has anatomy on three 
 days and first aid on two days. In the afternoon an hour 
 each is given to study and to recitations on nursing and on 
 four days to bandaging, with disinfection and the care of 
 instruments on the fifth day. 
 
 5. When the education of the recruit is considered com- 
 plete he is assigned to duty at some post, where his services 
 are utilized as nurse, cook, or attendant, according to his 
 special qualifications. 
 
 6. Privates who have served one year in the Hospital 
 Corps, and graduates in pharmacy who have served six 
 
THE HOSPITAL CORPS. 3 
 
 months and have shown particular fitness, may be recom- 
 mended for promotion by the surgeon. From those thus 
 recommended acting stewards are detailed after passing 
 examination as to physical condition, moral character, and 
 general aptitude, and in the principles of arithmetic, in 
 orthography and penmanship, the regulations affecting 
 enlisted men, care of sick, ward management, minor sur- 
 gery, hospital corps drill and first aid, the ordinary modes 
 of cooking, and elementary hygiene. 
 
 7. No person is appointed a hospital steward until he has 
 served a year as an acting steward, nor until he has shown 
 by examination a more extensive and detailed knowledge of 
 the above subjects than is required of the acting steward. 
 A re-examination before his first re-enlistment may not be 
 required if the surgeon certifies that the candidate has per- 
 formed his duties efficiently ; but a re-examination is called 
 for before a second re-enlistment, after which no further 
 examination is ordinarily required. 
 
 8. Every post is authorized by law to have a hospital 
 steward ; two, if the garrison contains six companies, and 
 one additional for every additional six companies ; there is 
 also provided for every post of two companies, or of a sin- 
 gle company of cavalry, an acting hospital steward, with 
 privates at the rate of three for each post of one company, 
 four for posts of two companies, and one man additional for 
 every additional two companies. 
 
 9. The duties of stewards and acting stewards are, under 
 the direction of the surgeon, to look after and distribute 
 hospital stores and supplies ; to care for hospital property ; 
 to compound and administer medicines ; to supervise the 
 preparation and serving of food ; to maintain discipline in 
 the hospital and watch over its general police ; to prepare 
 the hospital reports and returns ; to supervise the duties of 
 
4 THE SERVICE OF THE POST HOSPITAL 
 
 the hospital corps in hospital and in the field ; and to per- 
 form such other duties connected with their positions as 
 may, by proper authority, be required of them. 
 
 10. The steward must be an efficient disciplinarian, ex- 
 pert clerk, accurate arithmetician, and a trustworthy phar- 
 macist, with as much knowledge of materia medica, thera- 
 peutics, and minor surgery as will enable him to give sound 
 advice and suitable treatment in the minor ailments and 
 accidents which in civil life rely on the resources of domes- 
 tic medicine or on the knowledge of the nearest pharmacist j 
 in addition, he must have that higher knowledge, for use in 
 the wards, which enables the experienced nurse to appre- 
 ciate the condition of those who are seriously ill, that their 
 improvement may be fostered and all harmful influences 
 excluded. At small posts, during the temporary absence of 
 the surgeon, the unforeseen casualties and even many of the 
 exigencies of military life impose duties upon him the satis- 
 factory performance of which may be of the first importance 
 to the individuals concerned. 
 
 11. The daily routine of the service of a post hospital 
 begins at reveille, when, after roll call, the wards are tidied 
 up and breakfast is served and cleared away before surgeon* 's 
 call is sounded. Promptly on this call the First Sergeant 
 of each company brings his sick to hospital for inspection. 
 The surgeon examines each man, indicating in the sergeant's 
 book those who are to be treated in hospital and those who 
 are to be excused from duty or portions thereof as sick in 
 quarters, etc. Morning reports are then sent to the Adju- 
 tant's office for the information of the commanding officer. 
 Prescriptions for those in quarters are now filled; and the 
 Register of Sick and Wounded is brought up to date by the 
 careful entry of the morning's changes. The wards ar? 
 then visited and the prescription and diet orders recorded. 
 
THE SERVICE OF THE POST HOSPITAL. 5 
 
 After this the kitchen, dining-room, and other parts of the 
 hospital are inspected, and the regulation visit is at end. 
 Emergency calls bring the medical officer to the hospital at 
 any hour, and generally, when serious cases are on hand, he 
 may be expected before retreat or tattoo. After the morn- 
 ing visit he attends to his patients, in the families of officers, 
 married soldiers, laundresses, and other attache's of the gar- 
 rison, and his prescriptions reach the dispensary from time 
 to time during the forenoon. By the time these are filled 
 the steward has posted the records, supplied the wards with 
 needful articles of bedding, etc., given directions for the 
 diet of the day, and provided the required supplies from his 
 subsistence and hospital stores and hospital-fund purchases. 
 The afternoon may be devoted to drills, exercise, or amuse- 
 ment, in the absence of special calls for its occupation other- 
 wise, and the evening to study, or, at certain periods, to 
 the preparation of official reports and papers. 
 
 12. The studies of the members of the corps are naturally 
 such as will fit them to act intelligently in all matters relat- 
 ing to the management of the hospital and the sick and 
 wounded. Every surgeon supervises the instruction of his 
 men and the higher education of his stewards; the latter 
 guide and direct the acting stewards, and these perform 
 similar offices to those who serve under them. The medical 
 officer is required by regulations to devote at least eight 
 hours in each month to instructing the men of the corps in 
 the duties of litter-bearers and the methods of first aid. 
 These studies will eventually lead every capable member of 
 the corps to a stewardship ; but besides this personal influ- 
 ence they serve* a higher end by preparing the corps for a 
 sudden expansion in time of war. When every acting stew- 
 ard is qualified to undertake the duties of steward, and every 
 private ready to step into a higher position, the expansion 
 
6 REPORTS AND PAPERS. 
 
 of the command can be effected by merely recruiting for the 
 lowest grade. 
 
 13. The surgeon is responsible for the timely and accurate 
 rendition of the reports and papers required in the service 
 of a post hospital ; but the work, except in the case of spe- 
 cial and professional reports, is usually performed by a 
 member of the corps, to whom the clerical work has been 
 assigned. For all routine reports blank forms are provided 
 by the War Department, and full instructions are printed 
 on each of these to insure accuracy, the said instructions 
 having the force of Army Regulations. The reports and 
 papers are as follows : 
 
 14. Reports and papers relating to members of the Med- 
 ical Department and Hospital Corps and detached men in 
 hospital : 
 
 A Morning Report of the Hospital Corps, for the informa- 
 tion of the post commander. 
 
 A Monthly Report, in duplicate, Form 32, of the Person- 
 nel and Means of Transportation of the Hospital Corps, giv- 
 ing a nominal list of the members and the matrons on duty, 
 with the changes that have taken place in their status ; and 
 a numerical list of ambulances, harness, litters, etc., one 
 copy to the Chief Surgeon, the other to the Surgeon General 
 direct. Changes in the status of any member of the corps, 
 or matron, as by death, discharge, re-enlistment, or transfer 
 to meet emergencies, are to be reported immediately, by 
 information slip, to the Surgeon General through the office 
 of the Chief Surgeon. 
 
 A Monthly Personal Report from each medical officer to 
 the Surgeon General and Chief Surgeon on information slips, 
 and when at stations where no post return is made to the 
 Adjutant General by letter, giving post-office address, duty 
 on which engaged, and the source, number, and date of 
 
REPORTS AND PAPERS. 7 
 
 orders under which acting. Similar reports are required 
 when an officer arrives at or leaves a station. A hospital 
 steward on furlough reports to the Surgeon General and the 
 surgeon of his station. 
 
 Ration Returns call for the articles of subsistence for each 
 person who has to be provided for by the medical depart- 
 ment. Issues are made by the subsistence officer for a few 
 days, generally ten, at a time ; and at each issue settlements 
 are effected between the companies and the hospital to pre- 
 vent injustice from the sending of men to quarters after 
 they have been drawn for on hospital returns and vice versa. 
 The money value of articles on the return not drawn for use 
 is added to the hospital fund. Money thus accruing is 
 expended exclusively for the benefit of the sick and the 
 members of the corps in the purchase of such articles of 
 diet, comfort, and convenience as may be required. A State- 
 ment of the Hospital fund, Form 35, is forwarded monthly 
 to the Chief Surgeon for transmission to the Surgeon General. 
 Provision is made on this form for a Return of Durable 
 Property purchased with the fund. 
 
 Muster and Pay Rolls. 1 On the last day of February, 
 April, June, August, October, and December muster rolls 
 are made out in duplicate, one copy for the Adjutant Gen- 
 eral, the other to be retained ; and on the last day of every 
 month three muster and pay rolls are prepared, two for the 
 paymaster and one to be retained. These rolls bear the 
 names of the members and attaches of the hospital corps ; 
 soldiers in hospital, detached from their companies, are 
 mustered on separate rolls, one set for the men of each 
 regiment. The accounts of each soldier are settled up from 
 time to time, and when required their status is entered on 
 his Descriptive List and Pay and Clothing Account. ' When 
 1 Blanks from the Adjutant General's Office. 
 
8 REPORTS AKD PAPERS. 
 
 a soldier is transferred from one command to another his 
 descriptive list must be transmitted to the officer with whose 
 command he is next to be mustered, and all the data in the 
 said list must be noted in the Descriptive and Deposit Book. l 
 Clothing is drawn on Special Requisitions from the quarter- 
 master and is issued by the surgeon on duplicate Receipt 
 Rolls, in which is entered the money value of the articles. 
 The commutation value of the soldier's clothing allowance 
 constitutes a stated sum, against which the value of the 
 issued articles is entered in a Clothing Account Book, ' which 
 is balanced June 30th and December 31st. Balances due 
 the soldier are continued as a credit in the clothing account 
 book, but any indebtedness to the Government is charged 
 on the muster rolls and deducted from the pay. In the 
 case of transfer, desertion, discharge, or death the balance 
 due the soldier or the Government is stated on the muster 
 rolls, descriptive list, or final statements, as may be required 
 for the continuation or closing up of the account. Clothing 
 burned by order, to prevent contagion, is replaced on ap- 
 proval of the Surgeon General. When a soldier is discharged 
 from service he is furnished with Final Statements ' in dupli- 
 cate and a Discharge. ' The former give an exhibit of his 
 accounts and are the vouchers on which the paymaster set- 
 tles them. When a soldier in hospital detached from his 
 command is discharged the surgeon sends a copy of the 
 man's descriptive list to his company commander, to enable 
 the latter to enter on the muster roll which reports the dis- 
 charge all the information needful to an understanding of 
 the accounts. When a member of the hospital corps dies 
 Final Statements are prepared as in the case of discharge, 
 with an Inventory of Effects, ' in triplicate. These, except 
 one copy of the latter, which is retained, are forwarded 
 1 Blanks from the Adjutant General's Office. 
 
REPORTS AND PAPERS. 9 
 
 to the Adjutant General. When the effects are claimed 
 by relatives receipts are taken in triplicate to offset the 
 copies of the inventory; when sold by a Council of Ad- 
 ministration the money is deposited with a paymaster who 
 gives the necessary receipts. When a detached man dies his 
 company commander is notified as in the case of discharge. 
 
 15. Reports relating to sickness and other casualties or 
 changes in the garrison : 
 
 A Morning Report of Sick and Wounded for the informa- 
 tion of the commander. 
 
 A Monthly Report of Sick and Wounded, Form 25, to the 
 Chief Surgeon and the Surgeon General, which is practically 
 a transcript from the Register of Patients. This blank form 
 has spaces for Remarks on prevailing diseases, their causa- 
 tion, and the measures adopted for their prevention ; but his- 
 tories of cases possessing a professional interest should be 
 transmitted in the form of Special Reports to the Surgeon 
 General. When a sick or wounded soldier is transferred to 
 another hospital a Transfer Slip giving full particulars of 
 the case is forwarded with the patient. The surgeon of the 
 receiving hospital enters the data into his register and coun- 
 tersigning the slip forwards it to the Surgeon General. On 
 the occurrence of cholera, yellow fever, smallpox, or other 
 infection liable to become epidemic a report is sent to the 
 Chief Surgeon and Surgeon General ; a Monthly List of Pa- 
 tients Suffering from Epidemic Disease, Form 27, is fur- 
 nished in duplicate during the continuance of the epidemic 
 and a detailed history of the outbreak is called for at its 
 close. Local boards of health interested should be notified 
 at the beginning of the epidemic. 
 
 When a soldier completes his enlistment in the Regular 
 Army by taking the oath an Identification Card ' showing the 
 1 Blanks from the Adjutant General's Office. 
 
10 REPORTS AKD PAPERS. 
 
 situation and character of permanent marks and scars on 
 his person, is forwarded direct to the Surgeon General. A 
 card is forwarded also in the case of men received as re- 
 cruits from recruiting stations and rendezvous where there 
 is no Medical Examiner. A Monthly Report of the Physical 
 Examination of Recruits, Form 30, is required by the Sur- 
 geon General. 
 
 16. Keports relating to the post or post hospital : 
 
 A Monthly Sanitary Report, Form 41, giving expression 
 to the sanitary condition of the quarters, including all build- 
 ings belonging to the post, their drainage and sewerage sys- 
 tems, the character and cooking of the rations, the quantity 
 and quality of the water supply, and the clothing and habits 
 of the men, with such recommendations as are considered 
 needful. This report is acted on by the post commander, 
 who returns it to the surgeon that the action taken may be 
 entered in the Medical History of the Post. The report is 
 then forwarded through military channels to the Surgeon 
 General. 
 
 Estimates for Repairs, Alterations, or Additions to the Post 
 Hospital, accompanied by such drawings as are needful, are 
 forwarded to the Surgeon General by March 1st annually. 
 They are required to show in detail the kind and cost of the 
 materials and labor to be procured and to what extent the 
 labor can be performed by the troops. If no repairs are 
 required a communication to that effect should be forwarded 
 at the proper time. Estimates, distinct from those for the 
 hospital, are made at the same time for the Construction or 
 Repair of Hospital Stewards' Quarters. 
 
 A Meteorological Report, Form 29, is called for monthly 
 from certain posts to be transmitted to the Surgeon General 
 through the State office of the Weather Bureau. 
 
REPORTS AND PAPERS. 11 
 
 17. Papers relating to medical and other supplies: 
 
 Requisitions for Medical and Hospital Supplies, Form 15, 
 for the year beginning January 1, are forwarded in triplicate 
 to the Chief Surgeon, who transmits one copy to the Surgeon 
 General and another to the Supply Depot. They are made 
 for articles of the regular supply that are or probably will 
 be deficient, and they must show the quantity of every 
 article on hand, whether more is wanted or not. Unex- 
 pected deficiencies are provided for on Special Requisitions, 
 Form 16, in triplicate, giving a list of the articles and- the 
 quantity on hand. These are forwarded to the Chief Sur- 
 geon, who retains one copy and sends the others to the Sur- 
 geon General. In emergencies Chief Surgeons are empowered 
 to act on special requisitions, sending one copy with their 
 action to the Supply Depot, one to the Surgeon General with 
 an explanation of the circumstances, and retaining one ; but 
 Requisitions for Articles not in the Supply Table must in all 
 cases be forwarded to the Surgeon General. When the sup- 
 plies are received the Invoice, Form 18, and the Packer's 
 List, Form 17, are verified, and Receipts, Form 19, are pre- 
 pared in duplicate, one copy for the issuing officer and one 
 for the Surgeon General. 
 
 Requisitions, on the Surgeon General' s Office, for Blank 
 Forms for the reports and returns, etc., mentioned in this 
 list of official papers, with the exception of those noted 
 as furnished by other bureaus of the War Department, are 
 forwarded when necessary. 
 
 Returns of Medical Property, Form 20, are made out in 
 duplicate on December 31, annually, after an account of 
 stock has been taken for the preparation of the regular 
 requisitions, or when an officer is relieved from the duty to 
 which the returns relate. The original is sent to the Sur- 
 geon General; the duplicate with its vouchers is retained. 
 
12 KEPOETS AND PAPERS. 
 
 They show everything received, expended, etc. , and remain- 
 ing on hand. Names of articles that may be expended are 
 printed on the blank form in Roman type, of non-expend- 
 able articles in italic. Articles of the latter class, worn out 
 or unfit for use, are condemned on Inventory and Inspection 
 Reports of Unserviceable Property, l and these constitute the 
 vouchers relieving from responsibility. Articles destroyed 
 to prevent contagion are covered by the certificate of the 
 officer responsible ; articles lost or destroyed by certificate 
 in like manner or by the certificate of an officer or the affi- 
 davit of an enlisted man or citizen personally cognizant of 
 the circumstances. 
 
 Quarterly Returns of Quartermaster' s Supplies, 2 embodying 
 the responsibility of the surgeon for clothing drawn for issue 
 to the men of the Hospital Corps and soldiers detached from 
 their commands, and for ambulances, litters, tents, lamps, 
 etc., obtained by requisition on the Quartermaster's depart- 
 ment. They are made out in duplicate, one copy for the 
 Quartermaster General, the other to be retained, and 
 are accompanied with invoices for articles received, re- 
 ceipts for those transferred or issued, and other vouchers 
 specially called for in cases of loss, damage, or unservicea- 
 bility. 
 
 18. The Books of Record required to be kept are a Med- 
 ical History of the Post ; a Morning Report of Sick and 
 Wounded ; a Register of Patients ; a Register of the Hos- 
 pital Fund; a Register of the Physical Examination of 
 Recruits ; a Record of Deaths and Interments ; an Order 
 and Letter Book; a Meteorological Register at certain posts, 
 and a Book of Information Slips for use when formal letters 
 are unnecessary. In addition to these are the following 
 
 1 Blanks from the Inspector General's Office. 
 
 2 Blanks from the Quartermaster General's Office. 
 
THE HOSPITAL CORPS. 13 
 
 from the Adjutant General's office: A Descriptive and 
 Deposit Book; a Morning Keport Book of the Hospital 
 Corps, and a Clothing Account Book. 
 
 19. Drills by word of command are needful to perfect 
 men in movements that require concerted or co-operative 
 action. It is a mistaken notion to suppose that .because a 
 drill is authorized and provided for, the various details of 
 that drill must be rigidly observed on every occasion. The 
 drill is merely a means to an end. A well-manned battery 
 keeps up a rapid fire on the enemy because every man at 
 every gun knows the duty devolving upon him, and does it 
 without command at the precise moment when it should be 
 done ; but this perfection of co-operative work can be attained 
 only by repeated and careful drills in the consecutive move- 
 ments, each executed at the word of command. An analo- 
 gous drill with the litter, ambulance, and a representative 
 of the disabled human body familiarizes men with the 
 management of these objects, and prepares them to act 
 intelligently one with the other and irrespective of com- 
 mands when the necessities of the occasion require such 
 action. 
 
 20. The Drill Regulations for the Hospital Corps ' pre- 
 scribes the method of formation and alignment of the 
 detachment, its marchings, turnings, rests, and dismissal. 
 It then describes the litter and the methods of handling it, 
 closed, open, and loaded. After these instructions come 
 paragraphs on improvisation of litters; the removal of 
 wounded without litters ; the use of the travois, the horse, 
 the two-horse litter, and the ambulance; inspection and 
 muster, and the pitching and packing of hospital tents. The 
 book closes with Outlines of First Aid, which are used as a 
 text for the instruction of the enlisted men of the line, who 
 
 1 Washington, D. C., Government Printing-Office, 1896. 
 
14 THE HOSPITAL CORPS. 
 
 are required to be drilled by their company officers for at 
 least four hours in each month in the duties of litter-bearers 
 and the methods of rendering first aid. 
 
 21. The uniform of the corps for ordinary wear consists 
 of a dark blue flannel blouse arid trousers of light blue ker- 
 sey with stripes of emerald green, one half inch, one inch, 
 and one and a half inches wide respectively for privates, 
 acting stewards, and stewards. A brassard of white cloth, 
 three inches wide, with a red cross in the centre is worn on 
 the left arm of the private soldier. The chevrons of the 
 acting steward, consist of three bars of emerald-green cloth 
 with a red cross within, worn above the elbow, points down ; 
 those of the steward have in addition an arc of green cloth, 
 over the ends of the bars. The waist-belt is of leather, 
 black, with plate. The cap is of dark blue cloth, with a 
 rounded and sloping visor of black patent leather, the 
 private and acting steward having a white metal cross in 
 front, and the steward a similar cross in a wreath of white 
 metal. The equipment consists of the litter-sling and the 
 hospital corps or orderly pouch. 
 
 The uniform for ward service is of cotton duck. 
 
 For field service the cap of the barrack suit is replaced 
 by a campaign hat of drab-colored felt, and the legs are pro- 
 tected by leggings of strong cotton duck. The equipment 
 for field service consists of the litter-sling, hospital corps or 
 orderly pouch, canteen, and haversack. 
 
CHAPTER II. 
 
 ACTIVE SERVICE IN THE FIELD. 
 
 22. The size of a hospital establishment is proportioned 
 to that of the command to which it is attached ; for, when 
 troops are concentrating, every subordinate arrival brings 
 its quota to the hospital corps; At first, in the progress of 
 concentration, every material addition to the strength of the 
 command necessitates a corresponding change in the organ- 
 ization of its hospital, to provide their share of the work to 
 the newcomers. For organization consists essentially in 
 so apportioning the work to be done by a number of indi- 
 viduals as to produce satisfactory co-operative results. 
 But during the progressive concentration of troops there 
 comes a stage or period of the aggregation when the hospi- 
 tal corps is able to provide one man or set of men for every 
 part of the work ; and when every part of the work thus 
 assigned draws out the full energies of the man or men 
 charged with it, the organization is perfect. Further addi- 
 tions do not strengthen it, because there is no room for 
 them. They can be used to advantage only in building up 
 another such organization. This perfected hospital is the 
 unit of organization for field service in time of war ; and the 
 field hospital system of a large army consists of a series of 
 such units, just as the army itself consists of a series of 
 regiments which are the units of its organization for pur- 
 poses of drill, discipline, and administration. 
 
 23. The occurrence of the Civil War first aroused the 
 medical profession of this country to the necessity for a sat- 
 
ACTIVE SERVICE IK THE FIELD. 17 
 
 isfactory field hospital organization, but the succession of 
 important events in this war was so rapid that practice had 
 to meet emergencies without premeditation. In the end, 
 success was achieved; but every step taken toward a bet- 
 ter organization showed distinctly how much suffering would 
 have been prevented or alleviated by an earlier recognition 
 of its advantages. The lessons thus learned should never 
 be forgotten; yet there is danger of their fading from mem- 
 ory unless they are treasured by the medical officers of the 
 general and state governments as a precious heirloom bought 
 with the blood and sufferings of their fathers for use in the 
 possibilities of the future. 
 
 24. The unit of organization was at first the regimental 
 hospital, but the inefficiency of this was speedily recognized. 
 Its incompetency was strikingly conspicuous during the 
 emergencies of the battlefield. The medical strength of 
 the army was scattered along the rear of the line of battle. 
 Some regiments suffered more than others, and their ambu- 
 lances and stretcher-carriers were unable to remove the 
 wounded promptly from the field ; their medical officers 
 were overworked, yet could not accomplish all that they 
 desired ; their shelters were insufficient and their supplies 
 inadequate. Nor in this system could there be any efficient 
 co-operation, for other medical officers, whose regiments per- 
 haps had not become engaged, had to hold themselves in 
 readiness for the developments of the battle ; and although 
 they might be ready and willing to assist their overworked 
 comrades by their personal labors, they were warranted in 
 showing some hesitancy in sharing with others the stores 
 and dressings provided for their own men, if there was a 
 probability of their own command becoming engaged before 
 an opportunity would be afforded of replenishing supplies. 
 So the better to provide for the emergencies of battle, a 
 
18 ACTIVE SERVICE IK THE FIELD. 
 
 temporary consolidation was directed whenever an engage- 
 ment was imminent; and as the medical staff of a brigade 
 was able to furnish an officer for every special duty con- 
 nected with the hospital, and yet leave enough to give first 
 aid on the battlefield, the organization was usually effected 
 by brigades. In this way, when one regiment suffered 
 more than another, the medical officers of several regiments 
 participated in the care of its wounded, and individual cases 
 requiring operative proceedings came under the hands of 
 those surgeons in the brigade best qualified to undertake 
 them. At this time, as soon as the surgical work of the 
 engagement was completed the hospitals reverted to their 
 regimental status. An active campaign, however, or a 
 quick succession of battles, speedily demonstrated the advis- 
 ability of retaining the brigade organization as long as the 
 troops were within striking distance of the enemy; and 
 while preserved in this way for a probable emergency, the 
 consolidated field hospital for the brigade had an oppor- 
 tunity of showing its superiority to the regimental hospitals, 
 as well during the marches and strategic manoeuvres of 
 active service as during its battles. Fewer wagons were 
 required for the transportation of its property and supplies 
 than for those of the four or five small hospitals which it 
 replaced, because there was no unnecessary duplication of 
 material ; and the sick and wounded were held better in 
 hand for sudden movements. Under the regimental system 
 the sick of all the regiments were carried in ambulances, 
 which generally followed in rear of the division on the 
 march, and, at its close, were distributed among the several 
 regimental camps. Here the sick had to await the arrival 
 of the heavy trains before shelter or food could be provided 
 for them ; and it was precisely when both were most required, 
 that is, during rainy and inclement weather, that the delay 
 
THE DIVISION FIELD HOSPITAL. 19 
 
 in their arrival was greatest. They were cared for in the 
 ambulances during the day, but at night were transferred 
 to their regimental camp, where their regimental hospital 
 had merely an official, not an actual, existence. Under the 
 brigade system the hospital camp was formed where the 
 ambulances halted, and food and shelter were immediately 
 provided, irrespective of the arrival of the main supply 
 train. Regimental hospitals ultimately disappeared from 
 the camps of veteran troops even during seasons of inactiv- 
 ity and recuperation, their official existence being repre- 
 sented merely by the regimental surgeons, who gave first 
 aid in emergencies, and examined the command daily to 
 find out who, if any, should be sent to the consolidated hos- 
 pitals. A regimental hospital organization exists in most 
 of the state military forces, as this system appears to answer 
 the purposes of the Guard in their home service. Volunteer 
 troops, tendered by the State for Federal service, would 
 likely have a similar medical organization ; but when bri- 
 gaded for actual war service the field hospital system of the 
 Civil War should be substituted. 
 
 THE DIVISION FIELD HOSPITAL. 
 
 25. But the brigade hospital, although a great advance 
 on the regimental system, was found defective on many 
 occasions when the brunt of the battle fell on a particular 
 part of the line. A higher organization was found to be 
 necessary ; and this was effected by consolidating the brigade 
 hospitals of the same division into a division field hospital. 
 One medical officer exercised supervision over its various 
 parts, the brigade hospitals becoming merely wards or 
 sections of this larger organization. This consolidation, 
 effected, it might be said, under fire on the field of battle, 
 
20 THE DIVISION FIELD HOSPITAL. 
 
 continued to the end of the war to give thorough satisfac- 
 tion to those who had most experience of the difficulties to 
 be overcome. 
 
 26. At the post hospital the ambulance wagon is one of 
 the belongings of the hospital, and when there is need for 
 its use the driver and attendant litter-bearers are temporary 
 assignments from the hospital force ; and with small detach- 
 ments in the field, it similarly forms part of the field hos- 
 pital. But when the field hospital has reached that stage 
 of its growth which requires the presence of a surgeon in 
 charge for its proper management, the ambulance service 
 must be placed under a special officer, for on important 
 occasions the duties of the ambulance service lead it where 
 the surgeon in charge cannot be present to superintend. 
 
 27. The members of the hospital corps on duty with the 
 ambulances of the division are organized under the com- 
 mand of an officer, with brigade sections under junior 
 officers espcially assigned, and with stewards and acting 
 stewards as non-commissioned officers. The strength of 
 the command is proportioned to that of the division, and 
 is determined by the Surgeon General. For a division of 
 10,000 men, in three brigades, there should be three brigade 
 sections aggregating 50 ambulances, 50 non-commissioned 
 officers, and 250 privates. These would suffice to meet the 
 requirements of an active campaign under all but the most 
 unusual circumstances. The surgical history of our Civil 
 War testifies to this. * Improvements in firearms have 
 changed the conditions since then, but as yet, fortunately, 
 we have no other statistics to quote. The maximum per- 
 centage of loss which may befall a command depends upon 
 the size of the command. Some company always suffers 
 more than the average loss of the regiment, some regiment 
 more than the average of the brigade, and so on. The 
 
THE DIVISION FIELD HOSPITAL. 21 
 
 larger the command, the less the percentage of loss. Sup- 
 pose that 1,500 men were struck down in the division of 
 10,000 men. The records of the war show 4.565 men 
 wounded for every man killed. Of the 1,500 struck, 270 
 would remain for burial, while 1,230 would be entered 
 on the list of wounded. The number of those who reach 
 the hospital without assistance is always large, but it is rel- 
 atively larger after severe engagements, for when the dress- 
 ing and ambulance stations are crowded many will under- 
 take the journey on foot rather than wait for the return of 
 the wagons. Of 245,790 gunshot injuries recorded in the 
 Surgical History of the War of the Rebellion, 56 per cent, 
 were wounds of the upper part of the body and upper 
 extremities, including fractures of the bones of the hand, 
 which did not prevent their recipients from finding their 
 way to the rear without the assistance of the ambulance 
 service. This disposes of 689 of the 1,230 cases. Twenty- 
 four per cent, were fractures of the upper extremities, flesh 
 wounds of the lower extremities, and fractures of the bones 
 of the foot which did not require operative procedure at the 
 hospital. These cases, numbering 295 of the 1,230, may 
 be regarded as having been able to bear transportation in 
 the sitting posture. The remaining 20 cent., or 246 of 
 the 1,230 cases, were of such a nature as to require car- 
 riage by ambulance or litter in the recumbent position. 
 Viewing the capacity of an ambulance at seven, six inside 
 and one with the driver, and allowing one recumbent pas- 
 senger to be equivalent to three seated, the number of seats 
 required for the transportation of the wounded in the divi- 
 sion which lost 1,500 men in killed and wounded would be 
 1,033, or about three trips for each of the 50 ambulances. 
 Of course, an ambulance may make its trip without being 
 fully loaded, but as a rule, when the wounded are as plen- 
 
22 THE DIVISION FIELD HOSPITAL. 
 
 tiful as in the case supposed, there is seldom any spare 
 space in a wagon which is starting from a dressing-station. 
 
 28. Existing orders do not provide specifically for the 
 personnel of the Division Hospital. Its organization is left 
 to the discretion of the chief surgeon. A steward, an act- 
 ing steward, and ten men for each brigade, in addition to 
 the teamsters of the supply wagons, are required for efficient 
 service. When the hospital is crowded with wounded after 
 a battle, details may be made from the ranks of the litter- 
 bearers whose special duties for the time being have ceased. 
 
 29. The surgeon in charge is responsible for the care of 
 the sick and wounded on the march and in camp, and for 
 the comfort and general welfare of the wounded when 
 brought to his establishment by the ambulance service. He 
 makes requisition for medicines, medical and hospital stores, 
 supplies, and property, and is responsible for their proper 
 expenditure or use. An executive officer aids him in his 
 work of supervision, and has special charge of the records. 
 A subsistence officer superintends the cooking and diet of the 
 hospital, drawing rations from the Subsistence Department, 
 issuing to the brigade sections, and keeping the accounts of 
 the hospital fund ; he has also special charge of the hospital 
 stores and of such articles of hospital property as are con- 
 nected with the cooking and serving of food. A division 
 steward looks after all articles of property borne on the 
 returns of the surgeon in charge, taking care that by timely 
 requisitions all deficiencies are made good and the hospital 
 is always prepared for the coming emergency. 
 
 30. The attending surgeon cares for the sick of his bri- 
 gade on the march and in camp, and during an engagement 
 looks after the management of his wards, making notes of 
 operative procedures, deaths, and of the progress of cases 
 for subsequent report to the surgeon in charge and entry 
 
THE DIVISION FIELD HOSPITAL. 23 
 
 on the records of the hospital. Each brigade section 
 requires for its complement a steward and one or more 
 acting stewards, the former to have charge of the medical 
 supplies and instruments, the latter to act as wardmasters. 
 In the wagon train should be carried from thirty to forty 
 hospital tents, with picks, spades, and other implements for 
 use in pitching the tents, trenching the ground, digging 
 sinks, burying the dead, etc. ; bedsacks and blankets, and 
 cots, mattresses, and pillows for special cases. The surgeon 
 in charge should endeavor to have cots or spare litters for 
 all the cases that his canvas will cover, but restricted means 
 of transportation generally prevent this. Woollen and light 
 rubber blankets are brought from the field with the wounded, 
 so that the hospital stock is made use of only in cold or wet 
 weather, or to supply occasional necessities. Sheets, draw- 
 ers, and socks should be provided to replace those that have 
 become unfit for use. Kations of bread and beef stock, tea, 
 coffee, sugar, and salt are carried for use during an engage- 
 ment to insure food to the wounded until communication is 
 opened with the main supply trains after the battle ; and 
 when this communication has been effected these stores 
 should be immediately replaced to provide for the next emer- 
 gency of the kind. The ambulances may also be utilized 
 for the transportation of such supplies. Each should be 
 fitted up with a water-keg and a locked box, the latter con- 
 taining beef stock, tea, sugar, and hard bread, except in one 
 instance in each brigade, in which the contents should con- 
 sist of anaesthetics, morphine, antiseptics, and dressings. 
 Each should also be provided with an axe, lantern, candles, 
 and an iron pail which can be used in case of need as a 
 camp-kettle. By this arrangement field supplies and stores 
 are found by the side of the wounded as soon as they are 
 brought from the field, and the work of the hospital- can 
 
24 ON" THE MARCH. 
 
 progress on this preliminary supply until the arrival of the 
 main train. The heavy wagons of the hospital carry also the 
 ordinary army ration for its employees and sick for the num- 
 ber of days that will elapse before new issues are made from 
 the base or general supply train ; the kitchen outfits ; the 
 tents and personal baggage of the officers ; the blanket-rolls 
 of the men, and forage for the horses and mules. The 
 weight and bulk of this material are such that ten six-mule 
 army wagons will suffice for its transportation. The capac- 
 ity of an army wagon, on good roads and with full forage 
 for the animals, is about 3,000 pounds. A blacksmith's 
 forge accompanies the train. 
 
 ON THE MARCH. 
 
 31. Camp is usually broken up soon after reveille. Am- 
 bulance-drivers and teamsters groom, feed, and water their 
 horses ; litter-carriers pack up their shelters and blankets, 
 and fill the ambulance kegs with fresh water, while nurses 
 and cooks attend to their respective duties. After break- 
 fast, the sick are examined and medicines prescribed and 
 provided for their use during the day. They are then 
 transferred to the ambulances, while the hospital tents and 
 bedding, kitchen utensils, and other property are packed 
 up and stowed away in the heavy wagons, which by this 
 time have reported for their loads. The ambulances, med- 
 ical wagons, and those carrying the subsistence of the hos- 
 pital usually take position in the column of march immedi- 
 ately in rear of the division; but the transport wagons 
 remain in camp until the troops of the army corps or of the 
 army have passed, when they join the column of the regi- 
 mental baggage, ordnance, subsistence, and forage wagons, 
 under the protection of the rear guard of the army corps or 
 
ON" THE MARCH. 25 
 
 army. Generally, these wagons come into camp at the 
 close of the day's march shortly after the troops and their 
 ambulances have reached it; but occasionally the conditions 
 are such that the separation is for a longer period. 
 
 32. The ambulance train on the inarch receives those who 
 have fallen out of the column from accident or disease. 
 Usually each of these new cases has been examined by the 
 regimental medical officer and furnished with a permit to 
 await the passage of the train. The march has its sufferers 
 as well as the battlefield. With raw troops, the sick and 
 exhausted accumulate from day to day, until it becomes 
 necessary to relieve the ambulances by sending the serious 
 cases to the base of supplies. In the absence of transporta- 
 tion, this excess of sick may have to be left in extemporized 
 quarters, or, if need be, in a section of the field hospital 
 establishment. 
 
 33. At the conclusion of the day's march, when not 
 immediately in front of the enemy, the ambulances are 
 halted in rear of the division. While waiting the arrival 
 of the baggage wagons, the sick are examined and treated. 
 Such as are considered fit for duty are sent under charge of 
 a steward to their regiments ; and a notification is sent to 
 regimental surgeons in the case of men admitted without 
 permits and retained as unfit for duty, that these men may 
 be properly accounted for on the regimental reports. Mean- 
 while, wood and water are procured, and the fires are lighted. 
 
 34. As soon as the baggage train arrives, the men on 
 duty as pioneers and laborers unload and pitch as many 
 hospital tents as will accommodate the sick, and afterward 
 the tents of the officers ; the nurses fit into the tents such 
 bedding and other articles as are needful; and thereafter 
 the litter-carriers transfer the sick from the ambulance 
 wagons. Meanwhile, the cooks provide a refreshment of tea, 
 
26 ON THE BATTLEFIELD. 
 
 coffee, or consomme. Later in the evening dinner is served. 
 Pending its preparation, the ambulances and baggage wag- 
 ons are parked in rear of the tents, and the horses and mules 
 fed, watered, and groomed, while the litter-carriers pitch 
 their shelters between the wagon park and hospital tents, and 
 the pioneers trench around the wards to keep their floors 
 dry in case of rain. With dinner the labors of the day are 
 at an end, save for the wagon guard, the hospital guard, if 
 the season requires one to attend to the fires, and the spe- 
 cial work of medical officers and nurses in particular cases. 
 In the establishment of this camp each man, by drill and 
 experience, knows his particular duty, and by doing it well 
 enables the whole to be accomplished with ease and rapidity. 
 Less than an hour will suffice to transform a deserted field 
 into a hospital settlement as orderly and perfect in its 
 field appointments as if it had been in existence there for 
 many days. 
 
 ON THE BATTLEFIELD. 
 
 35. To meet the emergencies of battle, a standing order is 
 issued the requirements of which take effect as soon as it 
 is evident that a struggle is imminent. This order pre- 
 scribes the duties of each medical officer during the antici- 
 pated engagement. An operator and assistants report to 
 the surgeon in charge of the hospital for duty in each bri- 
 gade section. The other medical officers are assigned to 
 duties on the field or at the hospital, as may be determined 
 by the chief surgeon. A severe engagement seldom takes 
 place without premonitory signs. The chief surgeon is 
 aware of what is impending, and satisfies himself that his 
 command is well in hand. As soon as he learns the position 
 of the line of battle, he indicates to the surgeon in charge, 
 personally or by messenger, his views as to the location of 
 
ON THE BATTLEFIELD. 27 
 
 the hospital. The ambulance officer, on his return from a 
 survey of the roads leading to the front, may be the bearer 
 of this information. The particular locality in this neigh- 
 borhood is selected by the surgeon in charge, with due 
 consideration to questions of water and fuel, dry ness of 
 site, facility of communication with main roads, and availa- 
 bility of neighboring buildings as hospital accessories. 
 
 36. The hospital should not be too near the front. Noth- 
 ing is so depressing to the wounded, already more or less pros- 
 trated by their injuries, than exposure to fire while under the 
 hospital flag, as it is suggestive of a disaster to the line of 
 battle. Even in the best-disciplined establishments the 
 effect is sometimes demoralizing. The hospital cannot be 
 moved farther to the rear under these circumstances with- 
 out detriment to the wounded already brought in, while 
 those on the field would have to be left for so much longer 
 before obtaining shelter and care. Nor, for manifest rea- 
 sons, should the hospital camp be too far from the front. 
 A distance of from one and a half to two miles will give 
 fair security ; while, if the roads are good, there will be lit- 
 tle delay in the transport of the wounded. The immediate 
 vicinity of a farmhouse, country seat, or other dwelling 
 affords many advantages. Water, fuel, and direct commu- 
 nication with the main roads are usually associated with it ; 
 it offers a point of prominence for the display of the hos- 
 pital flag, should it become exposed to the fire of the enemy ; 
 and its rooms may be made use of as adjuncts to the hos- 
 pital should the number of wounded exceed the capacity of 
 the tents to accommodate them. 
 
 37. If the hospital train is not on the ground, special 
 messengers are despatched to hasten and guide it, and on 
 its arrival the pioneers, nurses, cooks, and teamsters pro- 
 ceed with the routine work of unloading, pitching, trench- 
 
28 ON" THE BATTLEFIELD. 
 
 ing, and furnishing the tents, building fires, and preparing 
 for the issue of beef soup, tea, and coffee, every section or 
 part of the work under the personal supervision of an officer, 
 every squad controlled by a non-commissioned officer, and 
 every man familiarized by practice with the duties required 
 of him. At the same time, on the ground allotted by the 
 surgeon in charge, each brigade steward opens his wagon 
 for service, and has the operating fly of his command pitched 
 and furnished with its table, instruments, appliances, and 
 supplies pending the arrival of the operating staff from the 
 front. 
 
 38. On orders issued by the Adjutant General of the 
 Division the services of musicians and members of the 
 drum-corps may be utilized in pitching tents and preparing 
 the hospital camp for the reception of the wounded. There- 
 after they may be employed according to their individual 
 capacities, the main body, however, being assigned to duty 
 as the police party of the camp. Some medical officers have 
 reported against the use of drum-corps details for such duties 
 on the ground that they are troublesome and unmanageable ; 
 others, however, have credited them with valuable services. 
 
 39. Meanwhile, at the front, the chief surgeon supervises 
 the arrangements for first aid to the wounded. Existing 
 orders require that the wounded shall receive attention at 
 three points on their way to the division hospital: 1st, on 
 the line of battle; 2d, at the first dressing-stations; and 
 3d, at the ambulance stations. 
 
 40. The attention they receive on the line is that afforded 
 by the litter-bearers of the ambulance company, who have 
 reached the front, under command of their company officers 
 and stewards. First aid here is limited to giving water or 
 some restorative, relieving the wounded man from harmful 
 pressure of equipments, and getting him by the shortest and 
 
ON THE BATTLEFIELD. 29 
 
 safest route to the dressing-station. Dangerous bleeding is 
 controlled by pressure and fractured limbs are adjusted for 
 transportation on the litter. 
 
 41. The dressing-stations are situated at the nearest point 
 where protection may be obtained from musketry fire. If 
 the men are fighting behind breastworks, the best protection 
 may be on the line itself; otherwise, advantage is taken of 
 some superficial depression, gully, ravine, fence, wall, or 
 building, two or three hundred yards in rear. Under such 
 cover as he can find, each medical officer who has been 
 assigned to this duty takes position with a steward and 
 orderly. The amount of surgical work performed here is 
 greatly affected by circumstances. If the cases are numer- 
 ous or the station exposed, many may be permitted to pass 
 to the ambulances after a glance at their condition and a 
 caution to permit no unauthorized handling of the wound, 
 while the attention is mainly devoted to arresting bleeding, 
 removing shock, and supporting fractures in slings or light 
 splints for ease in transportation. But if casualties are 
 infrequent and the station well protected, flesh wounds may 
 be thoroughly cleaned with boiled water, covered with 
 bichlorid dressings, and the patient tagged to intimate that 
 further interference is unnecessary. Dressing-stations are 
 distinguished during the day by Red Cross flags and at 
 night by red lanterns. 
 
 42. The ambulance stations are situated as close to the 
 rear of each brigade as the nature of the ground will permit. 
 Here the medical officers clean and place protective dress- 
 ings on wounds that escaped attention at the first dressing- 
 stations, marking such as require no further investigation, 
 and also such as seem to call for immediate operative pro- 
 cedure. They superintend the loading of the ambulances, 
 and see that every case is in the best possible condition to 
 
30 ON" THE BATTLEFIELD. 
 
 undertake the journey to the hospital. The topographical 
 features of the battlefield are often such that the first 
 dressing-stations and ambulance stations may be consoli- 
 dated. When the ambulances can get close up, there is no 
 need for an intermediate halt in the removal of the wounded ; 
 and when the roads and the ground permit of it, ambulance 
 stations should be established at more than one point in rear 
 of a brigade, in order to shorten the distance over which 
 the wounded have to be assisted or carried. In the event 
 of an advance or a yielding of the line of battle, a corre- 
 sponding change of position of the dressing and ambulance 
 stations must be effected. In the former case, a few of the 
 ambulances follow up the advancing line, leaving the greater 
 part to clear the field before participating in the forward 
 movement. In the latter case, positions are assumed in rear 
 of the re-formed line, except when the hospital becomes 
 exposed, in which case special orders from the chief surgeon 
 determine the further movements. 
 
 43. Generally, some time before the first ambulance load 
 of wounded arrives from the front, the surgeons on duty at 
 the hospital are engaged in receiving, dressing, or operating 
 on, injuries of the hand and flesh wounds attended with 
 little hemorrhage or shock. These cases probably left the 
 field stations without waiting for attention and made the 
 journey unaided and on foot. Each is assigned to a speci- 
 fied ward, the acting steward or wardmaster of which is 
 thereafter responsible for his comfort. Shelter-tents are 
 pitched at regular intervals near the hospital tents to form 
 the ward for these lighter cases. The pioneers attend to 
 this work, trenching the ground, weather-guarding the open 
 ends of the shelters, and providing some material, as hay, 
 straw, freshly cut grass, leafy twigs, wood-shavings, etc., 
 for bedding. If no suitable material can be found in the 
 
ON THE BATTLKFIELD. 31 
 
 immediate vicinity, one of the now-empty transport wagons 
 may be despatched to some point where a supply may be 
 obtained ; and if no such point is known, a detachment of 
 the drum-corps, under responsible leadership, may be sent 
 out as foragers. During inclement weather these slighter 
 cases may be housed in the as yet unoccupied hospital tents 
 until their special camp is prepared. When thus system- 
 atically camped, their wants are not overlooked, as each 
 wardmaster has his duties aggregated and defined. 
 
 44. When ambulances arrive from the field, the whole 
 staff of the hospital becomes at once engaged. Should the 
 reports from the front indicate that the tents will be insuffi- 
 cient for the accommodation of the wounded, the flies are 
 moved forward to extend the wards, and extra bedsacks are 
 filled with such material as may have been collected. If 
 this extension is insufficient for the shelter of the in-coming 
 wounded, the neighboring dwelling or its outhouses may be 
 utilized. 
 
 45. The end and aim of the work of the hospital is to 
 have all primary operations completed and the wounded 
 ready for transportation to the base of supplies at the earli- 
 est possible moment, because an advance or retreat is sure 
 to follow the battle unless it has left both sides unfit for 
 immediate aggression. The important part of this work 
 falls upon the operating staff. The surgeon in charge 
 should therefore see that these officers are provided with a 
 steady succession of cases until the work is finished. Time 
 lost in field surgery is lost between cases for want of that 
 systematic direction which enables all to be constantly em- 
 ployed. 
 
 46. The chief surgeon provides the transportation for the 
 removal of the wounded from the hospital. If railroad or 
 steamboat communications are available, the ambulances of 
 
32 OK THE BATTLEFIELD. 
 
 the division may be used to convey the sick and wounded 
 to the station or wharf; but if the journey is one of consid- 
 erable length, these wagons should not be employed unless 
 they can return to the hospital in time to secure needful 
 rest before the march is renewed. Ambulances from the 
 base may sometimes be sent forward to relieve the hospital. 
 Usually, however, the empty wagons of the subsistence and 
 ordnance trains are employed. The surgeon in charge 
 superintends the loading of these wagons, and provides the 
 medical officers to accompany them, with such articles of 
 food and medicine as are needful for the journey. He may 
 have to part with many of his mattresses, bedsacks, and 
 blankets in outfitting the train, but requisitions to replace 
 them, and to replenish supplies generally, may at the same 
 time be transmitted to the purveyor at the base. 
 
 47. The medical officer in charge of the wagon train 
 should be provided with a nominal list of the sick and 
 wounded intrusted to his care. Frequently, however, the 
 military conditions are such that no list of names can be 
 made out. At starting he may be able to learn of his train 
 merely that it consists of so many medical officers, or, if 
 small, of so many stewards and acting stewards, each of 
 whom reports himself responsible for so many men and 
 their supplies. On delivering up his charges to the author- 
 ities at the base hospitals, he should report back to the 
 surgeon in charge of the division hospital all the deaths or 
 other losses that have occurred during the journey, that they 
 may be entered on the register and communicated through 
 regimental surgeons to the company officers on whose 
 muster-rolls the names of the men in question are carried. 
 
 48. If, as an immediate result of the battle, the enemy 
 withdraws to another position, it is not necessary for the 
 hospital to follow up the advance of the troops unless the 
 
ON THE BATTLEFIELD. 33 
 
 distance is considerable. Should this be so, the hospital 
 moves forward, carrying the wounded, if few in number, 
 with it, or leaving them in a detached section of the estab- 
 lishment until they have been put in condition to undertake 
 a rearward journey in the supply wagons. 
 
 49. Should the battle be indecisive, the losses will prob- 
 ably be great, but time will usually be afforded for the com- 
 pletion of the surgical work, because neither party is in a 
 condition to renew the contest. The hospital, therefore, 
 remains undisturbed probably for several days; but so great 
 is the uncertainty of battlefield conditions that every effort 
 should be made to complete the surgical work. Promptly 
 on the cessation of the battle, medical officers who have been 
 on duty at the stations report to the surgeon in charge for as- 
 signment to temporary duty at the hospital. Extra surgical 
 help may also be drawn from the base or general hospitals, 
 if telegraphic and railroad connections have been kept up. 
 
 50. Should the troops in the line of battle be driven back, 
 the exposure of the hospital is unavoidable, unless antici- 
 pated by prompt action on the part of those in charge. 
 The hospital and its accumulated wounded should be moved 
 to a suitable site in rear of the new position. The wounded 
 left upon the field must be cared for by the medical depart- 
 ment of the opposing force; but such as have reached the 
 shelters prepared by friends should not be given up without 
 the strongest efforts to save them. Medical officers and 
 members of the hospital corps should be officially detached 
 to remain with any left behind ; and shelter, bedding, med- 
 ical and hospital supplies, and food should be amply provided 
 for them. Tents and supplies thus lost should be replaced 
 by immediate requisitions on the supply depots. 
 
 51. If the disaster is so serious that none of the wounded 
 can be removed, the surgeon in charge and ambulance officer 
 
 3 
 
34 ON THE BATTLEFIELD. 
 
 should endeavor to preserve the organization by withdraw- 
 ing the ambulances, wagons, supplies, stores, and personnel 
 not specially assigned to remain with the wounded. When 
 the hospital is thus disabled, an immediate renewal of hos- 
 tilities necessitates the occupation of the available buildings 
 in the vicinity of the new site; but this utilization of pre- 
 existing shelter would have been necessary if, without the 
 repulse, the wounded had been equally numerous. 
 
 52. If the disaster involves the capture of the transporta- 
 tion and supplies, while certain of the officers and men have 
 escaped, these must be organized by the senior medical 
 officer for the duty of caring for the wounded who may fall 
 in the skirmishes of a subsequent retreat. Notwithstanding 
 breaks in the ranks, their training holds them together for 
 this special service until the command is re-enforced and 
 refitted. 
 
 53. When a regiment or brigade is detached for perma- 
 nent assignment to some other command, it carries with it, 
 when needful, its section of the ambulance company, hospi- 
 tal property, and transportation; but when this detached 
 command is en route to a rendezvous where it can be refit- 
 ted, its section of the hospital is left behind and applied by 
 the chief surgeon in repairing deficiencies in other brigades, 
 or is held subject to disposal by higher authority. 
 
 54. The Treaty of Geneva has of late years done much to 
 mitigate the sufferings of the wounded of a defeated army. 
 The Articles of the Convention, which were adopted by 
 every European power and the majority of the South Amer- 
 ican States, at different times since 1864, provide: 1st. 
 For the neutrality of ambulances on the battlefield, and mili- 
 tary hospitals as long as they contain any sick ; 2d. For the 
 neutrality of the staff, medical, and administrative officers, 
 attendants and litter-bearers; 3d. That the neutrality of 
 
ON THE BATTLEFIELD. 35 
 
 these persons should continue after the occupation of their 
 hospitals by the enemy, so that they may stay or depart as 
 they choose; 4th. That if they depart they may take only 
 their private property with them, except in the case of am- 
 bulances, which they may remove entire; 5th. That a sick 
 soldier in a house shall be regarded as a protection to it, 
 entitling the occupant to exemption from quartering of 
 troops and from part of the war requisitions; 6th. That 
 wounded men shall, when cured, be sent back to their own 
 country on condition of not bearing arms during the rest of 
 the war ; 7th. That hospitals and ambulances shall carry, 
 in addition to the flag of their nation, a distinctive and uni- 
 form flag having a red cross on a white ground, and that 
 their staff shall wear an arm badge of the same colors, the 
 delivery of which shall be left to the military authorities ; 
 8th. That the details shall be left to the commanders of 
 the armies. The 9th and 10th articles are formal and 
 signatory. 
 
 55. In 1838 supplementary articles were agreed upon, but 
 they have not been ratified, though they were practically 
 adopted by Germany and France in the war of 1870. Their 
 provisions affecting armies are that, when a person engaged 
 in an ambulance or hospital occupied by the enemy desires 
 to depart, the commander-in-chief shall fix the time for his 
 departure; and that, if he remain, he shall be paid his full 
 salary; that the ambulances mentioned in the 1st and 4th 
 articles include field hospitals ; that in exacting war requi- 
 sitions account shall be taken not only of actual lodging of 
 wounded men, but of any display of charity toward them ; 
 and that the rule which permits sound soldiers to return 
 home on condition of not serving again shall not apply to 
 officers, as their knowledge might be useful. 
 
 56. Officially there is only one Red Cross, that of the 
 
36 ON THE BATTLEFIELD. 
 
 Geneva Convention ; but many good people in certain coun- 
 tries, when the treaty was signed, formed themselves into 
 Eed Cross societies to collect funds and stores for relief 
 purposes when war should come ; and these societies assumed 
 the Red Cross as their flag and insignia. They have, how- 
 ever, no legal or official status in connection with the army, 
 and are entitled only to such privileges as the military 
 authorities may desire to extend to them in the interest of 
 the sick and wounded. 
 
 57. When the army goes into a comparatively permanent 
 camp, as in winter quarters, during sieges, or in the occu- 
 pation of hostile territory, the sick and wounded need not 
 be sent away unless they accumulate beyond the capacity 
 of the hospital to accommodate them. Commanding officers 
 generally approve of retaining the men in the field hospital, 
 as return to duty on recovery is better assured than from 
 distant hospitals. "They therefore further the efforts of the 
 medical department in improving the condition of the hos- 
 pital. Lumber is obtained, and the tents are framed, floored, 
 and weather-boarded, while shelves, tables, and benches are 
 put in, with suitable stoves or brick fireplaces to warm the 
 wards. Board walks are laid, and the grounds fenced in 
 and thoroughly policed. As thus established the field hos- 
 pital presents an air of permanence and stability ; but it 
 should be kept in proper drill, and ready at a few hours' 
 notice to be packed up and following the division in the 
 column of march. 
 
 OFFICIAL PAPERS. 
 
 58. The medical records of field service in time of war 
 have an importance which is not always recognized by those 
 who are responsible for their accuracy and completeness. 
 While facing the suffering of the battlefield the mind be- 
 
FIELD REPORTS AND PAPERS. 37 
 
 comes careless of prospective considerations, and sometimes 
 looks upon the preparation of reports and papers as akin to 
 substituting the so-called red tape of bureaucratic methods 
 for the antiseptic dressings of the practical surgeon ; but 
 the value of these records may be at once appreciated when 
 it is realized that they are the corner-stone on which the 
 pension system is built. Defective records may cause much 
 suffering in the future by delaying or preventing the estab- 
 lishment of just claims for relief. 
 
 59. The senior medical officer of each regiment co-oper- 
 ates with company officers in providing the regimental com- 
 mander with the materials for his Field Return of killed, 
 wounded, and missing, which is filed in the office of the 
 Adjutant General, as the official record of the losses. The 
 senior medical officer is called upon also to forward to the 
 chief surgeon duplicate lists of wounded within two days 
 after an engagement. Outside of these battle returns the 
 only reports required from this officer are the mominy and 
 monthly reports of sick and wounded of his regiment. He 
 reports those that are in the field hospital as well as those 
 who are excused from duty on account of trivial ailments. 
 His morning report is for the regimental commander, but a 
 duplicate is sent to the chief surgeon. This report should 
 give also the names of such hospital corps men as are on 
 detached service with the regiment. In large commands, 
 as an army corps, a weekly report may suffice to keep the 
 chief surgeon informed as to the condition of the troops ; 
 but the medical officer on the staff of generals of brigade or 
 division may call for a copy of the morning report. The 
 monthly report forms a part of the permanent record, and 
 is transmitted to the Surgeon General. 
 
 60. The surgeon in charge of the hospital reports his sick 
 and wounded daily to the chief surgeon for comparison with 
 
38 FIELD REPORTS AND PAPERS. 
 
 the reports from the regiments ; and monthly to the Sur- 
 geon General and chief surgeon. He is accountable for the 
 medical and hospital property and supplies in use, signing 
 all requisitions, and making annual returns. He reports 
 the personnel of the hospital corps daily to the chief sur- 
 geon, and monthly to the Surgeon General and chief surgeon. 
 As commanding officer of the hospital corps, he keeps the 
 accounts of the pay, clothing, etc., of its members, includ- 
 ing their final statements in case of discharge or death, the 
 executive officer relieving him of the details of these duties. 
 He is responsible also for the subsistence of his hospital 
 and for the proper expenditure of its hospital ^fund, the 
 subsistence officer aiding him in these duties. 
 
 61. The ambulance officer is charged with the care of the 
 pay, clothing, and subsistence accounts of his men, and is 
 held responsible for the care of the ambulances, wagons, 
 tents, horses, mules, forage, etc. 
 
CHAPTER III. 
 
 SANITARY CARE OF CAMPS. 
 
 62. The site of a camp is of the first importance, because, 
 in the event of its insalubrity, no exercise of care in the 
 sanitary government can protect from evil consequences. 
 Ordinarily, in selecting a site the health and comfort of the 
 men is the first consideration ; but when a military object 
 is in view, the ground must be selected and the camp ar- 
 ranged for that object, other considerations being merely 
 secondary. 
 
 63. Dryness of site is essential to the healthfulness of -a 
 camp ground. It depends on the inclination of the surface 
 and the porosity and depth of the subsoil. The natural 
 drainage of a place is good when the surface sheds the rain- 
 fall into neighboring watercourses, or when the surface 
 layers are so porous as to soak up the rainfall and drain it 
 off to lower levels by underground channels. The natural 
 drainage is bad, and the site damp and insalubrious, when a 
 level or slightly undulating clayey surface retains the rain- 
 fall in shallow pools, or where the level of the subsoil water 
 is near the surface. The subsoil water is that which is 
 found in digging shallow wells rain- water which, having 
 penetrated a porous surface, is upheld below by a stratum 
 of impervious clay. 
 
 64. Moist soils, under their most favorable aspects, 
 induce catarrhs, sore throat, and other internal inflamma- 
 tions, develop consumptive and rheumatic tendencies, and, 
 by depressing the vitality of the system, render it an easier 
 
40 MALARIOUS CAMP SITES. 
 
 prey to the attacks of other diseases ; they also give rise to 
 an influence known as malaria, which is recognized as the 
 cause of intermittent, remittent, and congestive fevers, 
 enlargement of the spleen, congestion of the liver, dysen- 
 tery, many neuralgic affections, and that broken-down con- 
 dition of the system found in individuals who have lived 
 for some time in marshy districts. 
 
 65. Malarial fevers are caused by the presence of a micro- 
 scopic parasite, the Plasmodium malarise, in the blood. 
 The life history of the plasmodium outside the body is not 
 known, but it is believed to be connected with the fermenta- 
 tion of the organic matter in soils. For the production of 
 malarial manifestations there are needful: 1st, a certain 
 amount of decaying organic matter; 2d, a certain propor- 
 tion of moisture ; and 3d, a certain degree of heat. Under 
 the influence of heat and moisture, the organic matter 
 undergoes a fermentation during which the pernicious ele- 
 ment is evolved. If organic matter be not present, there 
 can be no fermentation; excess of moisture retards the fer- 
 mentation by reducing the heat below the required temper- 
 ature ; and excess of heat produces the same effect by dissi- 
 pating the needful proportion of moisture. 
 
 66. This theory fits well with much of our knowledge of 
 malaria. Dams, lakes, and ponds with an equable water- 
 level and well-defined margins are not unhealthy, but 
 grounds that are alternately submerged and exposed are 
 malarious. The artificial draining of ponds and the acci- 
 dental breaking of dams have occasioned disease in their 
 vicinity. Fever and ague prevail not during periods of 
 inundation, but during the subsequent periods of draining 
 and drying up, if the season be sufficiently warm. Shallow 
 mill-dams that uncover a portion of their storage area during 
 the use of the water are more dangerous than those that have 
 
MALARIOUS CAMP SITES. 41 
 
 depth enough to keep the area submerged. Shallow creeks 
 which open into salt water, and are subject to tidal influ- 
 ences, are generally malarious. 
 
 67. Malaria is diffused into the atmosphere with some 
 difficulty. When it drifts with the wind its course is along 
 the ground; hence, in an unhealthy locality, it is more dan- 
 gerous to sleep on the ground or on the ground floor of a 
 house than on a higher level. It is often associated with 
 mists or fogs, which, hanging low over the exhaling sur- 
 face, may be floated into neighboring valleys and upward 
 along the rising grounds. Floating mists of humidity and 
 malaria are intercepted by belts of trees : a growth of trees 
 between a pestilent marsh and a settlement has frequently 
 protected the latter from disease; and, conversely, the 
 removal of a screen of trees has been followed by an inva- 
 sion of malaria from neighboring swamps. 
 
 68. Although most of the recorded observations on the 
 attributes of malaria are explicable by the theory of an 
 exhalation from the soil during its fermentation, there are 
 some exceptional points. When organic matter and mois- 
 ture are present, the evolution of malaria appears to be pro- 
 portioned to the degree of heat, yet it is well known that 
 places which are deadly after sunset may be traversed with 
 impunity when the sun is high in the heavens ; and, although 
 its evolution is known, by the experience of ages, to be 
 most active in warm climates and in warm seasons, yet in a 
 temperate climate the malarial influence does not become 
 intensified during the hot summer months ; but, on the con- 
 trary, after its first manifestations in the spring, it appears 
 to lose much of its activity, until its autumnal period of 
 greatest prevalence and virulence is suddenly reached. 
 
 69. If, however, it be assumed that the emanation from 
 the soil be intended, like the carbon dioxid of the atmos- 
 
42 MALARIOUS CAMP SITES. 
 
 phere, for the support of vegetable life, and that it mani- 
 fests itself as a poison to animal life only when it is gener- 
 ated and exhaled in excess of the wants of the vegetation 
 of the locality, the whole of the observed facts may be 
 understood. During the day the vital activities of a luxuri- 
 ant vegetation absorb emanations which, during the night, 
 when vegetation is asleep, escape into the atmosphere as a 
 harmful agency. When spring advances and warm rains 
 fall, the fermentation of the organic matter of the soil begins 
 immediately; but as yet there is no green foliage to absorb 
 the emanations, and, in localities where the conditions for 
 fermentation are particularly favorable, malarial fevers are 
 found to be present. As the summer advances and the 
 annual growth becomes vigorous and luxuriant, these spring 
 fevers decline in prevalence. The luxuriance of vegetation 
 on a particular soil indicates the presence of a malaria 
 which would manifest itself by its action on the human sys- 
 tem but for the existence of the vegetation. Later in the 
 season the leaves wilt and fade, the seeds fall, and the plants 
 droop and die; but meanwhile, under a continuance of the 
 autumnal heat, fermentation goes on in the soil, and the 
 evolved malaria, no longer absorbed or destroyed by the 
 living vegetation, accumulates to a pestilential atmosphere. 
 70. While the generation of malaria depends upon fer- 
 mentation, its evolution, so as to produce morbific effects on 
 the human system, is due to a want of relationship between 
 the growing plants and the malaria generated. When the 
 verdure covering the soil is able to assimilate or dispose of 
 the whole of the generated malaria, there is no evolution. 
 If the fermentation in the soil be inactive, a covering of 
 grass may suffice to suppress exhalation ; but if the condi- 
 tions are strongly conducive to fermentative action, there 
 will be a richer growth of green vegetation on the sur- 
 
CAMP SITES. 43 
 
 face, as in the tangled undergrowth of unhealthy tropical 
 regions. 
 
 71. When an exact relationship exists naturally between 
 the conditions of the soil and the vegetation covering it, 
 there is no harmful evolution ; but when that relationship 
 is disturbed, malaria appears. The upturning of the soil 
 for agricultural purposes destroying existing vegetation 
 for the sake of a future cultivated growth is well known 
 to give rise to malarial diseases ; and even when continued 
 cultivation has resulted in a due adjustment of the soil to 
 its growing crop, popular experience has attached a baneful 
 influence to exposure to the " night air" during the harvest- 
 ing period. A similar result follows other interferences 
 with the growing vegetation, as in engineering operations 
 and the clearing of forests ; even drainage for sanitary pur- 
 poses is often harmful at first, by establishing new condi- 
 tions as to moisture, which interfere with the luxuriance of 
 the natural growth before a vegetation has been developed 
 suited to the dryer soil. 
 
 72. From what has been said concerning malaria the 
 value of certain suggestions in relation to camp sites may 
 easily be understood : Avoid the neighborhood of marshes, 
 river-bottoms, overflowed lands, deep alluvium, lands sub- 
 ject to occasional salt-water inundation, and sands with 
 subjacent water, however barren their surface. If water 
 cannot be had except in such localities, it is better to carry 
 the water some distance than to camp in its vicinity. 
 Grassy surfaces are usually accepted as good camping- 
 grounds: the elimination is small during the night, lies 
 low, and is completely absorbed in the early morning ; were 
 the elimination greater than is sufficient for the grass, other 
 and more luxuriant plants would be growing on the soil. 
 Shrubs on a moist soil indicate dangerous ground, for their 
 
44 CAMP DISEASES. 
 
 more extensive verdure implies an increased evolution which 
 has to rise higher before reaching the absorbing surfaces ; 
 and, moreover, camp cannot be established without some 
 clearing of the ground and the consequent diffusion of ema- 
 nations which would otherwise have been absorbed. 
 
 73. There are other points which enter into the considera- 
 tion of camp sites. Advantage in cold climates should be 
 taken of hills and woods as a protection against wintry 
 winds ; and in hot climates, of woods for shade, if not so 
 dense as to interfere with ventilation; prevailing winds 
 should be observed, that the camp may be placed to wind- 
 ward of swamps or other insanitary localities. In the 
 mountain districts of warm latitudes the nightly breeze from 
 hill to plain must be remembered in its bearing on the 
 healthfulness of sites. Canons are hot during the day, 
 oppressive at night by radiation from heated rocks, and 
 liable to inundation from rain-clouds on the mountains ; the 
 reflected glare from sand and rock is often distressing and 
 injurious to the men. A dusty site is hurtful to the eyes, 
 combined, as it usually is, with a garish light; moreover, 
 dust, like mud, renders the best-disciplined troops careless 
 of their personal appearance and weakens the hygienic gov- 
 ernment'. Old camping-grounds should be avoided on ac- 
 count of their filthy condition and the possibility of their 
 infection [79]. 
 
 74. Experience has shown that troops may be aggregated 
 in camps on a healthy site without the occurrence of disease 
 among them. Camp diseases are therefore preventable 
 diseases. Among the diseases usually regarded as camp 
 diseases are: 
 
 75. (a) Those occasioned by exposure to climatic or me- 
 teorological influences, such as catarrhs, bronchitis, inflam- 
 mation of the tonsils, larynx, or lungs, rheumatism, con- 
 
CAMP DISEASES. 45 
 
 gestion of the spinal membranes, simulating to some extent 
 rheumatic troubles, congestion of the bowels leading to 
 diarrhea and dysentery, ophthalmia, sunstroke, etc. Inad- 
 equate clothing .and shelter induce a greater prevalence of 
 these morbid conditions among troops on active service in 
 the field than among men surrounded by the comparative 
 comforts of civil life; and the attacks are generally of 
 greater severity on account of the more intense action of 
 the cause and the sometimes exhausted condition of the 
 troops, but in other respects there is nothing special in 
 these diseases when they are found in a military camp. 
 
 76. (b) Errors of diet, attributable to faulty cooking, 
 individual indulgence, imperfect mastication, and improper 
 food are prolific sources of intestinal irritation which may 
 end in dysenteric ulceration. The last includes all articles 
 which have suffered damage by imperfect preservation, and 
 meat which, while on the hoof, has been overdriven, badly 
 fed, or affected with disease, or which has been kept too 
 long in the slaughter-house after killing, or in the haver- 
 sack after issue or cooking; and to these must be added 
 many of the articles that are sold by sutlers and traders. 
 Organic impurities in the drinking-water, and an excess 
 of those salts which give hardness to a water, are occasion- 
 ally responsible for diarrheal attacks. When the internal 
 congestions which result from the malarial infection in- 
 volve the intestinal mucous membrane, diarrheas are pro- 
 duced. Foul odors, as from unpoliced sinks or unburied 
 carcasses, also occasion diarrheal efforts to rid the system 
 of the noxious matters which have been absorbed from the 
 air. Moreover, any influence which interferes witr the 
 normal action of the skin, as rapid cooling after cessation 
 of exercise, may be a cause of diarrhea. 
 
 77. (c) Diet deficient in quantity predisposes the soldier 
 
46 CAMP DISEASES. 
 
 to disease by lowering the resisting powers of his system. 
 When defective in quality from a sameness involving a 
 deficiency of the salts that are contained in fresh vegeta- 
 bles and acid fruits, a taint of scurvy becomes manifest. 
 This shows itself first in loss of spirits and disinclination 
 for exertion, muscular pains simulating rheumatism, a 
 slight tumefaction of the gums where they embrace the 
 teeth, a slight fetor of the breath, and, perhaps, when spe- 
 cially looked for, some small spots of ecchymosis, like 
 flea-bites, 011 the skin of the calf or other parts of the lower 
 limbs. In all commands that have been confined to a salt 
 ration for some time, these symptoms should be carefully 
 looked for and promptly suppressed by an improved dietary. 
 When the possibility of scurvy is not held in view, such 
 cases are liable to be confounded with muscular rheumatism 
 or diarrhea, for the latter disease, occurring in a scorbutic 
 patient, is persistent and may for a time be held account- 
 able for the deteriorated condition. Later, when the gums 
 become swollen, spongy, and bleeding, the teeth loose, and 
 the skin covered with ecchymosed patches, hard swellings, 
 and foul ulcerations, there is no doubt of the character of 
 the cases ; but the disease should not be permitted to give 
 such manifestations of its existence in a military camp. 
 Camp hygiene requires the absolute banishment of alcoholic 
 liquors from the lines. The medical and court-martial rec- 
 ords of all camps where whiskey could be procured furnish 
 data sufficient for insistance on its exclusion as the cause of 
 much disease and many injuries and violent deaths. 
 
 78. (d) Malaria. Protection is obtained by care in the 
 selection of sites, the avoidance of all unnecessary fatigue, 
 and, in cases of special exposure, the use of prophylactic 
 doses of quinine, with hot coffee and generous diet. 
 
 79. (e) The infection of typhoid fever is spread chiefly 
 
CAMP DISEASES. 47 
 
 by the intestinal excreta of the patient; but many circum- 
 stances observed in connection with the development of this 
 fever indicate that the evolution of its germs is associated 
 with a fermentation in the soil when the soil has lost that 
 proportion of moisture which is needful to the generation 
 of malaria. Typhoid fever follows malarial fevers when 
 man begins to drain for agricultural and building purposes. 
 In some localities, which seem to be a border-land for the 
 two diseases, malarial fevers prevail in moist, and typhoid 
 in dry, seasons; and in America, as in Europe, the preva- 
 lence of typhoid has been found to coincide with a lowering 
 of the level of the subsoil water and a corresponding dry- 
 ness of the superficial strata. The facts and arguments in 
 favor of a soil origin of typhoid fever, were they even less 
 convincing than they are, would have to be accepted by the 
 military sanitary officer as offering the only sure basis on 
 which to attempt the preservation of his command from the 
 attacks of this disease; for soldiers, unless prevented by 
 active interference and supervision, will build quarters for 
 themselves which are, to all intents and purposes, hotbeds 
 for the production of fever [05], and the experience of 
 every army has shown that the disease is seldom absent 
 from such quarters when occupied by raw troops. 
 
 80. Every regiment of new troops in time of war under- 
 goes a typhoidal seasoning, not necessarily, but because of 
 the difficulty of excluding the cause of the disease. It is a 
 specific disease, affecting the individual but once, as in 
 that one attack it exhausts his susceptibility to its deleteri- 
 ous influence. Every new regiment, particularly if raised 
 in healthy country districts, contains young men who are 
 susceptible to the disease, and their number gives a corre- 
 sponding susceptibility to the regiment. Such a command 
 will suffer more from its localized epidemic of typhoid than 
 
48 CAMP DISEASES. 
 
 one raised in the slums of a city in which the disease is 
 constantly present, for the majority of the young men from 
 the unhealthy city have already undergone their experience 
 of typhoid fever. The removal to hospital of each case as 
 it occurs, the disinfection of excreta and soiled clothing 
 [558], and the protection of the water supply will guard 
 against the propagation of infection from that particular 
 case; but if the disease be due to infection from the soil, 
 these measures will be ineffectual. In fact, in view of the 
 difficulty of preserving a susceptible regiment from succumb- 
 ing temporarily to a typhoid epidemic, the medical sani- 
 tarian cannot afford to overlook the probable soil origin of 
 the disease ; and the measures he suggests for preserving the 
 purity of the soil, water, and air of the camp and quarters 
 of the men must be all the more thorough since the precise 
 conditions of typhoid evolution have not been determined. 
 Removal to a new site is always in order as a means of 
 lessening the spread of miasmatic-contagious diseases. 
 
 81. (/) Dysentery, occurring as an epidemic in camp, is 
 usually a miasmatic-contagious disease. It so frequently 
 follows the breaking up of fresh ground that its miasmatic 
 origin is unquestioned ; and foul and infected sinks are sup- 
 posed to spread the disease. Although it is difficult to 
 prove the latter mode of propagation because its effects can- 
 not be separated from those of the primary miasm, disinfec- 
 tion of the sinks and of all dysenteric discharges [536] is 
 called for as a precautionary measure irrespective of theo- 
 retical views. 
 
 82. (g) Cholera and yellow fever cannot be considered 
 camp diseases, as they are as prone to attack the civilian as 
 the soldier. In fact, the camp, being mobile and under bet- 
 ter discipline, may sometimes be preserved while neighbor- 
 ing cities are prostrated by disease [559]. 
 
CAMP DISEASES. 49 
 
 83. (A) The systematic vaccination of recruits at the 
 camps of instruction and organization removes small-pox 
 from the list of camp diseases. When an occasional case 
 occurs the civilian employees of the Quartermaster's Depart- 
 ment, and other attache's and followers of the army, are 
 more likely to become affected than the fighting force [546 ] . 
 
 84. (t) With measles [556], however, the case is different; 
 there is no protection except that given by a previous attack, 
 and when a regiment consists of susceptible material that 
 is, of young men who have not had the disease its efficiency 
 may be utterly destroyed for two months or more by the 
 introduction of the infection. Individually the cases as a 
 rule are by no means dangerous to life, but the conditions 
 of service in the field are such that a satisfactory conva- 
 lescence is impossible, and many men have subsequently to 
 be discharged on account of persisting pulmonary com- 
 plaints. Under such circumstances the regiment should be 
 relieved from duty and provided with comfortable quarters 
 and ample hospital accommodation until it has recovered 
 from its attack. In this way only can it be saved from the 
 deadly inroads of pulmonary disease, which are sure to fol- 
 low the eruptive fever when its convalescents are subjected 
 to the hardships and exposures incident to service in the 
 field. 
 
 85. (k) Typhus fever was once the scourge of military 
 camps and of all other places in which men were closely 
 crowded together. Some of the names applied to it, camp, 
 ship, prison, and hospital fever, indicate its association with 
 overcrowding. But of late years the sanitary knowledge 
 which has insisted on a certain air-space for each individual 
 and a certain ration of air to revivify the blood in his lungs 
 [230] has done much to stamp out its contagion. The expe- 
 rience of recent wars has demonstrated that typhus fever 
 
 4 
 
50 CAMP DISEASES. 
 
 can be generated at will, and that, if this fever is generated 
 in a military camp, it is due to gross negligence or ig- 
 norance on the part of those in authority, for the disease 
 does not spring unexpectedly into existence full armed for 
 destruction, but gives successive warnings of its coming, 
 each more emphatic than that which came before. When a 
 number of men are confined in a limited and poorly venti- 
 lated shelter, the organic emanations permeate and adhere 
 to everything, and continually taint the air. Overcrowding 
 of this kind is incompatible with cleanliness even where 
 facilities for cleanliness exist, but in such cases these are 
 generally absent; and in consequence the fermentation of 
 extraneous filth usually combines with the natural exhala- 
 tions to alter the quality of the air and the constitutions of 
 those who have to breathe it. The inmates lose vigor and 
 appetite; they are subject to digestive disorders and head- 
 aches, and their sleep is unrefreshing. They become less 
 able to withstand the ordinary exposures of service, and 
 the febrile action which is associated with their bronchitis 
 or other local disease is of an obscure yet prostrating char- 
 acter, as if the system did not have vitality enough to react 
 and throw off the disease in a free perspiration, or a tran- 
 sudation from the affected mucous membrane. Presently, 
 pneumonia appears to be the only disease that is developed 
 by exposure, and this pneumonia is of that low or asthenic 
 character which is called typhoid. If malarial fevers are 
 present they are never well-defined and vigorous intermit - 
 tents, but obscure remittents that are doubtfully treated 
 with quinine they have so much the appearance of true 
 typhoid. If the command is suffering from an epidemic of 
 typhoid fever the mortality rate is exceedingly high, as the 
 patients sink into a state of prostration from which it is 
 impossible to rally them. Moreover, at such times cases of 
 
CAMP DISEASES. 51 
 
 sudden death in the persons of those who have not hereto- 
 fore been ailing occasionally cause alarm in the camp. 
 These are apparently due to some cause which deranges the 
 blood, producing internal congestions, and perhaps cutane- 
 ous ecchymotic spots. They are called congestive fevers if 
 the camp is malarious ; malignant measles if that disease is 
 prevailing; and virulent typhoid if the regiment is under- 
 going its typhoid seasoning; while the presence of epidemic 
 cerebrospinal 'meningitis or spotted fever is feared by some, 
 and typhus fever by others. At such times also there is an 
 alarming suggestion of contagion in the hospitals and quar- 
 ters, even in diseases which, like pneumonia, are not ordi- 
 narily regarded as having any contagious qualities. Many 
 regiments during our late war suffered from disabling and 
 needless experiences of this kind from an utter want of 
 knowledge of the principles of camp sanitation on the part 
 of those who should have possessed that knowledge. For- 
 tunately this generation of the contagious typhus miasm 
 was checked at an early period. The condition of the com- 
 mand attracted the attention of superior authority, and 
 some officer of experience, sent as an inspector, appreciated 
 the typhus-generating conditions to which the men were 
 subjected, and speedily effected their removal. Some of 
 these regiments were hutted in small squads of three to five 
 men under shelter- [88] or wedge-tent [89] roofs, others 
 were aggregated in larger squads in the Sibley tent [90], 
 and others again quartered by companies in extemporized 
 barracks or in rude buildings specially erected for their use ; 
 but in all such instances there was an utter disregard of the 
 necessity for ventilation and cleanliness in addition to the 
 overcrowding of the men. The tent-covered huts were usu- 
 ally dugouts [95] ; the extemporized quarters wholly unfit 
 for crowded occupation, and the barrack- buildings hastily 
 
52 SANITARY CARE OF CAMPS, ETC. 
 
 constructed shells, enclosing three-tiered rows of beds, with 
 no special provision for the introduction of fresh air, and 
 all the cjrevices of their imperfect construction carefully 
 stoppft up by the men. 
 
 86. It will be seen from this brief review of the diseases 
 which prevail among soldiers in active service that they are 
 not peculiar to military camps. Greater exposures give 
 greater prominence to the diseases that result from exposure. 
 Dietetic errors arising from many causes and combining 
 with other influences which occasion intestinal congestions 
 give a notable prevalence, persistence, and gravity to diar- 
 rheal diseases. Contamination of the soil and surroundings 
 of camp, including its water supply, promotes the genera- 
 tion and propagation of the typhoid germ among young men 
 who are susceptible to its influence ; and the close contact 
 of adjoining squads and companies affords the best facilities 
 for the transmission of contagious diseases. But none of 
 this increased prevalence and gravity is directly and unpre- 
 ventably dependent on the aggregation of so many men in 
 camps. The typhus miasm or contagion, which intensifies 
 the danger of every other affection, and is in itself, when 
 fully endowed with its virulence, a more deadly enemy than 
 all the others to which the camp is subject, is not inherent 
 in the system of military camping, but is a development 
 from local overcrowding in individual tents, huts, barracks, 
 or hospitals. 
 
 87. The infantry line of battle camp affords about 4.5 
 square yards of ground as the site of the quarters of each 
 soldier; and when each man bivouacks, wrapped in his 
 blanket, on this area, there is ample space for free ventila- 
 tion j but if the men be grouped in squads under the shelter 
 of tents or huts, a most unhealthy condition may exist 
 within. A large tent is a dangerous shelter; for assuredly 
 
SANITARY CARE OF CAMPS, ETC 53 
 
 as many men will be packed into it as it can hold. If fif- 
 teen or twenty men lie shoulder to shoulder during the night 
 rebreathing a deoxygenated air laden with unwholesome 
 exhalations from the lungs and skin, disease will in time 
 make its appearance in the squad, no matter how thoroughly 
 the streets and intervals of the camp may be ventilated, for 
 the evil is within and not without the shelter canvas. The 
 larger the squad and the smaller the superficies allowed it 
 under shelter, the greater will be the danger of the speedy 
 
 The shelter-tent. 
 
 generation of typhus or crowd-poisoning among the men. 
 The shelter-tent carried by troops in a campaign has this 
 great advantage over more ostentatious quarters, that it 
 breaks up the company into small squads and scatters the 
 men over the company area. 
 
 88. The shelter-tent is made of cotton duck, weighing 
 eight ounces to the linear yard. Two pieces, each about 5 
 feet 6 inches square, are required to construct a tent. Each 
 piece has buttons and button-holes which permit of its being 
 fastened to any other piece. The lower edge is furnished 
 with a loop at each corner and one at the foot of the central 
 seam by which the piece may be pegged to the ground. 
 Pegs and uprights are issued as part of the tent, but sol- 
 diers generally rely on the camp-ground to provide them 
 
54 SANITARY CARE OP CAMPS, ETC. 
 
 with extemporized substitutes. Each piece weighs 2 pounds 
 6 ounces ; and as usually carried it is rolled with the blanket 
 into a long cylinder, which is slung from the shoulder to 
 the opposite hip, where the ends are tied together with the 
 guy-rope. Two pieces, when pitched on uprights 45 or 50 
 inches in height, give a spread at the base of 6 to 7-J feet 
 and a covered area of 17 to 20 square feet for each of the 
 two men. 
 
 The wedge-teut. 
 
 89. The comm,on, wedge-, or ^4-tent, sometimes issued, has 
 a spread of 8 feet 4 inches at the base, and a height and 
 length of 6 feet 10 inches. The entrance is a perpendicular 
 cut to the bottom in the centre of its front, which admits of 
 each half being thrown back to expose its interior. It has 
 a sod-cloth along its lower edge to prevent the entrance of 
 air below. It has no provision for ventilation, and when 
 rendered impervious in wet weather by the swelling of its 
 fibres, the only entrance or exit for air is between the closed 
 lapels of the doorway. This tent affords better protection 
 than the shelter-tent, and in mild weather makes excellent 
 quarters for two or three men. 
 
SANITARY CARE OF CAMPS, ETC. 55 
 
 90. The Sibley tent, occasionally used in our service, is a 
 conical tent 18 feet in diameter and 13 feet high ; the con- 
 ical-trail tent gives more room for its area; but the large 
 number of men, fifteen or twenty, crowded into these tents 
 renders them an undesirable shelter. 
 
 91. The shelter-tent, however, .is usually all that our 
 troops have to rely upon for protection from the inclemen- 
 cies of the weather during field service. If the occupation 
 of the camp is to last for more than one night, and espe- 
 cially if the site or weather be damp, the men should build 
 bedsteads of poles and forked uprights on which to spread 
 the hay, straw, grass, or whatever they may be able to pro- 
 cure as a mattress. Any further stay on the same ground 
 should be marked by improvement in the condition of the 
 shelters and the company and regimental areas, the char- 
 acter of which will depend on the available material and 
 the influences from which protection is sought. Reliance 
 can generally be placed on the ingenuity of a body of men 
 to make the most of the materials at command ; but their 
 efforts must as generally be checked by intelligent super- 
 vision. In seeking shelter from that which assails the senses 
 they are likely to expose themselves to more subtile and dan- 
 gerous influences which are unfelt and unknown to them. 
 In summer camps or those of warm climates there is little 
 danger of harmful results ; the men seek the air and only 
 such protection from the heat and glare of the sun and 
 occasional wind and rain storms as will not interfere with 
 the cooling influence of free ventilation. Such camps usu- 
 ally consist of the shelter-canvas roofing over walls of 
 leafy willow-work, with a canopy of brushwood erected 
 high above the tents to afford a better shade. But in 
 winter camps, or those of cold climates, the attempt to 
 preserve a certain degree of warmth in the interior of 
 
56 SANITARY CARE OF CAMPS, ETC. 
 
 the shelters is virtually an effort at the suppression of 
 ventilation. 
 
 92. The general opinion of army medical officers is in 
 favor of huts for occupation during cold weather ; and many 
 of those who have written on the subject have put them- 
 selves on record as insisting on 40 square and 400 cubic 
 feet per man, with double walls, raised floors, ridge-ventila- 
 tion, and warmed air supply, all of which requirements 
 imply the presence on the camping-ground of specially pro- 
 vided material and labor; but huts built by the troops, and 
 huts built for them, are two different things. In the settle- 
 ment of a large army in its winter quarters the amount of 
 transportation required for an attempt to house it as might 
 be desired is not always available ; hence the men must rely 
 upon their shelter-tents and such materials as are afforded 
 by the country in the vicinity of their camping-ground. 
 
 93. In the establishment of winter camps four men usu- 
 
 Army of Potomac log hut. 
 
 ally join their shelter-pieces to form a roof over low walls, 
 generally in our well-timbered country constructed of logs. 
 The length of this roof is 10 feet 8 inches, and its spread 7 
 feet; but as the canvas has to be brought down over the 
 outer face of the logs, the interior of the hut is lessened in 
 
SANITARY CARE OF CAMPS, ETC. 57 
 
 proportion to the thickness of its walls. Putting these at 
 six inches gives the hut an area in the clear of 9 feet 8 
 inches by 6 feet, or sufficient for two double bunks with 
 the narrowest of passage-ways between them. But what 
 with absentees, sick, and on furlough, and the regular details 
 for guard and picket duty, it seldom happens that more 
 than three men pass the night in the four-pieced hut. A 
 broad bedstead for three men is accordingly built at one 
 end, having a space at the other of about 3 by 6 feet as a 
 living room, on the floor of which the occasional fourth 
 man spreads his poncho and blankets at night. The door- 
 way opens into this space from the street; a cupboard or 
 shelves are placed in the angle near it, and an open fire- 
 place in the opposite wall. The preservation of the chim- 
 ney is a source of much labor and constant anxiety to the 
 occupants of the hut, as, although sometimes built of stone 
 or brick, it is more frequently a narrow wooden shaft, with 
 layers of clay to prevent its timbers from catching fire ; yet 
 it is deserving of all the attention bestowed on it, as when 
 in good working order it gives a cheerful warmth to the 
 interior while in steady operation as an efficient means of 
 ventilation. 
 
 94. The experience of our Civil War has shown that under 
 certain conditions these small and rudely constructed huts 
 may give wholesome shelter to their occupants during the 
 inclement season with far less risk of the development of 
 diseases due to local overcrowding, or the spread of those 
 propagated by specific causes, than the large army tents 
 and squad barracks of the European services. These con- 
 ditions are : 1st. The site of each hut should be free from 
 moisture. The sides of the company streets and intervals 
 should be deeply trenched, and transverse cuts made between 
 these, uniting them and mapping out the sites of the indi- 
 
58 SANITARY CARE OF CAMPS, ETC. 
 
 vidual cabins. Surface drainage from higher grounds should 
 be intercepted and turned aside. If rain fall during the 
 period of preparation and building, the canvas should be 
 pitched to protect the sites; otherwise they are better ex- 
 posed. 2d. The floor should be cleared of all herbage, the 
 soil well stamped with sand and gravel, and subsequently 
 concreted ; but if the site be retentive of moisture the floor 
 should be raised about a foot from the surface by being 
 made of split or dressed logs closely set, or of lumber which 
 may be raised from time to time to air the underlying sur-. 
 face. 3d. The shelter-canvas should be so fastened that it 
 may be unhitched with readiness when it is desirable to sun 
 the interior. 4th. The chimney should draw well, as being 
 the only means of securing ventilation. 5th. The interior 
 should be inspected daily to insure perfect cleanliness. 6th. 
 The camp-ground, as a whole, should be in good condition, 
 for a satisfactory cleanliness of the person and quarters can- 
 not be expected if the surroundings counteract all efforts to 
 this end. 
 
 95. When these requirements are not observed the log 
 shanty speedily degenerates into a den of filth and disease, 
 unfit for human habitation. The soldier in cold weather is 
 prone to burrow, and special attention must be directed to 
 guard against this tendency. In fact, a protest must be 
 entered against everything which is conducive to dampness 
 of the interior. The earth must not be banked up on the 
 outside of the logs ; the floor must not be dug out to bring 
 its level below that of the surrounding ground, nor must a 
 side-hill be dug into to form a part of the end or side walls 
 of the proposed hut. When a hut is converted into a half- 
 sunk cellar by a combination of excavation inside and bank- 
 ing up outside, it is impossible in damp weather to preserve 
 a healthsome, dry interior ; and irrespective of diseases due 
 
SANITARY CARE OF CAMPS, ETC. 69 
 
 solely to humidity, as catarrhs, sore throats, rheumatism, 
 etc., there is imminent danger of the development of noxious 
 miasms. The heat of the hut, when well warmed by its 
 open fireplace, will recommence changes in the organic 
 matter of the humid soil which the external winter temper- 
 ature had checked, and a localized and artificial generation 
 and evolution of malaria may be set up, prostrating the occu- 
 pants with intermittents, remittents [78], and dysentery 
 [81] ; or, if the soil be less damp, the miasm evolved may 
 be that of typhoid fever [79]. The external cold prevents 
 emanations from the camp site as a whole, but each hut 
 becomes a hotbed for the generation of miasms which oper- 
 ate with intensity for the energies of the occupants are 
 devoted rather to excluding the cold than to ventilating 
 their quarters, and dissipating or diluting their dangerous 
 atmosphere. Moreover, as the occupants begin to feel the 
 effects of their unwholesome dwellings they drop into an 
 apathetic condition in which all soldierly qualities are lost. 
 Their personal appearance and surroundings cease to inter- 
 est them, and they care only to pass the time in their bunks 
 when they are not on the detail for duty. The ignorance 
 or carelessness of company and regimental officers which 
 permitted the construction of the dangerous dugouts mani- 
 fests itself as well during their subsequent occupation : In- 
 spections are perfunctory, filth accumulates, and ultimately 
 the typhus miasm gives added virulence to the pre-existing 
 causes of disease, and raises an alarm which may fortunately 
 put an end to the insanitary conditions that are ruining the 
 command [85]. 
 
 96. The shelter-tent is invaluable in summer, when the 
 men live in the open air and make use of the tent only as a 
 protection to their bedstead; but it covers too small an 
 area for comfort when, in winter, many hours of the day 
 
60 
 
 SANITARY CA11E OP CAMPS, ETC. 
 
 have to be spent under it as in a living-room. The best log 
 hut which the troops can construct is limited in its area by 
 the means of roofing it; and a small increase of area under 
 such circumstances makes all the difference between com- 
 pression and comparative comfort. Generally the wear and 
 tear of a summer's campaign renders the shelter-tents unfit 
 for service as a winter protection, and issues of new shelter- 
 canvas have to be made. This being the case, it would con- 
 tribute much to the health and comfort of the troops if the 
 
 Winter hut for four men the canvas roof protected by a fly which is 
 fastened to a rail near the eaves. 
 
 Quartermaster's Department were to supply to every squad 
 of four men a special roofing-canvas consisting of two 
 pieces one, 14 by 12 feet, as a roof, and the other, somewhat 
 larger, as a fly to protect it. These would admit of the con- 
 struction of a log hut having an interior measurement of 13 
 by 7 feet, and giving room by its length for a double bedstead 
 at each end, and an intervening moving space between the 
 doorway in the front wall and the fireplace opposite. With 
 the wall six feet high, which should be its minimum, the 
 
SANITARY CAKE OF CAMPS, ETC. Gl 
 
 hut would have a capacity of 700 cubic feet, the air of which 
 would be freely renewed by the chimney-draught and the 
 ventilating aperture in the roofing-canvas under the protec- 
 tion of the fly. Theoretical hygiene may object to the area 
 and air space of the proposed hut, but the measurements 
 are suggested advisedly, and are based pn a knowledge of 
 the military tendency to close up and occupy unoccupied 
 space. When a hut affords possible bed and elbow room 
 for one more man, that man will immediately become an 
 inmate, and the hut will no longer be a hut for four, but for 
 five, men. 
 
 97. Any tendency to crowding the huts on each other 
 should be strenuously opposed; the minimum interval be- 
 tween adjacent gables should be equal to the height of the 
 walls, six feet, while the passage between the rear walls 
 of adjacent rows should equal the height of the ridge, 
 about ten feet. If the company front be too small to afford 
 this space without undue narrowing of the street, the camp 
 should be formed in column of divisions. 
 
 98. Besides the trenching, which is intended to give a 
 dry site to individual huts, every effort should be made to 
 improve the general surface of the camp. Surface depres- 
 sions which form pools in rainy weather should be drained 
 and filled up. The company streets should afford a firm 
 and dry footing when the men turn out at roll-calls. Path- 
 ways or sidewalks along the streets to the kitchens, officers' 
 quarters, sinks, etc., should, by trenching, grading, grav- 
 elling, planking, or other means, permit of a dryshod per- 
 formance of the routine business of camp life even in 
 unfavorable weather. The perfection of this work will de- 
 pend on the permanence of the camp ; but the main features 
 of the system of drainage should be worked out at once, 
 leaving improvements to follow as the stay is prolonged. 
 
62 SANITARY CARE OF CAMPS, ETC. 
 
 99. Company officers are responsible for the police of the 
 huts, kitchens, and company areas belonging to their com- 
 mands, and for the personal cleanliness of their men. They 
 should see that the interiors are kept scrupulously clean, 
 and that the canvas roof is removed from time to time for 
 thorough ventilation; blankets should be aired on every 
 available occasion. 
 
 100. Personal cleanliness in winter quarters depends con- 
 siderably on the facilities provided for that purpose. Huts 
 should be built as lavatories, with safe drainage to carry off 
 the waste water either by surface trenching or through a 
 covered sink. A hot-water supply can be obtained by 
 means of a boiler and barrels of water connected by circu- 
 lating pipes. 
 
 101. The regimental commander is responsible for the 
 condition of the camp as a whole; and to enable him to 
 sustain this responsibility captains of companies are detailed 
 in rotation as superintendents of police, under the military 
 title of officer of the day. This officer has command of all 
 the guards and prisoners, and is responsible to his superior 
 officer for the order and cleanliness of the camp. He makes 
 use of the prisoners in policing the grounds ; and if they 
 are insufficient for the work, fatigue details are granted 
 him. As every day brings a fresh officer to superintend, 
 the system is satisfactory with efficient officers. 
 
 102. With inexperienced troops and careless or incapable 
 hygienic government a good natural site can speedily be 
 rendered unhealthy by contamination of the soil with or- 
 ganic impurities. Change of site may thus become needful 
 in a very short time, particularly in warm or moist climates 
 or seasons, for if police parties fail to remove the dangerous 
 material from the camp, the-camp must be removed from 
 the dangerous material. Even in the best-governed camps 
 
SANITARY CARE OF CAMPS, ETC. 63 
 
 the occupation of winter quarters should not be prolonged 
 after the advent of warm weather, for when the constant 
 traffic on the company area and the steady accumulation of 
 refuse engendered by it are remembered, soil contamination 
 is seen to be merely a question of time. 
 
 103. The regimental area should not only be regularly 
 and carefully policed, but the necessity for this work should 
 be reduced to a minimum by systematic arrangements for 
 the disposal of all the waste or refuse matters of the camp. 
 Moreover, the intervals between regiments should be pre- 
 served in as wholesome a condition as any other part of the 
 grounds; the labors of regimental police parties should 
 overlap, rather than fail to meet. Besides cleaning up the 
 regimental area, general police details attend to the condi- 
 tion of the sinks, remove kitchen refuse and stable manure, 
 repair defective trenching for surface drainage, and keep the 
 pathways passable during snowfalls and rainy weather. 
 All gleanings from the surface should be collected in heaps 
 and carted to a selected dumping-ground at some distance 
 from the camp and its water supply. Covered barrels for 
 the reception of kitchen refuse should stand on a wooden 
 platform for the better protection of the surface from con- 
 tamination by decaying organic matters ; and their contents 
 should be carted away daily. Slaughter-house offal and the 
 carcasses of dead horses, mules, etc., should be buried at 
 the dumping-ground. 
 
 104. The sinks in an aggregation of regimental camps are 
 of necessity in front of the men's and in rear of the officers' 
 quarters ; but in detached camps, where there is choice of 
 ground, they should be placed in such a position that the 
 prevailing winds will not carry odors over the company 
 areas. They are usually long trenches about eight feet 
 deep and two feet wide, with the excavated earth piled on 
 
64 SANITARY CARE OF CAMPS, ETC. 
 
 one side, whence a part of it can readily be thrown by the 
 police party over the daily accumulations. On the other 
 side a short pole is laid horizontally on forked uprights at 
 a proper height for the convenience of the men. The whole 
 is surrounded by a thick-set hedge of brushwood, through 
 which admission is given by an oblique or valvular entrance. 
 Small sinks for each company are better than three or four 
 of large size for the regiment. When the stay in camp is 
 prolonged beyond a day or two, the horizontal pole should 
 be superseded by box-seats open behind so that earth can 
 be thrown in. While in winter quarters the mouth of the 
 trench should be completely boxed with covered seats, one 
 side being hinged to admit of layering the daily deposits 
 with earth. When filled within two feet of the surface, 
 each sink should be replaced by a new one, those disused 
 being filled up and banked over to mark their site. 
 
 105. No satisfactory provision can be made to prevent 
 soil contamination from urinary excretion. During the day 
 the sinks are the receptacles for a large percentage of such 
 discharges ; but in bad weather their distance leads the men 
 to find some concealed place near their quarters, often in 
 the intervals between the huts, and at night all parts of 
 the area are liable to contamination. Unless officers are 
 vigilant, certain angles about the huts will soon begin to 
 evolve ammoniacal odors. The plan of providing night- 
 tubs is objectionable, as they cannot be of use to all with- 
 out being too near to some. The medical officer should indi- 
 cate such places, if any, as may be used in addition to the 
 sinks, and the men be held to a strict observance of camp 
 sanitary orders. 
 
 106. The water supply should be jealously guarded by 
 the regimental medical officers. If from a stream, care 
 should be taken that the drainage of one camp does not 
 
SANITARY CAKE OF CAMPS, ETC. 65 
 
 contaminate the supply of another. Special points below 
 that from which the water supply is derived should be indi- 
 cated for the washing of clothes, watering of horses, etc. 
 When wells are used, their depth and distance from the 
 sinks should be carefully considered, as also the character 
 and incline of the strata through which they penetrate. 
 There is no time for chemical or bacteriological analysis to 
 determine the quality of water supplies in the field. The 
 water is a dangerous water when the taste or odor testifies 
 to the presence of vegetable organic matter, or when it is 
 known that sewage, even in small quantity, enters it. It 
 is useless to treat a water with alum, permanganate of pot- 
 ash, or other purifying chemicals, because if it is of such a 
 character as to require this treatment it should be boiled. 
 Boil ing a water for ten or fifteen minutes destroys all infec- 
 tions, malarial, typhoid, dysenteric, and choleric. Soldiers 
 should be taught to fill their canteens over-night with well- 
 boiled weak coffee as the water supply for the next day's 
 march. Filters are made which strain out the germs of dis- 
 ease from an infected water. Portable filters have been 
 used by small commands, and are useful on certain marches 
 and expeditions ; but it is doubtful if they could be relied 
 on in time of war to supply pure water to the troops of a 
 large army. An effort, however, should be made to accom- 
 plish it. 
 
 107. The Regulations provide for a satisfactory condition 
 of all camps by means of official inspections j but the army 
 looks to the medical officer for its preservation from pre- 
 ventable diseases. He is the sanitary officer of the com- 
 mand, and must render a monthly sanitary report as called 
 for in the service of the post hospital [16]. The medical 
 officer is not confined to this regular sanitary report as a 
 means of bringing his recommendations to the notice of his 
 5 
 
66 SANITAKY CARE OF CAMPS, ETC. 
 
 immediate commander and superior authority. When any 
 fault or error in the sanitary arrangements is detected, it 
 should be immediately reported for the action of the regi- 
 mental commander. 
 
 108. When troops are embarked on transports the utmost 
 care is enjoined by the Regulations for the preservation of 
 the health of the men, for when thus crowded together in 
 narrow limits, with imperfect means of ventilation, the 
 absence of healthful exercise, and probably a defective diet, 
 a tendency to typhus and scurvy is readily developed. 
 Officers are required to enforce cleanliness as indispensable 
 to health. When the weather permits, bedding is brought 
 on deck every morning for airing. The men, in hot weather, 
 are not allowed to sleep on deck or in the sun ; and they 
 are encouraged and required to take exercise on deck, in 
 squads, by succession, when necessary. All the troops turn 
 out at a prescribed hour in the morning without arms or 
 uniform, and in hot weather without shoes or stockings, 
 when every individual is inspected as to his personal clean- 
 liness; the same personal inspection is repeated thirty 
 minutes before sunset. On these occasions the medical 
 officers are required to examine the men to observe whether 
 there be any appearance of disease. 
 
 109. This chapter is fitly concluded by the instructions 
 of Surgeon General Sternberg, issued in view of a probable 
 invasion of Cuba by our regular and volunteer troops : 
 
 " In time of war a great responsibility rests upon medical 
 officers of the army, for the result of a campaign may 
 depend upon the sanitary measures adopted or neglected by 
 the commanding generals of armies in the field. The med- 
 ical officer is responsible for proper recommendations relat- 
 ing to the protection of the health of troops in camp or in 
 garrison, and it is believed that as a rule medical officers of 
 
SANITARY CARE OF CAMPS, ETC. 97 
 
 the United States army are well informed as to the neces- 
 sary measures of prophylaxis, and the serious results which 
 infallibly follow a neglect of these measures, especially 
 when unacclimated troops are called on for service in a 
 tropical or semi-tropical country during the sickly season. 
 In Cuba our army will have to contend not only with mala- 
 rial fevers and the usual camp diseases typhoid fever, 
 diarrhea, and dysentery but they will be more or less 
 exposed in localities where yellow fever is endemic, and 
 under conditions extremely favorable for the development 
 of an epidemic among unacclimated troops. In view of 
 this danger, the attention of medical officers and of all others 
 responsible for the health of our troops in the field is invited 
 to the following recommendations : 
 
 " When practicable, camps should be established on high 
 and well-drained ground not previously occupied. 
 
 " Camps should be changed to fresh ground every ten days, 
 or oftener. 
 
 " Sinks should be dug before a camp is occupied, or as 
 soon after as practicable. The surface of fecal matter 
 should be covered with fresh earth or quicklime or ashes 
 three times a day. 
 
 " New sinks should be dug and old ones filled when con- 
 tents of old ones are two feet from surface of ground. 
 
 " Every man should be punished who fails to make use 
 of the sinks. 
 
 " All kitchen refuse should be promptly buried, and per- 
 fect sanitary police maintained. 
 
 " Troops should drink only boiled or filtered water and 
 coffee or tea (hot or cold), except where spring water can 
 be obtained which is pronounced to be wholesome by a med- 
 ical officer. 
 
 " Every case of fever should receive prompt attention. 
 
68 SANITARY CARE OF CAMPS, ETC. 
 
 If albumen is found in the urine of a patient with fever, it 
 should be considered suspicious (of yellow fever), and he 
 should be placed in an isolated tent. The discharges of 
 patients with fever should always be disinfected at once 
 with a solution of carbolic acid (5 per cent.), or of chlorid 
 of lime (6 oz. to gallon of water), or with milk of lime made 
 from quicklime. 
 
 " Whenever a case of yellow fever occurs in camp the 
 troops should be promptly moved to a fresh camping-ground 
 located a mile or more from the infected camp. 
 
 "No doubt typhoid fever, camp diarrhea, and probably 
 yellow fever are frequently communicated to soldiers in 
 camp through the agency of flies, which swarm about fecal 
 matter and filth of all kinds deposited upon the ground, or 
 in shallow pits, and directly convey infectious material, 
 attached to their feet or contained in their excreta, to the 
 food which is exposed while being prepared at the company 
 kitchens or while being served in the mess tent. It is for 
 this reason that a strict sanitary police is so important. 
 Also because the water supply may be contaminated in the 
 same -way, or by the surface drainage. 
 
 " If it can be avoided, marches should not be made in the 
 hottest part of the day from 10 A.M. to 5 P.M. 
 
 " When called upon for duty at night or early in the 
 morning a cup of hot coffee should be taken. 
 
 " It is unsafe to eat heartily or drink freely when greatly 
 fatigued or overheated. Ripe fruit may be eaten in moder- 
 ation, but green or over-ripe fruit Avill give rise to bowel 
 complaint. Food should be thoroughly cooked and free 
 from fermentation or putrefactive changes. 
 
 "In decidedly malarious localities from three to five 
 grains of quinine may be taken in the early morning as a 
 prophylactic j but the taking of quinine as a routine prac- 
 
SANITARY CARE OP CAMPS, ETC. 69 
 
 tice should only be recommended under exceptional circum- 
 stances. 
 
 " Light woollen underclothing should be worn ; and when 
 a soldier's clothing or bedding becomes damp from exposure 
 to rain or heavy dew, the first opportunity should be taken 
 to dry it in the sun or by fires." 
 
CHAPTER IV. 
 
 GENERAL HOSPITAL SERVICE. 
 
 110. General hospitals are those established at points 
 distant from the field of actual warfare. The first of these 
 to which the wounded man is transferred is usually that at 
 the base of supplies ; but his stay here is seldom of long 
 duration, as this hospital is in reality merely a resting and 
 shipping point on the route to places of greater security. 
 It is organized on the general hospital system, and may 
 indeed be viewed as the general hospital of the army to 
 which it is attached ; but as its existence in a locality is 
 dependent on military movements, its accommodations and 
 appointments have usually more of the character of a field 
 than of a general hospital. Associated with it are hospital 
 boats or trains of hospital cars, all of which are manned by 
 assignments from the Surgeon General' s office. 
 
 111. A general hospital is practically an expansion of the 
 post hospital. The latter consists of an administration 
 building and one or two attached wards which may be 
 lengthened or shortened, within limits, to suit their capacity 
 to the requirements of the time and place. The former 
 consists of a series of long pavilion wards, each capable of 
 accommodating forty to sixty patients, with an administra- 
 tion building, kitchens, laundry, stables, repair-shops, etc., 
 and quarters for the officers, employees, and guard, on a 
 scale proportioned to the size of the hospital. At the 
 beginning of our Civil War, hotels, churches, court-houses, 
 factories, and other large buildings were used as general 
 
GENERAL HOSPITAL SERVICE. 71 
 
 hospitals ; but the advantages of the pavilion system were 
 soon recognized, and extemporized hospitals became replaced 
 by special constructions. In these the wards were variously* 
 arranged to secure a full allowance of ventilation and sun- 
 light for each, and at the same time keep them within con- 
 venient distance of the offices and other buildings. In some 
 hospitals they were arranged in a line, with their gables 
 facing the front and rear, the administration building in 
 the centre of the line, and the other buildings disposed in the 
 rear. In others they were placed en echelon in the form of 
 a V, with the administration building at the apex, the 
 kitchens and dining-rooms in the interior, and the other 
 buildings closing in the base. In others, again, the pavil- 
 ions enclosed a circular or oblong space, the administration 
 building occupying a central position among the wards, and 
 the other buildings within the enclosure. Adjacent wards 
 were separated from each other by a clear space of about 
 thirty feet. The wards, kitchens, dining-rooms, and offices 
 were connected by means of a covered corridor or walk. 
 The plan of the Hicks Hospital, Baltimore, Md., submitted 
 on page 72, illustrates one method of arrangement. 
 
 112. Each ward of a general hospital was a ridge-venti- 
 lated pavilion from 145 to 187 feet long, 24 wide, and 14 
 to the eaves. The smaller length, for forty patients, was 
 generally preferred to the larger one, for sixty. At each 
 end of the ward there were partitioned off two small rooms 
 9 by 11 feet, with a six-foot passage-way. Those at the at- 
 tached end were used as a wardmaster's room and pantry; 
 those at the free end as a bathroom and water-closet. In 
 some instances the latter were cut off from the ward by a pas- 
 sage-way giving cross ventilation, and in others they were at- 
 tached to the lateral aspect of the pavilion at one of the 
 angles of its free end. The floors were raised at least 18 
 
GENERAL HOSPITAL SERVICE. 
 
 nn 
 
 aoQ 
 
 GROUND PLAN OP HICKS HOSPITAL, BALTIMORE, MD. 1, 1, 1, 1, wards; 2, ad- 
 ministration building ; 3, linen-room; 4, dispensary and operating-room; 5, 
 dining-hall; 6, kitchen and laundry; 7, ward for detailed men; 8, knapsack- 
 room; 9, subsistence storehouse; 10, quartermaster's storehouse; 11, tank; 
 12, quarters for the guard; 13, stable; 14, wagon -house; 15, sutler's store ; 16, 
 steward's quarters; 17, 18, officers' quarters (of which there are several not 
 shown on the plan); 19, guard-room; 20, guard-house near entrance gate ; 21, 
 workshop; 22, contagion- ward, this was more distant than is represented. 
 The wards, dining-room, and administration building are connected by a 
 covered way, 
 
 Water-closet attached to lateral aspect of free end of a ward : a, interior of 
 ward; 6, water-closet; c, lavatory and bathroom; d, pantry; e, wardmaster's 
 room; /,/, ventilating-hall and passage-ways. 
 
GENERAL HOSPITAL SERVICE. 
 
 73 
 
 inches from the ground, and had free ventilation underneath. 
 The beds were placed at regular intervals from each other, 
 two occupying the floor space between adjacent windows. 
 During warm and mild weather the wards were ventilated 
 by the ridge. The opening, about one and a half feet wide, 
 extended the whole length of the building, and was pro- 
 tected by a ridge-roof which lapped well over it on either 
 side. During winter the ridge was closed and ventilation 
 by shafts and special fresh-air inlets was substituted. The 
 
 Ventilation and heating of a ridge- ventilated ward. 
 
 inlets were boxed channels from the side walls opening 
 beneath the stoves, which were each partially surrounded 
 by a jacket of sheet-iron or zinc. The air, more or less 
 warmed in its passage into the ward, became diffused and 
 was ultimately drafted through ventilating-shafts 18 inches 
 square which extended from the level of the tie-beams to 
 beyond the ridge. The heat of the stove-pipe was utilized 
 in promoting the escape of foul air through these shafts. 
 113. The size of a ward, as compared with the numbeD 
 
74 GENERAL HOSPITAL SERVICE. 
 
 of occupied beds in it, is a matter of importance. Many of 
 the diseases which in former days increased the mortality 
 in hospitals were due to overcrowding. Erysipelas has be- 
 come infrequent, and hospital gangrene unknown [372], 
 since a proper amount of space has been assigned to each 
 bed. Typhus fever has also become a disease of the past, 
 as well as that typhus-like character which overcrowding 
 impressed on pneumonia and all other febrile diseases [85]. 
 The air space in the hospitals of the war was from 924 to 
 1,033 feet per bed; but all the beds were rarely occupied 
 at the same time. More space is required for suppurating 
 wounds, infectious diseases, and such as confine the patient 
 to bed than for trivial cases or convalescents to whom the 
 ward is merely a sleeping-room. When a liberal air space 
 is afforded, ventilation can be effected with less risk of creat- 
 ing a draught. If a ward give 3,000 feet of space [230] to 
 each patient, its air would have to be renewed only once per 
 hour to insure good ventilation ; whereas, if it be crowded 
 with one man for every 500 feet of its capacity, the air 
 would have to be renewed six times in the course of an hour 
 to preserve its quality. 
 
 114. The administration building was usually two-storied, 
 and contained the general office, office of the surgeon in 
 charge, chaplain's office, dispensary, linen and store rooms, 
 lodging-rooms for officers, etc. The kitchen was divided 
 into two parts, the larger for the preparation of ordinary 
 diet, the smaller for extra diet. The dining-room seated a 
 number equal to two- thirds of the number of beds; it com- 
 municated with the kitchen usually by the centre of one of 
 its sides. The subsistence and quartermaster's store-room 
 contained boxes and shelves for the various parts of the 
 ration, a room for clothing, and on its second story lodging- 
 rooms for the cooks; an ice-house was connected with it. 
 
GENERAL HOSPITAL SERVICE. 75 
 
 A knapsack-house received the effects of the patients while 
 in hospital. The laundry was a two-storied building, hav- 
 ing quarters for the laundresses on the second floor. Spe- 
 cial quarters, including dining-room and kitchen, were 
 provided for female nurses. The other buildings consisted 
 of quarters for officers; an operating-room and a dead- 
 house, both lighted by skylights, the former near the admin- 
 istration building, the latter in a retired part of the grounds ; 
 a chapel, with library and reading-room attached j guards' 
 quarters, stables, repair-shops, etc. 
 
 115. When the water supply was not derived from the 
 mains of a city, steam was usually employed to raise it 
 from the wells, springs, or streams which formed its source, 
 and in this case the engine was generally situated near the 
 kitchen and laundry that the steam might be made available 
 in cooking and the power utilized in working the washing 
 and mangling machines. It was usually considered advis- 
 able to have some reserve tanks or cisterns kept always full 
 in case of danger from fire. 
 
 116. Rain-water is wholesome water if properly collected 
 and stored. The roofs or other shedding surfaces should 
 be clean ; if they are foul, the first fall of a shower should 
 be run to waste by a cut-off, if a sedimenting cistern or 
 filter be not interposed between the watershed and the reser- 
 voir. Cisterns are usually constructed of brick, lined with 
 Portland cement, or of wood, generally cypress wood. Un- 
 less care is exercised in excluding the washings of the water- 
 shed, the cistern will soon accumulate a thick sediment of 
 foul mud, which must be cleaned out from time to time. 
 In warm weather, when the water-level in the cistern is 
 low, this sediment may seriously affect the quality of the 
 water. Underground cisterns, from their cooler situation, 
 are less prone to suffer from the fermentation of an accumu- 
 
76 GENERAL HOSPITAL SERVICE. 
 
 lated sediment. Moreover, the mineral or earthy matters 
 of which the underground cistern is constructed introduce 
 into the stored water certain bacteria which transmute am- 
 monia into nitric acid. These are called the micro-organ- 
 isms or bacteria of nitrification. Organic matter that may 
 be present in the water from the air-washing which it has 
 effected, or from foul accumulations on the watershed, in 
 the conductors, or in the cistern itself, is decomposed into 
 ammonia, and this is subsequently transformed into nitric 
 acid. The tendency of the water during its storage in the 
 cistern is to improvement ; but it is important to observe 
 that this does not hold good in wooden tanks, unless the 
 bacteria of nitrification are introduced, as by throwing into 
 the cistern a quantity of clean gravel. 
 
 117. Surface water, as from rivers, lakes, ponds, etc., is 
 often impure from filth washed from the watershed. The 
 subsoil water, tapped by shallow wells, is free from the tur- 
 bidity often found in surface waters ; but it is not generally 
 accepted as a wholesome water. If the soil be a clean sand 
 in an unsettled locality the water may be as good as any 
 filtered cistern water; but if it be impure from the soakage 
 into it of the wastes of human life and occupation, the water 
 will be more or less tainted with these impurities. The 
 water of deep wells is usually organically pure, but often 
 so charged with saline matters as to be undesirable as a 
 potable supply. 
 
 118. There is no easily performed chemical or other test 
 for organic matter in a water. If a quart bottle half filled 
 with the water at a temperature of 70 or 80 Fahr. be 
 shaken vigorously for a few minutes and then placed to the 
 nose, an organic odor may be detected in the air of the bot- 
 tle if the water is of doubtful or bad quality ; but bad waters 
 do not always have an odor. The best of the easy modes 
 
GENERAL HOSPITAL SERVICE. 77 
 
 of chemical inquiry is to burn the residue. Evaporate 100 
 c.c. of the water to dryness in a platinum or porcelain cap- 
 sule; then ignite the dish over the flame of a lamp. If 
 there be no blackening, or at most only a darkening of the 
 residue, which is speedily dissipated by a continuance of 
 the heat, the water is probably good. If the thin crust of 
 the residue blacken all over, and the carbon be afterward 
 dissipated with difficulty, the water has probably an excess 
 of vegetable matter. If, in addition to the blackening, 
 nitrous fumes are evolved, and the carbon sparkles in points 
 with the energy of its combustion, the water may be sus- 
 pected of containing organic matter of animal origin. The 
 organic matter found in drinking-water may be of a harm- 
 less or dangerous character; but it must be conceded that 
 where there is much organic matter the likelihood of the 
 presence of dangerous matter is greater than where there is 
 little. 
 
 119. The presence of salts of lime and magnesia gives a 
 water the quality of hardness. Soap does not form a lather 
 with hard water until the lime and magnesia have been pre- 
 cipitated in the form of curdy salts of the fatty acids of the 
 soap. When a hard water is boiled, white flakes of car- 
 bonate of lime appear in it, and its temporary hardness is 
 removed. When the earthy salts are present in the water 
 as sulphates the hardness caused by them is called perma- 
 nent because it is not removed by boiling. Such waters in- 
 duce diarrhea, particularly in those who are unaccustomed to 
 their use. Soft waters contain but little of these earthy salts. 
 
 120. As water is frequently distributed by leaden pipes, 
 and sometimes stored in lead-lined cisterns, the possibility 
 of the solution of poisonous quantities of the metal must be 
 held in view. The symptoms are violent neuralgic pains 
 in the abdomen, simulating colic, but oftentimes affecting 
 
78 GENERAL HOSPITAL SERVICE. 
 
 also the limbs and trunk, with constipation and gradual 
 loss of strength. When lead is used for service-pipes the 
 water which has stood in the pipes over-night should be run 
 to waste before drawing a supply for use. Rain and other 
 soft waters act on lead with facility. When metal is used 
 for cisterns, iron, coated with asphalt paint or black varnish, 
 should be employed. Zinc, which forms the protective 
 coating of the iron in galvanized tanks and pipes, is acted 
 on by most waters, but without producing notable harmful 
 effects on the consumers. 
 
 121. When the water supply was adequate it was intro- 
 duced into the water-closets attached to the wards and into 
 the latrines for the use of convalescents and others. Water- 
 tight boxes, which were emptied and cleaned regularly, 
 were used in the absence of a water service. The earth- 
 closet, consisting of a closet- seat over a pail or other small 
 portable receptacle, with dry earth as a deodorant, was not 
 brought into general use until a few years after the war. 
 The drains and sewers of hospitals within municipal bounds 
 were connected with the general sewerage system. In other 
 cases the sewers of the hospitals found an outlet into some 
 neighboring stream or tide-water ; but where no satisfactory 
 outlet was obtainable, the sewer terminated in a cess-pool 
 from which liquids percolated or overflowed by a suitable 
 conduit into a natural incline leading from the hospital, and 
 solids were removed from time to time as they accumulated. 
 
 122. The sewerage system includes water-closet basins, 
 each with a water-seal to prevent the inflow of foul air 
 through their discharge-pipes, a soil-pipe leading downward 
 from the water-closets on the various floors and receiving 
 the waste-pipes from bath-tubs, kitchen traps, and other 
 water fixtures, and a drain connecting the lower end of the 
 soil-pipe with the sewer. 
 
GENERAL HOSPITAL SERVICE. 79 
 
 123. Water-closets are of several forms and many varie- 
 ties. The hopper-closet is the simplest, because it has no 
 mechanical parts to get out of order. It consists of a fun- 
 nel-shaped bowl which leads the deposits into the water of 
 an S-shaped trap. Its efficiency depends on the quantity 
 of water available and the manner of its distribution from 
 the flushing rim over the curved sides of the basin. Pan- 
 closets and valve-closets are objectionable as liable to become 
 
 Hopper-closet with water-seal. 
 
 foul and out of order. In the plunger-closet the outlet from 
 the bowl is at the side instead of below, and is closed by a 
 heavy metal piston or cylinder which, on being raised, dis- 
 charges the contents into an S-shaped trap leading into the 
 soil-pipe. Leakage from the bowl sometimes occurs when 
 the plunger, on account of fouling, fails to completely close 
 the outlet. 
 
 124. Bath-tubs, wash-basins, and the fixtures of the laun- 
 dry are connected with the soil-pipe usually by lead pipes 
 one to two inches in diameter, trapped by a deep S-shaped 
 bend close to the aperture of outflow. Small overflow pipes 
 
80 GENERAL HOSPITAL SERVICE. 
 
 are generally provided, aud these are either trapped them- 
 selves or connected with the main outflow on the near side 
 of the bend. Kitchen and pantry sinks have two-inch out- 
 flows provided with a strainer and trapped close to the bot- 
 tom of the sink. As the trap becomes sometimes choked 
 with sediment and accumulations of grease, it has usually a 
 screwed cap on its convexity by which it may be entered 
 and cleaned. Hot water often carries liquefied grease to a 
 considerable distance along the outflow before it becomes 
 congealed. An occasional flushing with a solution of soda 
 
 Plunger-closet with water in basin and in S-trap and hub on soil-pipe side of 
 trap for attachment of vent-pipe. 
 
 or potash will tend to clear the two-inch pipe, and the 
 ammoniacal fermentation of water-closet discharges has a 
 similar scouring influence on the main drain. 
 
 125. Soil-pipes descend vertically through the building 
 from above the roof to the cellar. Each is open at the top 
 and ends below in a curve which connects it with the house- 
 drain. Water-closet outflows and the wastes of bath-tubs, 
 wash-basins, and kitchen trays, etc., join it by Y-shaped 
 
GENERAL HOSPITAL SERVICE. 81 
 
 branches. All junctions must be solidly made. Iron pipes 
 are joined by pouring melted lead into the sockets when the 
 lengths are in position, a small packing of oakum having 
 been previously introduced to prevent the liquid metal from 
 penetrating into the interior; and when cold the lead is 
 driven securely home by a hammer and caulking-iron. 
 Lead is joined to iron by tipping the leaden pipe with a 
 brass ferrule, which is afterward caulked into the iron with 
 melted lead. 
 
 126. It is better to have these pipes in sight than boarded 
 up, as any flaw in the plumbing is more readily detected. 
 When a leak is suspected the peppermint test is recom- 
 mended for its discovery. A fluid ounce of this volatile oil, 
 or a corresponding quantity of its essence, is poured into 
 the upper end of the soil-pipe, and a flush of water is sent 
 down after it. The odor of the oil is so penetrating that it 
 speedily makes itself felt at any leaky point or flaw in the 
 S3 r stem of pipes; but the search for its presence must be 
 conducted by one who has kept himself free from any recent 
 contact with the oil, and the man who made use of the test- 
 liquid must remain at his post until the end of the investi- 
 gation, lest he carry an odor with him which would interfere 
 with the discovery of a leak. 
 
 127. The house-drain, of iron pipe six inches in diameter, 
 should traverse the building along the ceiling or walls of 
 the cellar, or, if it be needful to place it under the floor, it 
 should be laid in a concreted trench with a fall of at least 
 1 in 100, and a cover which can easily be removed for 
 inspection. Outside the walls the drain may be either of 
 iron or vitrified pipe. Iron should be used if the ground is 
 liable to sag, or if the drain passes within the drainage 
 area of a well-water supply, or near the roots of trees, which, 
 in their search for water, will penetrate the joints of vitri- 
 
 6 
 
82 GEKERAL HOSPITAL SERVICE. 
 
 fied pipes and choke their interior. The term drain, which 
 custom has applied to this pipe, is sometimes misleading. 
 Drainage is the system by which the surface and subsoil 
 are relieved from an excess of moisture, and drains are 
 properly the tile-pipe or other channels by which this is 
 effected ; while sewers are the channels of the sewerage sys- 
 tem by which sewage is removed. Evidently the pipe in 
 question is rather a house-sewer than a house-drain. 
 
 128. At some convenient point, .either inside or outside 
 the walls, this house-drain or sewer should be trapped by a 
 deep-sealed S-bend to cut off all communication between 
 the air of the common sewers and that of the system of 
 pipes within the building. This trap should be well pro- 
 tected against freezing in cold weather. When rain-con- 
 ductors join the main drain on the near side of its trap they 
 require no special trapping, but if their junction be effected 
 on the far side they will, if untrapped, become ventilators 
 for the sewers, and may diffuse unwholesome gases through- 
 out the upper part of the building. 
 
 129. The water-closet system presents two guards against 
 the entrance of sewer air into a building the main trap on 
 the house-drain, and the traps on the individual waste-pipes. 
 Should the former be forced by some sudden air pressure in 
 the common sewers, the foul air enters the soil-pipe, but on 
 account of its open upper end no pressure is brought to bear 
 on the interior traps. But the interior of the pipes on 
 the house side of the trap on the main drain may be so 
 coated with fermenting organic matters that the air con- 
 tained in them may differ but little in quality from that of 
 the sewers. The open end of the soil-pipe above the roof 
 has of itself no ventilating or purifying influence. The 
 evaporation of the water in the trap of an unused bath-tub 
 or wash-bowl might therefore give entrance to very unwhole- 
 
GENERAL HOSPITAL SERVICE. 83 
 
 some gases from the soil-pipe. It is advisable on this 
 account to have the whole system of pipes on the hither side 
 of the main trap as freely ventilated as possible. This is 
 accomplished by means of a fresh-air inlet into the drain. 
 The inlet usually takes the form of a four-inch iron pipe 
 which extends from some distance above the surface of the 
 ground to the drain, tapping the latter at a convenient point 
 between the lower end of the soil-pipe and the main trap. 
 Its free end is covered with a cowl or raised cap to prevent 
 the entrance of foreign matter. The warmth of the soil- 
 pipe in the interior of the house and the aspiratory force 
 of the wind on the open mouth of its upper end above 
 the roof establish a constant current of fresh air through 
 it which materially lessens the danger attaching to acci- 
 dentally unsealed traps. Unsealing is sure to occur if the 
 plumbing fixture remains unused for a certain length of 
 time, depending on the warmth of the weather or room, and 
 the depth of the water in the trap. The remedy in this 
 case is obvious. 
 
 130. Sometimes, however, water-traps are unsealed by 
 what is called siphonage. When the upper bend of an 
 S-trap becomes filled, full bore, by a sudden discharge of 
 water, the trap acts as a siphon, and may draw off so much 
 of the water as to leave itself with its seal broken. As 
 might be expected, small pipes and shallow seals are more 
 likely to be siphoned than large pipes and deep seals. 
 Again, the sudden rush of a discharge from a water-closet 
 through the soil-pipe may suck out the water-seal of a 
 neighboring trap. Both of these accidents are prevented 
 by means of a vent-pipe on the soil-pipe side of the trap, 
 which permits of the entrance of air in the one case to break 
 the siphon, and in the other to fill the vacuum caused by 
 suction. Vent-pipes from traps unite into a single pipe, 
 
84 
 
 GENERAL HOSPITAL SERVICE. 
 
 which may end above the roof like the soil-pipe, or open 
 into the latter at a point above the highest fixture. Me- 
 chanical devices are sometimes used to increase the efficiency 
 of the water-seal or guard against its loss. Thus, in Bow- 
 er's trap, a rubber ball is buoyed by the water against the 
 mouth of the pipe leading from the fixture. The discharge, 
 in passing, temporarily displaces it, but it immediately 
 resumes its guard, closing the aperture so long as enough of 
 water remains iiv the trap to float it into position. 
 
 S-trap showing water-seal, screw cap 
 on convexity for convenience in clean- 
 ing, and vent-pipe to prevent siphoning. 
 
 Water-seal with rubber ball act- 
 ing as a valve. Bower's trap. 
 
 131. Latrines consist of a series of hopper or other closets 
 over a brick trench or iron receptacle containing water. 
 From time to time the plug which guards the outlet of the 
 receptacle is raised and the contents are flushed out through 
 an S-trap into the soil-pipe. 
 
 132. Sewers are generally built of considerable size, to 
 carry off the rainfall as well as the sewage ; and heavy rains 
 do much good from time to time in flushing out and cleans- 
 ing their channels. The rain-leaders from a building usu- 
 ally enter the house-drain on the near side of the trap [128] ; 
 but in climates where the winters are not severe they may 
 end in surface channels which carry the water through a 
 
GENERAL HOSPITAL SERVICE. 85 
 
 grating into a catch-box for gravel, the overflow passing 
 through a trapped drain to the sewer. 
 
 133. Ground areas on which rain-water would otherwise 
 accumulate are often drained by means of what is called 
 the bell-trap. A perforated metal plate permits the water 
 to enter a basin which lies underneath it, and when the 
 water rises to a certain height in the basin it overflows into 
 
 The bell-trap. 
 
 a central pipe which carries it into the house drain. A 
 hemispherical cup attached by its bottom to the under sur- 
 face of the plate makes a loosely fitting cover for the mouth 
 of the pipe, and by dipping into the water contained in the 
 basin prevents the escape of emanations from the drain. It 
 should be remembered that traps of this kind are readily 
 unsealed by evaporation. 
 
 134. The surgeon in charge of a general hospital has full 
 and complete military command over the persons and prop- 
 erty connected with it. At small hospitals he is his own 
 executive officer ; but in large establishments an officer is 
 detailed to aid him in his supervision. The duties of this 
 officer are those of an adjutant to a commanding officer, 
 with those of subsistence officer and quartermaster super- 
 added. He has charge of the office and records, and of the 
 men detailed as clerks and orderlies; he keeps the clothing 
 and other accounts of the detachment and of the detached 
 men ; he supervises the preparation of all regular reports, 
 
86 GENERAL HOSPITAL SERVICE. 
 
 promulgates all orders, and conducts the general correspond- 
 ence. He distributes the patients received for admission, 
 and looks after the general well-being of the establishment 
 as aid to his superior. The same reports and returns are 
 rendered and books of record kept as at a post hospital. 
 
 135. Several stewards, with clerical assistance, are re- 
 quired in the service of a large general hospital. One takes 
 charge of the books and papers relating to the military gov- 
 ernment of the establishment, he is practically the ser- 
 geant-major of the command ; a second attends to matters 
 of subsistence; a third to quartermaster's property and the 
 issue of clothing ; and a fourth to medical and hospital 
 property and supplies. A steward superintends the work 
 of the dispensary ; one has general charge of the operating- 
 room, wards, and dead-house; one looks after the kitchen 
 and dining-room ; and one attends to the laundry and the 
 work of disinfection. 
 
 136. Each ward surgeon is responsible for the profes- 
 sional treatment and general comfort of his patients; for 
 the police of his ward, the care of its property, and the 
 faithful discharge of their duties by his subordinates. He 
 makes a record of all cases of professional interest, and 
 sends a morning report to the executive officer, stating all 
 changes and recommending others, such as the return to 
 duty, furlough, discharge, or transfer of particular individu- 
 als. An officer of the day is detailed daily by roster from 
 the number of the ward surgeons. This officer must not be 
 absent from the hospital during his tour of duty. He ad- 
 mits patients in the absence of the executive officer, and 
 prescribes in cases of emergency in the absence of the ward 
 surgeons. He inspects the meals and visits the wards at 
 bedtime, and again after midnight, to regulate lights and 
 note the vigilance of ward attendants. The detail for guard 
 
GENERAL HOSPITAL SERVICE. 87 
 
 is under his command to enable him to enforce discipline at 
 all times; but if the guard consists of a special body of 
 troops, its senior officer is held responsible for the general 
 police of the grounds and the preservation of order within 
 the limits of the command. 
 
 137. The chaplain, in addition to duties of a purely spir- 
 itual character, usually keeps a record of special patients, 
 with the post-office addresses of the nearest relatives; he 
 superintends the postal service, library, reading-room, and 
 cemetery. 
 
 138. Each ward is under the care of an acting steward or 
 private assigned as wardmastvr, who is responsible for the 
 comfort, diet, and medication of the patients, the perform- 
 ance of their duty by the nurses, the preservation of the 
 ward property, the regulation of the fires, lights, and venti- 
 lation, and the cleanliness of the bed-linen and clothing, 
 lavatory, bath, water-closets, etc. Two nurses are suffi- 
 cient for a pavilion of fifty beds when the cases are not of 
 an acute character; but three, four, five, or more may be 
 required, according to circumstances. These are detailed 
 from the allowance provided for the hospital by the Surgeon 
 General. 
 
 139. The hospital fund of the general hospital differs in 
 no respect in its management from that of the post [14]. 
 Where hospital gardens are cultivated this fund is usually 
 capable of supplying all the needs of the extra-diet kitchen. 
 One of the most important duties of the hospital steward is 
 to see that the hospital fund does not suffer from ignorance 
 or want of economy in the kitchen. 
 
 140. Special care is needful at a large general hospital to 
 guard against danger from fire. Every member of the hos- 
 pital corps should at all times be on the alert for the gen- 
 eral protection. Full buckets and axes should be kept in 
 
88 GENERAL HOSPITAL SERVICE. 
 
 each building, with a suitable length of rubber hose for 
 attachment to the water service. These provisions suffice 
 for the suppression of fire when discovered in its incipiency ; 
 but to provide for the protection of patients and property 
 on an occasion of general danger, the whole command should 
 be organized and drilled, from time to time, as a fire 
 brigade. 
 
PART II. 
 
 ANATOMY AND PHYSIOLOGY. 
 
 141. The body consists of a multiplicity of living tissues 
 aggregated into organs, each of which has its special func- 
 tion to perform in order to preserve the integrity of the 
 whole. These organs may be divided into three sets : 
 
 I. Those of locomotion consist of the bony skeleton, which 
 gives form and stability; the joints, which permit of motion 
 between the bones, and the masses of contractile flesh or 
 muscle, which effect the motion. 
 
 II. Those concerned in the processes of organic life con- 
 sist of an alimentary system, which renews the blood by 
 elaborating it from the raw material of food; a nutritive 
 apparatus, which feeds the various parts by the circulation 
 of a liquid, the blood, and a depurative or excretory system, 
 consisting of lungs, skin, kidneys, etc., which removes from 
 the blood the impurities gathered in its course. 
 
 III. Those of the administrative system include the organs 
 of the senses and the nervous system, from which emanate 
 all the powers of vitality. 
 
 CHAPTER I. 
 
 THE LOCOMOTOB SYSTEM. 
 
 142. .Z?07ie consists of animal tissue permeated with earthy 
 salts, chiefly phosphate of lime. The animal tissue may be 
 demonstrated by dissolving the earthy salts in dilute hydro- 
 
90 BONES, JOINTS AND MUSCLES. 
 
 chloric acid. Each bone is covered with a strong fibrous 
 membrane, the periosteum, in which the blood-vessels of the 
 bone subdivide [183] before entering the bony tissues. 
 
 143. The muscles constitute the flesh or lean of the ani- 
 mal tissues. Each consists of a mass of parallel fibres 
 aggregated into bundles and bound together by a fine elastic 
 webbing which is called the areolar, cellular) or connective 
 tissue. Every fibre recognized by the eye is composed of a 
 vast number of microscopic fibrils, each of which is marked 
 with close-set, transverse lines ; and when the. fibril con- 
 
 Bundles of striated muscular fibrils. 
 
 tracts the lines come nearer to each other, as the coils of a 
 spring are closer when they are compressed than when they 
 are expanded. These markings are called stria} ; and the 
 muscles that present them, striated muscles. All the volun- 
 tary muscles, or those under the control of the will, are 
 striated. Muscular fibres which contract independently of 
 the power of the will, such as those which move the intes- 
 tinal contents, are flattened, band-like fibres without striae. 
 144. At each end of a voluntary muscle the contractile 
 fibres become blended with strong fibrous tissue, which 
 interweaves with the periosteum of the bone and gives the 
 muscular fibres a strong attachment. In some instances, 
 as in the muscles of the forearm, the fibrous tissue assumes 
 the rounded form of a tendon or sinew. Generally one of 
 the two attachments of a muscle is more readily moved 
 than the other. A muscle which extends from the shoulder 
 
BONES, JOINTS AND MUSCLES. 91 
 
 to the forearm will, by its contraction, bend the elbow, and 
 raise the hand to the shoulder ; but if the hand be made the 
 fixed point, as when we seize a bough or bar overhead, and 
 endeavor to raise the body by sheer strength of arm, the 
 same muscle, by its contraction, will raise the shoulder to 
 the hand. 
 
 145. Although the contractility of a muscle is ordinarily 
 exhibited only through the influence of the will, the ten- 
 dency to contraction is continually in force. When the 
 belly of a muscle is cut across, the fibres contract toward 
 their point of attachment, and a gaping wound is the result. 
 When a bone, as the arm-bone, is fractured, the muscles 
 which extend from above to below the fracture may, by 
 their contraction, cause the broken ends to override and 
 give rise to shortening of the limb. 
 
 146. The lack-bone or vertebral column extends from the 
 skull down along the middle line of the back. If the fin- 
 gers be drawn along this line a number of bony prominences, 
 called spinous processes, will be felt, each of which belongs 
 to one of the bones composing the column. The motion 
 between adjoining bones is slight, but the combined motion 
 of the whole is considerable. In position in the body these 
 bones or vertebrae constitute a pliant pillar about twenty- 
 seven inches long, rounded and smooth in front, irregular 
 from many projections behind and at the sides, and having 
 in its interior a long canal formed by the apposition of cir- 
 cular apertures in the individual bones, There are seven 
 vertebrae in the neck, or cervical region ; twelve in the back, 
 or dorsal region ; and five in the loins, or lumbar region. 
 They are held in position in the erect attitude, and moved 
 as required by powerful muscles inserted into their spinous 
 and other processes; and these muscles afford protection 
 from injury by acting as a padding to the column. Sus- 
 
92 
 
 BONES, JOINTS AND MUSCLES. 
 
 pended in the canal of the column is the spinal cord, or that 
 portion of the nervous system from which are given off 
 most of the nerves that superintend 
 motion and transmit sensation. Aper- 
 tures are left between the vertebrae 
 along each side of the column for the 
 passage of nerves from the cord to the 
 various organs and tissues. 
 
 147. This flexible pillar is supported 
 upon a bone called the sacrum, which 
 is wedged into a triangular interval 
 between the hip-bones behind. It con- 
 tains within its canal the final breaking 
 up of the spinal cord for the nerve sup- 
 ply of the lower extremities. The sa- 
 cmm is tipped below by a small bone, 
 the coccyx. See page 102. 
 
 148. The skull is divided into the 
 cranium and the face. The bony 
 plates forming the vault of the crani- 
 um consist of two layers of compact 
 tissue and a thin interlying layer of 
 spongy bone. The cranial bones are 
 united by close-fitting sutures, a series 
 of projections and notches on one bone 
 fitting into a corresponding series on 
 the adjoining bone. The brain or 
 organ of the intelligence and nervous 
 power is contained in the cranium, 
 and is continuous below with the 
 spinal cord through a large circular 
 
 opening in the base immediately over the canal of the ver. 
 tebral column. 
 
 Side view of vertebral 
 column : a, bodies of the 
 vertebrae; 6, cartilages 
 between vertebrae ; c, 
 apertures for nerves; d, 
 facets for ends of ribs; 
 e, facets for support of 
 ribs ; /, spinous processes 
 projecting behind ; g, 
 prominent spine of sev- 
 enth cervical vertebra. 
 
BONES, JOINTS AND MUSCLES. 03 
 
 149. The bones of the face are very irregular in form,, 
 and, with the exception of the lower jaw, are closely sutured 
 together. The rounded head of the lower jaw may be 
 felt in front of the lobe of the ear, and when the mouth is 
 opened the finger may be pressed into the back part of the 
 cavity of the joint [476]. 
 
 150. The cervical vertebrae are deeply embedded in the 
 muscles by which the movements of the head are effected. 
 These muscles surround and protect the larynx, or organ of 
 voice, the cartilages of which project in the middle line in 
 front [224] ; the trachea, or windpipe, which stretches from 
 the lower part of the larynx down behind the notch in the 
 upper part of the breast-bone [222] ; the cesopkagus, or gul- 
 let, which lies behind the larynx and trachea, and the large 
 blood-vessels and nerves which are embedded on either side 
 of these tubes. One of the most noteworthy of the muscles 
 of the neck is the stemo-mastoid, which stretches as a firm, 
 fleshy mass from the junction of the breast-bone and collar- 
 bone on either side upward and backward to the bony 
 prominence behind the ear, its outline being distinctly 
 marked on the surface when the head is turned to the oppo- 
 site side. 
 
 151. The dorsal vertebrae have connected with them the 
 bones which form the framework of the chest. These con- 
 sist of twelve ribs on each side and the sternum, or breast- 
 bone, in front. The outline of the individual ribs and their 
 arrangement as a whole can usually be made out without 
 difficulty on the person. The seven upper ribs on each side 
 are attached in front to the margin of the sternum by means 
 of a cartilaginous prolongation of the bony tissue. Carti- 
 lage is an opaque, bluish-white elastic substance, familiarly 
 known as gristle. The cartilages of the eighth, ninth, and 
 tenth ribs curve upward on either side of the epigastrium, or 
 
94 BONES, JOINTS AND MUSCLES. 
 
 pit of the stomach, and unite with that of the seventh rib. 
 The eleventh and twelfth are called floating ribs, because 
 they have no fixed attachment in front. The cartilages 
 add greatly to the elasticity of the ribs, lessening the risk 
 of fracture and injury to the contents of the chest. The 
 movements of the ribs in inspiration are upward and out- 
 ward, enlarging the capacity of the chest in all directions. 
 The chest contains the lungs, heart, and great blood-vessels, 
 and the gullet on its way downward to the stomach. 
 
 152. The clavicle or collar-bone lies between the upper 
 part of the breast-bone and the point of the shoulder, where 
 it is united to a projection of the shoulder-blade, called the 
 acromion process. The triangular outline of the flattened 
 scapula or shoulder-blade can be defined by the eyes or by 
 the pressure of the fingers, its base forming part of the 
 breadth of the shoulder, and its apex reaching a little below 
 the eighth rib. Immediately below the junction of the col- 
 lar-bone and shoulder-blade at the point of the shoulder, 
 the bony tissue of the latter forms a shallow depression, 
 the glenoid cavity [478], in which the rounded head of the 
 arm-bone has free play for its movements. 
 
 153. The bony surfaces which move on each other, con- 
 stituting & joint, are bound together by strong fibrous tissue 
 which forms a capsule around them to prevent dislocation 
 while admitting of the needful degree of motion. Where 
 the strain is greatest the fibrous tissue is strengthened by 
 interlaced bands which are called ligaments. The joint- 
 ends of the bones are in the living body coated with a 
 layer of elastic cartilage, and this is covered over with a 
 thin, smooth membrane which gives a highly polished sur- 
 face to the interior of the joint and secretes a lubricating 
 liquid called synovia. The interior of the capsule has a 
 similar lining, while externally it is strengthened by the 
 
BONES, JOINTS AND MUSCLES. 95 
 
 apposition of neighboring muscles. The capsule of the 
 shoulder-joint is strongly supported by muscles : in front, 
 the pectoral muscles, which converge from the front of the 
 chest to be inserted into the inner side of the arm-bone 
 below the capsule; behind, the muscles which converge 
 from the scapular region to be inserted into the upper and 
 back part of the arm-bone ; and on the outer side forming a 
 cap to the joint, the deltoid muscle, which curves from the 
 clavicle and scapula above the joint to the outer side of the 
 arm-bone a little above its middle. Nevertheless the shal- 
 lowness of the glenoid cavity and the laxness of the cap- 
 sule which give to this joint its freedom of motion, render 
 it correspondingly liable to dislocation [478]. 
 
 154. The muscles mentioned in the last paragraph have 
 an interest in connection with fractures of the arm. The 
 deltoid raises the limb, pulling it away from the side; the 
 pectoral muscles act in the opposite direction; the scapular 
 muscles raise it. When the arm is broken just below the 
 line of the arm-pit, the front wall of which is formed by the 
 pectoral muscles in their passage from the chest to the arm, 
 these muscles drag the upper fragment inward, while the 
 deltoid draws the lower fragment, to which it is attached, 
 upward and outward. On the other hand, if the fracture 
 is above the attachment of the pectoral muscles, the upper 
 fragment will be displaced outward by the power of the 
 scapular muscles. 
 
 155. The liumerus or bone of the arm consists of a cylin- 
 drical shaft expanded at its ends to enter into the formation 
 of the joints. The shaft, like that of all the long bones, 
 consists of a compact bony tissue hollowed along the centre 
 into a canal containing a fatty substance or marrow. The 
 ends are of spongy tissue covered with harder bone. The 
 upper end or head [478] has a rounded surface on its inner 
 
96 BONES, JOINTS AND MUSCLES. 
 
 aspect for articulation with the glenoid cavity, and rough 
 prominences or tuberosities on its outer aspect for the attach- 
 ment of muscles. Toward its lower end the shaft becomes 
 flattened from before backward, to have greater breadth 
 for its hinge-like joint with the bones of the forearm; and 
 on either side of the articular surface is a projection or con- 
 dyle for the attachment of muscles. Both condyles can be 
 outlined by the fingers, but the inner is more prominent 
 than the outer. 
 
 156. The bones of the forearm are the radius on the outer 
 or thumb side, and the ulna on the inner or little-finger 
 side. The latter, at its upper end, is scooped out from 
 before backward into a semicircular surface which hinges 
 with the lower end of the humerus. When the forearm is 
 bent on the arm the back part of this semicircular notch 
 forms the olecranon process, or point of the elbow. The 
 upper end of the radius is small and rounded, but it may 
 be felt below the external condyle on the posterior and outer 
 aspect of the joint. The muscles on the back of the arm 
 extend or straighten the forearm at the elbow. The mus- 
 cles in front flex or bend it. One of these flexors, the 
 biceps, passes to the radius just below the elbow-joint; it 
 forms the fleshy mass 011 the front of the arm. Other flex- 
 ors stretch from the inner condyle along the front of the 
 forearm to operate on the fingers; these become tendinous 
 as they approach the wrist. 
 
 157. In addition to accompanying the ulna in its hinge- 
 motion on the humerus, the radius has a kind of circular 
 motion on the ulna by which the hand is rotated. When 
 certain of the muscles on the front of the forearm contract, 
 the lower part of the radius is rolled over and in front of 
 the ulna, so that the back of the hand looks upward or to 
 the front ; this is called pronation. When certain of the 
 
BONES, JOINTS AND MUSCLES. 
 
 97 
 
 posterior muscles contract, the motion is reversed, throwing 
 the jw//// itjitnird or to the front ; this is called supination. 
 When the fingers of the observer are placed firmly on the 
 head of the radius, while the hand of the patient is alter- 
 nately pronated and supiuated, the 
 rolling motion of the bone is easily 
 observed [460]. 
 
 158. Eight small bones, fitted close- 
 ly together in two rows, form the 
 wrist or carpus. The upper row ar- 
 ticulates with the lower end of the 
 radius; the lower row with the bases 
 of the five metacarpal bones. All 
 these joints are encrusted with car- 
 tilage and lined with synovial mem- 
 branes. The first metacarpal bone is 
 the uppermost of the three bones 
 which enter into the formation of the 
 thumb. The four other metacarpal 
 bones form the framework of the 
 palm of the hand. At the knuckles 
 they articulate with the bones of the 
 fingers. The four fingers consist each 
 of three pieces or phalanges jointed 
 
 together with hinge-joints; the thumb has but two pha- 
 langes. 
 
 159. The tendons of the flexor muscles on leaving the 
 front of the forearm pass under a strong ligament at the 
 wrist into the palm of the hand, where they split up for 
 attachment to the various joints of the fingers. The ex- 
 tensors on the back of the forearm and wrist are arranged 
 in a similar manner. 
 
 160. Muscular and tendinous layers attached to the lum- 
 
 7 
 
 Back view of right 
 wrist and hand : a, radi- 
 us; 6, ulna; c, bones of 
 carpus ; d, ligaments, 
 shown only on left side 
 of illustration; e, e, row 
 of metacarpal bones; /, 
 g, h, 1st, 2d, and 3d pha- 
 langes. 
 
98 BONES, JOINTS AND MUSCLES. 
 
 bar vertebrae, the hip-bones, and the ribs close in the ab- 
 dominal cavity in front and protect its contained organs. 
 The pelvis or floor of this cavity is formed mainly by the 
 two hip-bones, the upper margins or crests of which can be 
 felt curving from a sharp point in front, just above the 
 outer part of the flexure of the groin, outward and back- 
 ward toward the sacrum, which is wedged in between them 
 like the centre stone of anarch [page 102]. The pelvis 
 contains the bladder and the lower part of the intestine, 
 over which are packed away the mass of the intestines, the 
 kidneys, liver, spleen, stomach, etc. 
 
 161. These organs are separated from the contents of the 
 chest by the diaphragm, a thin but strong muscular and 
 tendinous partition attached to the inner surface of the cir- 
 cumference of the lower part of the chest. It forms the 
 floor of the chest or thoracic cavity and the roof of the 
 abdominal cavity. When the fibres contract, the tendency 
 of their action is to stretch the diaphragm tightly like a 
 drumhead between the two cavities, but when they relax, 
 as after an expiration, the partition bulges upward into the 
 chest. On account of this invasion of the thorax by the 
 dome-like convexity of the diaphragm, some of the abdom- 
 inal organs are situated within the lower part of the cage 
 of the ribs. The liver lies usually within the lower ribs 
 and cartilages of the right side. If the middle finger of 
 the left hand, laid flat along one of these ribs, be struck 
 sharply and perpendicularly with the tips of the fingers of 
 the other hand, a dull or flat sound will be elicited as com- 
 pared with the resonant sound yielded by similar percussion 
 over the higher parts of the chest where the air-filled lung 
 instead of the solid liver underlies the finger. When a 
 person lies on his back, the pressure of the other abdominal 
 organs forces the liver wholly within the ribs ; in the upright 
 
HONES, JOINTS AND MUSCLES. 
 
 99 
 
 or sitting posture its lower edge may be felt just below the 
 ribs, and if a deep-drawn breath be taken it will be farther 
 depressed. The stomach occupies the greater part of the 
 
 View of thoracic and abdominal organs; anterior walls removed, but the 
 relative position of the ribs, navel, etc., indicated: a, heart; 6, great vessels ; 
 c, c, lungs; d, d, diaphragm; e, liver; /, gall bladder; g, stomach; h, spleen: 
 i, ascending colon; j, transverse colon; fc, coils of small intestine; Z, position of 
 ileo-caecal valve at junction of small and large intestines; wi, urinary bladder. 
 
 epigastrium, the space below the end of the sternum and 
 between the diverging cartilages of the ribs ; and on its left 
 side, covered by the lower ribs, is the spleen. The large 
 
100 BONES, JOINTS AND MUSCLES. 
 
 intestine traverses the right side from the fold of the groin 
 to the under surface of the liver, where it crosses the abdo- 
 men, between the umbilicus or navel below and the stomach 
 and spleen above, to the left side, which it occupies in its 
 descending course to its termination. The small intestine 
 is gathered into coils which fill the space corresponding 
 with the front of the abdomen below the navel; but the 
 bladder, when distended, rises from its position in the pel- 
 vis into the lower part of this space. The kidneys are 
 attached to the rear wall of the abdomen, one on each side 
 of the lumbar vertebrae, so that their position corresponds 
 externally with the loins. These organs are covered with 
 a fine membrane, the peritoneum, similar to the synovial 
 membrane [153] lining the joints, which permits them to 
 glide easily on each other during the constant changes of 
 position incident to the respiratory and other movements. 
 
 162. The umbilicus or navel is the* remains of an opening 
 through which the blood-vessels of the fetus communicated 
 with those of the mother. At birth these vessels, constitut- 
 ing the umbilical cord, are tied and cut about an inch and a 
 half from the abdominal wall. The stump withers, and in 
 two or three days drops off, leaving a raw surface which, 
 on healing, contracts into the navel. In rare cases, when 
 the umbilical aperture is large, some portion of the abdom- 
 inal contents may be accidentally forced through it, form- 
 ing a soft swelling under the skin called a hernia or rupture. 
 It is treated by means of an abdominal belt, with a pad of 
 suitable size, to support the weak point. 
 
 163. Inguinal hernia is a protrusion through the passage 
 by which the vessels and nerves of the testicle communicate 
 with the interior of the abdomen. During straining or vio- 
 lent exertion, something is felt to give way, and a soft 
 swelling is found above and to the outside of the pubes 
 
BONES, JOINTS AND MUSCLES. 101 
 
 [164]. It may subside when the patient" lies 'down; but it 
 reappears when he resumes the upright position ; coughing 
 communicates a notable impulse to it. In aggravated cases 
 the protruded parts may be quite bulky, extending into the 
 scrotum. When they can be returned into the abdomen 
 by making the patient lie on his back, with his knees raised 
 to relax the abdominal muscles, the hernia is said to be 
 reducible. Any manipulation to aid its return must be ap- 
 plied with intelligence and gentleness. To press the pro- 
 trusion in an upward and backward direction with the hand 
 would merely flatten it against the small aperture through 
 which it had escaped. Gentle pressure should be made on 
 the tumor as a whole, but at the same time the effort of 
 the fingers should be to make the part that came down last 
 go up first, upward, outward, and backward, through the 
 aperture and along the track of the descent. A truss, con- 
 sisting of a steel spring to go around the lower part of the 
 body, and a pad to close and support the weak point, 
 should be applied as soon as the hernia is reduced. . The 
 circumference of the body taken in inches, just below the 
 iliac crests, gives the size of truss that will fit a given case. 
 Sus2)ensory bandages are used for support in irreducible 
 cases. Hernial protrusions constitute a grave danger to 
 life when they become inflamed. The unyielding aperture 
 constricts or strangulates the swollen parts, and the inflam- 
 mation ends in gangrene unless the constriction is promptly 
 relieved by a surgical operation. Rupture occurs also, but 
 with less frequency, at the middle of the groin where the 
 femoral vessels [182] pass from the abdomen to the thigh. 
 This is known as femoral hernia. 
 
 164. The hip-bones form a strong arch, supporting the 
 body and giving attachment to the powerful muscles which 
 move the lower extremities. Each consists of three bones 
 
.*. : :: .... J. . 
 
 s'oldere'cl togettter *ihkf one irregularly shaped whole; the 
 ilium forms the crest and massive side of the bone ; the 
 ischium constitutes its under portion, or that on which a 
 person rests in sitting; while ihepubes joins in front with 
 the corresponding bone on the opposite side to form the 
 pubic arch. About the middle of the outer aspect of this 
 
 Bony pelvis and upper ends of thigh-bones: A, ilium united behind with B, 
 the sacrum ; a, the crest of the ilium, and ft, its spine ; C, the ischium, and c, its 
 tuberosity ; D, the pubes, and d, the pubic arch formed by the meeting of the 
 two bones ; e, the obturator foramen or opening, closed in the body by a strong 
 membrane; E, three segments of the coccyx, the tip hidden by the pubic arch; 
 P, the femur or thigh-bone; /, its head in the cotyloid cavity; g, its neck; ft, 
 the great trochanter, and i, the small trochanter. 
 
 composite bone is a deep cavity, the cotyloid cavity, or 
 socket for the head of the thigh-bone. Dislocation is rare 
 at this joint, as compared with its frequency at the shoul- 
 der, on account of the depth of the socket, the greater 
 strength of the ligaments forming its capsule, and the 
 power of the overlying muscles. 
 
 165. The femur or thigh-bone has a strong cylindrical 
 
BONES, JOINTS AND MUSCLES. 103 
 
 shaft which expands below into an articular surface and 
 condyles [155] at the knee, and above into a round head on 
 its inner aspect, and a large tuberosity on its outer aspect. 
 The head is mounted on a neck by which it is projected 
 upward and inward from the axis of the shaft to the coty- 
 loid cavity. This carries the shaft clear of the hip-bone 
 and gives greater freedom of movement. The tuberosity, 
 the (jreat trochanter, can be felt on the outer aspect of the 
 joint, and when the foot or knee is rolled in or out, the 
 trochanter follows the motion. 
 
 166. The knee is a hinge-joint formed by the lower end 
 of the femur and the upper end of the tibia or principal 
 bone of the leg. The massive muscles on the front of the 
 thigh are inserted by a single tendon into the libia just 
 below the joint; they extend the leg on the thigh. Inti- 
 mately connected with this tendon is a roundish bone, the 
 patella or knee-cap, which protects the joint in front. The 
 muscles on the back of the femur are inserted by tendons 
 on each side of the posterior aspect of the head of the tibia, 
 constituting the outer and inner hamstring muscles; their 
 contraction flexes the leg. 
 
 167. The shaft of the tibia is three-sided, presenting one 
 of its angles along the front of the shin. At its lower end 
 it expands into an articular surface for the ankle-bone, 
 which it encloses and protects on its inner side by a projec- 
 tion called the internal malleolus. The fibula or outer bone 
 of the leg is much smaller than the tibia, to which it is 
 applied as a support or splint. Its upper end or head is 
 attached to the head of the tibia, where it may be felt just 
 below the outer aspect of the knee-joint. Its lower end 
 forms the external malleolus, which encloses and protects 
 the ankle-bone on its outer side. The muscles of the calf 
 are inserted by a strong tendon, the tendo Achillis, into the 
 
104 BONES, JOINTS AND MUSCLES. 
 
 point of the heel; they extend the foot at the ankle-joint. 
 The muscles beneath those of the calf become tendinous in 
 their lower part and pass under a ligament, between the 
 inner malleolus and the heel, to the sole, where they split 
 up into the flexor tendons of the toes. The extensors stretch 
 from the outer and fore part of the leg under a retaining 
 ligament in front of the ankle and along the upper surface 
 of the foot to the toes. 
 
 168. As the upper extremity is terminated by carpal, 
 metacarpal, and phalangeal bones, arranged as a prehensile 
 organ, the lower is terminated by analogous bones, tarsal, 
 metatarsalj and plialangeal, modified to secure strength and 
 pliability. There are seven tarsal' bones. The astragalus 
 or ankle-bone is rounded on its upper surface, which is re- 
 ceived into the concavity formed by the end of the tibia 
 and the two malleoli. It is supported on the calcaneum or 
 heel-bone; and these two articulate with the others which, 
 with the long metatarsal bones, complete the arch of the 
 foot. The phalanges are in general similar in their ar- 
 rangement to those of the fingers [158]. 
 
CHAPTER II. 
 
 THE SYSTEM OF ORGANIC LIFE. 
 
 169. THE BLOOD is the essential part of the system of or- 
 ganic life ; the accessories are the organs which elaborate the 
 blood, those which distribute, and those which purify it. 
 Every portion of the body, from the bony framework up to 
 the delicate cerebral tissues, which give a material home to 
 the INTELLIGENCE itself, depends on the supply of blood for 
 its growth and well-being. 
 
 170. The blood consists of a colorless liquid serum, 
 plasma, or liquor sanguinis, and a vast number of micro- 
 scopic cells or corpuscles which give the liquid its red color. 
 The serum contains dissolved in it albumen, similar to that 
 constituting white of egg, fibrin, which, under certain con- 
 ditions, coagulates spontaneously, and some inorganic salts. 
 When blood is drawn from the body its fibrin consolidates 
 into a soft clot which entangles the corpuscles and serum 
 in its meshes. After some hours the clot becomes smaller 
 and firmer as the coagulated fibrin squeezes out the greater 
 part of the serum which was at first enclosed in it. If the 
 coagulation takes place slowly, affording time for the cor- 
 puscles to settle a little before becoming fixed in the con 
 solidating material, the upper surface of the clot may be 
 covered with a buffy coat, a grayish-yellow layer of com- 
 paratively pure fibrin. Blood sometimes coagulates within 
 the body, as when an artery is tied [388]. 
 
 171. The cells which give color to the blood are called 
 the red corpuscles. They are circular flattened discs, yel- 
 
106 THE BLOOD ASTD ITS CIRCULATION. 
 
 lowish and translucent, each like a minute, double-concave 
 lens. They consist mainly of a substance called hcemo- 
 globin, which combines readily with oxygen, thus enabling 
 them to fulfil their mission, which is to carry oxygen to the 
 tissues for the oxidation and removal of used-up material. 
 
 172. White or colorless corpuscles are also found in the 
 blood, one for every four or five hundred of the red corpus- 
 cles. They are somewhat larger than the latter and contain 
 granular matter. In shape they are usually spherical, but 
 when closely watched they may be seen to elongate their 
 substance in one or more directions ; and as the amoeba, one 
 
 Blood-corpuscles: a, red corpuscle, full view of one side; 6, profile view; c, 
 common mode of aggregation during clotting like piles of coin ; d, a red cor- 
 puscle corrugated, probably old and ready to break down ; e, amoeboid move- 
 ments of a white corpuscle ; /, a spherical colorless corpuscle. 
 
 of the lowest forms of living matter, moves in this way, 
 these movements are said to be amoeboid. They have the 
 power of penetrating the walls of the minute blood-vessels ; 
 and as they are always present in large numbers when 
 fibrin coagulates in the tissues, they are supposed to be 
 concerned in the coagulation. 
 
 173. When the serum of the blood escapes through the 
 walls of the small blood-vessels, as a liquid through filter- 
 ing-paper, and accumulates in the tissues or cavities of the 
 body, it constitutes what is called an effusion. When the 
 white corpuscles penetrate the walls and the effused serum 
 becomes coagulated, the solidified matter is called an exu~ 
 
THE BLOOD AND ITS CIRCULATION. 107 
 
 dation. The red corpuscles escape only through accidental 
 breaks, and their presence in the tissues is known as an 
 extravasation of blood. 
 
 174. THE CIRCULATION. The living body is in a state 
 of constant change. There is a popular belief that the 
 body is renewed every seven years; but the finger-nails 
 require only a few months for their complete renewal. 
 Every organ undergoes change from day to day by the 
 removal of some of its, used-up tissue and its replacement 
 by fresh materials. A regiment may have now about the 
 same number of officers and men that it had a few years 
 ago, but the individuals that compose its numerical strength 
 are not the same ; those lost by discharge and death have 
 been replaced by recruitments. So the organs of the 
 human body are subject to processes of disintegration on 
 the one hand, and renovation by the blood on the other. 
 In every movement some minute particles of the muscles 
 become unfit for further service and have to be replaced; 
 in every thought or mental impulse some part of the ner- 
 vous system becomes used up, as the plates of a galvanic 
 battery are dissolved to develop its power. To effect the 
 repair of this constant waste a constant circulation of the 
 reparative material is needful; but although this is pro- 
 vided by nature, the activity of the destroying influences 
 is so great that recurring periods of rest or sleep are re- 
 quired to permit of the perfect recuperation of the tissues. 
 
 175. The circulation of the blood is effected by the heart, 
 which drives it through the system ; the arteries, which con- 
 duct it to the tissues ; the capillaries, from which the repara- 
 tive operations are conducted, and the veins, which gather 
 up the blood and return it in an altered and impure condi- 
 tion to the heart. Before the blood starts again on its sys- 
 temic round it is driven to the lungs, where it becomes 
 
108 THE BLOOD AND ITS CIRCULATION. 
 
 purified. This accessory to the systemic circulation is 
 called the pulmonary circulation. 
 
 176. To keep up these two currents of blood, the heart 
 is divided by a partition into two sides or chambers, the 
 left receiving and delivering pure or arterial blood, the 
 right receiving and delivering impure or venous blood. 
 These chambers are formed of muscular walls, which by 
 their contraction drive the blood into the vessels, as the 
 
 Diagram of the circulation. 
 
 hand, by its contraction on the rubber bulb of an atom- 
 izer, drives the air through its tube. The upper part of 
 each side forms a receiving-chamber or auricle for the 
 venous blood on the one side and the arterial blood on the 
 other. They become filled while the lower part of each, 
 the ventricle or delivering-chamber, is contracted in the act 
 of sending out its charge of blood. As soon as each ven- 
 tricle is emptied it relaxes, receives into its cavity the ac- 
 cumulated blood from the auricle, and again contract* to 
 
THE BLOOD AND ITS CIRCULATION. 109 
 
 
 
 drive out this fresh supply [262 J. The two sides of the 
 heart act simultaneously, so that at the ventricular contrac- 
 tion the arterial blood on the left rushes off to the tissues, 
 and the venous on the right to the lungs. To prevent a 
 reflux into the auricles at this time, the communication 
 between the chambers is guarded by valves ; and to prevent 
 a return from the vessels "during the subsequent relaxation 
 of the ventricles, the mouths of the former are similarly 
 guarded. The left ventricle is thicker and stronger in its 
 muscular walls than the other chambers, as it has to drive 
 the blood to the uttermost parts of the system. The dis- 
 charging capacity of each ventricle is about two fluid 
 ounces. 
 
 177. The heart is conical in shape, and about the size of 
 the closed fist of the individual. It is imbedded between 
 the lungs, and sustained in its position by the many large 
 vessels which connect with its upper part. A strong fibrous 
 membrane, the pericardium, forms a loose sac around it; 
 and as the interior of this sac and the exterior of the heart 
 are both coated with a smooth serous membrane, the move- 
 ments are effected without friction. The heart lies behind 
 the middle of the sternum, extending from the central line 
 of the body about three inches toward the left, but only 
 half that distance toward the right. Its lower end or apex 
 corresponds with a point two inches below the left nipple 
 and one inch to its inner side (page 99). When the ear 
 is laid over the cardiac region the heart-sounds are heard. 
 They have been likened to the pronunciation of the sylla- 
 bles lubb-dup, and are separated from the next following 
 repetition by a well-marked pause. The first sound corre- 
 sponds with the contraction of the ventricles and the rush 
 of blood through the great arteries; the second is chiefly 
 caused by the sudden closing of the valves in these arteries 
 
110 THE ARTERIES. 
 
 when ventricular relaxation begins; and the pause corre- 
 sponds with the passage of the blood from the auricles into 
 the relaxing ventricles. 
 
 178. The great artery of the systemic circulation, the 
 aorta, begins at the upper part of the left ventricle, and, 
 passing upward behind the sternum for a short distance, 
 curves backward to the left side of the vertebral column. 
 From the upper aspect of the arch arise the vessels which 
 supply the head, neck, and upper extremities. 
 
 179. The carotid arteries run upward in the neck on each 
 side of the trachea and larynx, underneath the inner margin 
 of the sternomastoid muscle, giving off large branches for 
 the neck and face, and a large vessel, the internal carotid, 
 for the interior of the cranium. One of its branches, the 
 temporal, may be felt pulsating in front of the ear, just 
 above the articulation of the lower jaw, and a branch of 
 this, the anterior temporal, may often be seen pulsating as 
 it crosses the temple on a line from the upper border of 
 the ear to above the orbit. 
 
 180. The subclavian arteries run upward and outward 
 from the arch of the aorta behind the clavicle and over the 
 upper and outer surfaces of the first rib to the axilla or 
 armpit. The axillary artery is the continuation of the 
 subclavian as it passes along the inner side of the shoulder- 
 joint and upper part of the shaft of the humerus. The 
 artery below the insertion of the pectoral muscles [153] 
 is called the brachial ; it lies along the inner margin of the 
 biceps muscle, passing from the inner side of the humerus 
 in its upper part to the front of the bone at the elbow- 
 joint, where it divides into two branches, the radial and 
 ulnar. These branches descend the forearm, overlapped 
 by muscles, but near the wrist they become superficial and 
 are easily detected by the fingers. The radial is the vessel 
 
THE ARTERIES. Ill 
 
 usually selected for ascertaining the rate and other charac- 
 ters of the arterial pulse. On reaching the palm the two 
 vessels reunite over the metacarpal bones, and from the 
 arch formed by their junction branches descend between 
 the bones, breaking up at the clefts into terminal branches 
 which course along adjacent sides of the fingers to their tips. 
 
 181. After completing its arch the aorta descends in the 
 thorax along the left side of the spinal column until, oppos- 
 ite the fourth lumbar vertebra, it breaks up into two large 
 vessels, the common iliac arteries. Each of these extends 
 downward and outward into the pelvis, where a large branch, 
 the internal iliac, is given off to the contents of the cavity, 
 its walls and the muscles connected with the outer surface 
 of the ilium. The continuation of the main trunk, under 
 the name of external iliac, reaches the middle of the groin, 
 where it enters the thigh and becomes known as the femoral 
 artery. 
 
 182. The pulsation of the femoral may be discovered by 
 the fingers from the middle of the groin downward for a 
 short distance. It then dips under the muscles and be- 
 comes lodged in a canal of fibrous tissue along the inner 
 side of the bone. At the junction of the middle with the 
 lower third of the thigh it passes backward into the poples or 
 ham, where under the name of popliteal artery it descends 
 to below the knee-joint, where it divides into two tibial 
 branches. The anterior tibial artery penetrates to the front 
 of the leg between the heads of the tibia and fibula, de- 
 scends, covered by muscles, along the outer side of the tibia, 
 and under the name of the dorsal artery of the foot forms 
 an arch from which branches are distributed to the pha- 
 langes. The posterior tibial descends along the back part 
 of the leg, becoming superficial below, where it passes be- 
 tween the internal malleolus and the tendo Achillis [167] to 
 
112 THE ARTERIES. 
 
 reach the sole. Here it forms the plantar arch for the sup- 
 ply of the toes. 
 
 183. Each of the various arteries that have been men- 
 tioned gives off branches to the parts in its neighborhood. 
 These divide and sub-divide until they reach a size but lit- 
 tle larger than the capillaries in which they terminate. 
 The small arterial vessels form a network or vascular 
 framework, in which the tissues are bedded like the cellu- 
 lar substance of a leaf between the meshes of the veinlets 
 derived from the leaf -stalk. 
 
 184. The walls of an artery are so strong and elastic that 
 when empty they do not collapse, but remain open like 
 a rubber tube. They consist of an outer coat of tough elas- 
 tic tissue, a middle layer of muscular and elastic tissue, and 
 a smooth interior lining. When the heart throws its charge 
 of blood into the arterial tubes the walls of the latter yield 
 to the dilating force, but this yielding is momentary ; the 
 contractility of the muscular coat of the vessels, closing on 
 the contained blood, forces it onward to the tissues, back 
 flow being prevented by the valves in the aorta. 
 
 185. An organ or tissue does not require the same quan- 
 tity of blood at all times. The brain when actively en- 
 gaged requires more than when asleep ; a muscle in active 
 use requires more than when it is at rest. An increase in 
 the action of the heart provides more liberal supplies when 
 the requisition is made by the system as a whole ; but local 
 requirements are supplied by the contractility of the arte- 
 ries under the superintendence of the nervous system. 
 When an organ requires an increased supply its arteries 
 become larger by the relaxation of their muscular fibres. 
 Congestions or local determinations of blood [305] in cases 
 of injury or disease are effected by this action of the mus- 
 cular coat. Nervous impressions often operate on the size 
 
THE PULSE. 113 
 
 of the vessels, as when the face becomes pale or flushes 
 under the influence of certain emotions. The contractility 
 of the middle coat has also an important bearing on the 
 suppression of hemorrhage [386]. 
 
 186. The expansion of the arterial tubes, consequent on 
 the sudden delivery into them of the contents of the left 
 ventricle, constitutes the pulse-wave as felt at the wrist or 
 elsewhere. The average pulse in the adult is about 70 or 
 75 per minute; in children it is more rapid; in infants, 110 
 or 120. A natural pulse is of normal frequency, equal 
 or regular, that is, having all its pulsations similar and at 
 equal intervals, and neither hard like a cord nor soft or 
 easily obliterated, yet susceptible of a certain degree of im- 
 pressibility by the finger. As regards the number of beats 
 per minute, the pulse is said to be slow, frequent, or rapid ; 
 the term quick pulse has no reference to frequency, but to 
 suddenness of impulse. A pulse is irregular when its beats 
 lack uniformity in strength or intervals ; intermittent when 
 one beat is omitted after a certain number of regular beats. 
 A full pulse is one of large calibre; a small pulse is gener- 
 ally rapid and weak or feeble, thready or wiry if it be 
 hard, and fluctuating if soft. A febrile pulse is rapid, 
 full, and hard if the patient be robust; rapid and small if 
 he be prostrated. Exercise increases the frequency of the 
 pulse. Its beats are more frequent when one is sitting or 
 standing than when lying. Weak pulses suffer greater ac- 
 celeration by exercise than strong ones. 
 
 187. If a part be deprived of its supply of blood for a 
 certain length of time, it will mortify. To lessen the 
 danger from accidental obstructions, the branches of one 
 artery communicate or anastomose with those of another. 
 When an artery, such as the axillary, has been wounded 
 and tied, the blood supply for the limb is kept up by 
 
 8 
 
114 THE CAPILLARIES. 
 
 anastomosis. The direct route being blocked up, the 
 current passes through one or more of the branches given 
 off above the ligature, and these, by their connections with 
 those given off below the ligature, establish 'a collateral cir- 
 culation by which the parts below the obstruction are sup- 
 plied with blood. Anastomosis is more extensive in the 
 upper than in the lower extremity, and hence gangrene 
 after injury is less common in the hand than in the foot. 
 Where the anastomosing branches are large and the collat- 
 teral current readily established, there is danger of the re- 
 currence of bleeding from the lower or far end of a divided 
 artery, unless that end as well as the upper or near one be 
 closed by a ligature. 
 
 188. As the arteries subdivide into smaller branches 
 their walls become thinner, until they end in a vast number 
 of minute tubes which surround the elementary cells or 
 fibres of the various tissues with a freely anastomosing vas- 
 cular network. The vessels of this, the capillary system, 
 are just large enough to permit the passage of the red cor- 
 puscles in single file. Their delicate walls permit the 
 plasma to exude into the tissues for the processes of growth 
 and repair ; the red corpuscles yield up the oxygen which 
 they have brought from the lungs for the oxidation or com- 
 bustion of used-up materials; heat is developed, and the 
 liquor sauguinis dissolves and washes back into the vascu- 
 lar current the carbonic acid and other more complex mat- 
 ters which result from the oxidation. These changes are 
 manifested in the blood by that darkening of its color which 
 distinguishes venous from arterial blood. 
 
 189. The veins collect the blood from the capillaries and 
 carry it back to the heart. The venous system is more 
 capacious than the arterial, for many veins have no corre- 
 sponding arteries, and all the smaller and some of the large 
 
THE VEINS. 115 
 
 arterial vessels are accompanied by two returning veins. 
 The radial, ulnar, and brachial arteries, and those of the 
 leg, have each two companion veins; but from the axillary 
 and popliteal onward to the heart the arteries have but one 
 associated vein. 
 
 190. The veins of the upper extremity unite into a single 
 trunk, the axillary vein, which, on crossing over the first 
 rib behind the clavicle, becomes the subdavian vein. Be- 
 hind the sternoclavicular articulation the subclavian unites 
 with the internal juyular, the companion of t>he common 
 carotid artery, which returns the blood from the head, face, 
 and neck. The trunks formed by these two large veins 
 join behind the sternum, forming the superior vena cava, 
 which terminates in the upper part of the right auricle 
 (page 119). 
 
 191. The veins of the inferior extremity unite into a 
 single trunk, the popliteal, which becomes successively the 
 femoral, the external iliac, and the common iliac vein. By 
 the junction- of the common iliacs is formed the inferior 
 vena cava, which runs upward on the right side of the aorta 
 and ends in the right auricle. 
 
 192. The inferior cava, in its passage upward along the 
 spine, receives blood from the kidneys, the testicles, and the 
 abdominal walls; but the blood from the organs of digestion 
 passes through the liver before entering the direct channel 
 to the heart. The veins from the intestines, the stomach, 
 and the spleen unite into one large vessel, the portal vein, 
 which enters the liver, subdividing, like an artery, into 
 smaller branches, and ultimately into a capillary system, the 
 blood of which is gathered up by a vein, the hepatic, and 
 passed into the inferior cava as the latter vessel passes up- 
 ward behind the posterior border of the organ. There are 
 thus in the liver two series of blood-vessels in fact, two cir- 
 
116 THE VEINS. 
 
 culations; the ordinary arterial circulation, ending in the he- 
 patic vein, and intended for the nutrition of the organ; and 
 the portal circulation, also ending in the hepatic vein, but 
 intended apparently for the exposure of the venous blood 
 of the digestive organs to some special action prior to its 
 admission into the general circulation. As the veins of the 
 portal system contain much crude material absorbed from 
 the stomach and intestines, it may be inferred that the ob- 
 ject of passing their blood through the liver is to prepare 
 the crude material for future use as a part of the mass of 
 the circulating blood. 
 
 193. The veins which have no corresponding artery are 
 usually superficial in position; and as the object of their 
 existence appears to be to furnish a route for the returning 
 blood when the deeper veins are temporarily occluded [195], 
 their intercommunicating branches are numerous and large. 
 The external jugular returns the blood from the exterior of 
 the head and certain parts of the face ; its branches unite to 
 a single trunk, which extends from just below the ear, down- 
 ward, across the sternomastoid, and then parallel to the pos- 
 terior border of that muscle, to the middle of the clavicle, 
 where it ends in the subclavian vein. 
 
 194. The superficial veins on the back of the fingers and 
 hand, and on the ball of the thumb and little finger, become 
 aggregated into three sets of vessels. Those on the outer 
 side of the forearm unite near the elbow to form a large 
 vein, the cephalic, which courses up along the outer border 
 of the biceps muscle to join the axillary vein. Those on 
 the inner side form the basilic vein, which continues along 
 the inner border of the biceps to join the brachial veins. 
 Those on the front of the forearm unite to a single trunk, 
 the median, which runs upward to the bend of the elbow, 
 where it divides into two short branches, the median cephalic, 
 
THE VEINS. 117 
 
 extending obliquely outward to join the cephalic, and the 
 median basilic, extending inwards to the basilic. In former 
 times when bleeding was extensively practised, the outer of 
 these communicating veins was usually selected for the 
 operation, as the inner one lies immediately over the brach- 
 ial artery, just above its point of division into the radial 
 and ulnar. The external saphenous vein collects blood from 
 the upper and outer part of the foot and the posterior as- 
 pect of the leg, and discharges into the popliteal. The in- 
 ternal saphenous vein passes along the inner aspect of the 
 
 Valves of veins : The arrow indicates the direction of the flow toward the 
 heart. 
 
 leg and the middle of the thigh to a little below the groin, 
 where it joins the femoral vein. 
 
 195. The walls of the veins are so thin that when filled 
 the color of their contents shows through them, and when 
 empty they collapse. Slight pressure closes them and ob- 
 structs their circulation. They have none of the contractil- 
 ity or elasticity that characterizes the arterial walls. After 
 death the arteries are emptied by means of this contractility, 
 but the veins are found to contain blood. The lining mem- 
 brane of the veins is pinched up at various points into folds 
 which act as valves, permitting the passage of blood toward 
 the heart, but overlapping each other and forming a parti- 
 tion across the tube when any pressure tends to force the 
 current back on the capillary system. When a muscle con- 
 tracts, the veins in its neighborhood are subjected to a pres- 
 sure which obliterates their channels ; but owing to the free 
 communication of their branches, the blood escapes into col- 
 
118 VARICOSE VEINS. 
 
 lateral veins j and this escape, by virtue of the system of 
 valves, is always in the direction of the heart. Muscular 
 movements thus accelerate the venous current. The heart 
 operates automatically. When the ventricles are filled they 
 contract to discharge the blood, and then relax to be filled 
 again. In the healthy condition the rapidity of the heart's 
 action depends on the inflow from the veins. Exercise calls 
 for more blood to the muscles, but this same exercise hastens 
 the return of the venous current and enables the heart to 
 meet the demand. When, for instance, one is rowing, the 
 deep veins are alternately filled and emptied by muscular 
 action at each sweep of the oars filled from the capil- 
 laries, and emptied in the direction of the heart through 
 the superficial veins. 
 
 196. As the walls of the superficial vessels have little 
 support from adjoining textures, they sometimes yield to 
 the pressure of the contained blood, and become permanent- 
 ly dilated or varicose. The internal saphenous vein and its 
 branches are often thus affected, becoming large, tortuous, 
 and knotty. Some long-continued obstruction is generally 
 concerned in the causation, as the pressure of tight garters 
 or that of constipated bowels on the venous trunk within 
 the pelvis. The benefit to be derived from elastic stockings 
 in such* cases is obvious. Bleeding from the rupture of vari- 
 cose veins should be restrained by compresses with a firmly 
 applied bandage. Hemorrhoids or piles are enlargements 
 of the veins around the anus and lower part of the bowel, 
 due to the pressure of constipated bowels or to conditions 
 of the liver, which obstruct the passage of the blood through 
 the portal system [192]. 
 
 197. The venous blood returned to the right auricle by 
 the superior and inferior venae cavse, is retained in that 
 chamber only until the relaxing ventricle opms to receive 
 
THE PULMONARY CIRCULATION. 119 
 
 it. The distentiou of the ventricle is immediately followed 
 by its contraction, which drives the blood into the pulmo- 
 nary artery, the branches of which divide and subdivide 
 until they reach the terminal subdivisions of the air pas- 
 
 J> 
 
 THE THORACIC ORGANS : a, right lung divided into three lobes, and 6, left 
 lung into two lobes, their anterior margins thrown back to expose the deeper 
 parts; c, trachea with its cartilaginous rings; d!, right bronchial tube; e, right 
 auricle, receiving from above/, the superior venacava, which is formed by the 
 junction of g, g, the right and left innominate veins, and each of these by the 
 confluence of /i, 7i, i, i, the jugular and subclavian of its own side; j, the right 
 ventricle, giving issue to fc, the pulmonary artery, which divides into two 
 branches, that for the right lung passing behind the other great vessels; Z, I, /, I, 
 pulmonary veins, bringing oxygenated blood to m, the left auricle ; n, the left 
 ventricle, from which the blood is carried to the organs and tissues by o, the 
 aorta; p. p, g, 3, carotid and subclavian arteries, given off from the arch of the 
 aorta. 
 
 r 
 
 sages, where they end in a capillary system which sur- 
 rounds each air cell with a vascular network. Here the 
 blood undergoes changes which are the reverse of those 
 which take place in the systemic capillaries. The red cor- 
 puscles exhale carbonic acid and absorb oxygen, and, as a 
 
120 ALIMENTATION. 
 
 result, the Wood loses its dark color and becomes a florid 
 red; heat is carried off by the watery vapor and the accom- 
 panying exhalations [243]. The oxygenated or arterialized 
 blood is gathered up by veins which complete the circuit 
 by joining the left auricle. 
 
 ALIMENTATION. 
 
 198. As the blood is subjected to a continuous loss of its 
 nutritive materials in the capillaries of the systemic circu- 
 lation, provision is made by nature to supply its elementary 
 principles. The materials of the blood are obtained from 
 the substances ingested as food. These are divided into 
 three classes the nitrogenous, the non-nitrogenous, and 
 the inorganic. The nitrogenous contribute the albuminous 
 and fibrinous principles for the repair of the muscular sys- 
 tem. They include the albumin of fresh meat, the casein 
 of milk, the gluten of flour [574] and analogous principles 
 in other vegetables as peas, beans, mushrooms, etc. The 
 non-nitrogenous replace those elements of the tissues that 
 are destroyed by oxidation during the production of force 
 and the development of animal heat. They include the 
 fats, starches, and sugars, all of which consist of carbon 
 and hydrogen in a readily oxidizable form. Taken in ex- 
 cess of the immediate wants of the system, they are stored 
 up as surplus fat, to meet the emergencies of sickness or 
 impoverished diet. The inorganic consist of various salts 
 which are usually found already prepared by nature in the 
 substances that are used as food. In wheaten flour there 
 is nearly one per cent, of mineral matters, which are just 
 those that are required by the human system ; in fresh meat 
 and all other alimentary substances there is a similar sup- 
 ply of inorganic matter common salt is perhaps the only 
 
ALIMENTATION. 121 
 
 one of this class which is added specially to the diet. To 
 these three classes a fourth is sometimes added, comprising 
 such articles as have been called accessory foods tea, coffee, 
 cocoa, alcohol, pepper, and other condiments ; but these are 
 stimulants rather than foods. Water is not usually re- 
 garded as a food, although it enters the system along with 
 the food and forms so large a percentage of the various 
 tissues of the body. Death occurs from its deprivation 
 more quickly than from the deprivation of food; men 
 have fasted for many weeks, but they will die for want of 
 water in as many days. 
 
 199. Each of the natural substances used as food con- 
 tains a proportion of all the elementary principles that are 
 needful to the formation of the blood supply. Wheaten 
 flour contains 10 to 15 per cent, of gluten, 60 of starch, 7 
 of sugar, and over 1 each of fatty and inorganic matters; 
 fresh meat yields 20 per cent, of albuminoids, varying pro- 
 portions of fat, and nearly 2 per cent, of salts; pork, 10 
 per cent, of albuminoids and a larger proportion of fat. 
 
 200. If any one of these substances contained the ele- 
 ments in the proportion in which they are required by the 
 human body, that substance would be a perfect food. Milk 
 is a perfect food for the child. It contains nitrogenous 
 matter in the form of casein, fat globules in the cream, and 
 lactose or sugar of milk and salts, chiefly phosphate of lime, 
 dissolved in its water. The requirements of the infant do 
 not vary from day to day, and the one food suffices for its 
 growth and development; but as it grows older, varying 
 conditions of exercise or repose call for more or less of the 
 nitrogenous elements, and varying conditions of external 
 temperature for more or less of the non-nitrogenous. Milk 
 then ceases to afford the proportions fitted for all the con- 
 ditions in which t.lxe individual may be placed, and articles 
 
122 ALIMENTATION". 
 
 of diet must be selected which in their totality give the 
 proportions required by the system. Great exertion calls 
 for a larger proportion of nitrogenous, great cold for a 
 larger proportion of fatty matters, while the starches and 
 sugars suffice for the wants of the system in the absence of 
 these special calls. Variety in diet, which is generally re- 
 garded as a matter of taste, originated in the necessities of 
 the system. 
 
 201. The total quantity of food necessary for support is 
 also measured by the conditions affecting the body. A 
 man who passes the day in hard labor or active exercise 
 requires that full diet of which the army ration is an illus- 
 tration. If he be in hospital with some chronic discharge, 
 which acts as a drain upon the system, a full diet is also 
 needful. Ordinarily a patient in> hospital requires much 
 less, particularly of the fatty elements, than is allowed by 
 the army ration ; and the money value of the unused por- 
 tions of the ration constitutes the hospital fund. 
 
 202. When an excess of food is taken, it is not absorbed, 
 but accumulates in the intestinal canal, undergoing changes 
 which tend to putrefaction. The acrid matters thus pro- 
 duced are taken up into the blood and induce a febrile con- 
 dition, or they irritate the intestinal canal and cause a 
 diarrhoea which brings about their expulsion. 
 
 203. A deficiency of food occasions a feeling of faintness 
 or sinking at the epigastrium, gnawing pain in the stom- 
 ach, headache, and weakness. Want of food is a common 
 and often unsuspected cause of sleeplessness. Patients in 
 hospital should never be dosed with opium when a cup of 
 beef tea with a cracker will remedy their complaint. When 
 the deficiency of food is continued, progressive weakness 
 and emaciation follow with increased liability to disease 
 and a special tendency to the scorbutic condition [77]. 
 
THE TEETH. 123 
 
 204. Mastication and Swallowing. When the pharma- 
 cist desires to extract the active principle from some root or 
 tough vegetable product, he slices, beats, or breaks it into 
 small portions that his menstruum may penetrate it and 
 dissolve out the valuable material. So nature operates in 
 dealing with the crude materials from which the elements 
 of the blood are to be extracted. To facilitate their reduc- 
 tion a liquid, the saliva, oozes from its secreting glands into 
 the mouth, to be incorporated with the triturated food which 
 it transforms into a soft pultaceous mass. The mouth, 
 
 fauces or throat, and oesophagus or gullet, are lined, like 
 the rest of the alimentary canal, with a membrane, which 
 secretes a thick viscid liquid called mucus, which lubricates 
 their interior, and enables the mouthful to glide easily into 
 the stomach. 
 
 205. If mastication be not thoroughly performed, the 
 stomach suffers in the long run. Those who would be free 
 from dyspepsia should have good teeth and make good use 
 of them. Nature provides man with two sets of teeth. In 
 the milk or temporary set there are ten teeth in each jaw; 
 four incisors, or sharp-edged cutting teeth, in front, with 
 one sharp-pointed canine, or tearing tooth, on each side of 
 them, and two broad -crowned molars, or grinding teeth, on 
 each flank of the dental line. The central incisors of the 
 lower jaw appear about the sixth or seventh month, those 
 of the upper set closely following; the lateral incisors of 
 the lower about the tenth month, followed by the corre- 
 sponding upper teeth; the anterior molars shortly after the 
 end of the first year, the canine or eye-teeth at a year and 
 a half, and the posterior molars during the third year. 
 Teething is sometimes attended with considerable local irri- 
 tation, restlessness, loss of sleep and appetite, and even 
 symptomatic febrile action ; diarrheal troubles occasionally 
 
124 THE TEETH. 
 
 alternate with inflammatory conditions of the skin covering 
 the buttocks or scalp, and sometimes convulsions are devel- 
 oped. Relief may often be afforded in such cases by lanc- 
 ing the gums when it is evident that the tooth is close to 
 the surface. 
 
 206. The permanent teeth are sixteen in number in each 
 jaw : Four incisor and two canine teeth supplant those of 
 the temporary set; four small or false molars, two on each 
 
 Central incisor of Canine or eye-tooth Second bicuspid of 
 upper jaw. of upper jaw. lower jaw. 
 
 side, called also bicuspids, because they have two points or 
 cusps on their crown, replace the molars of the child; and 
 six large or true molars, three on each side, called also 
 multicuspids, because they have several points on their 
 crown to facilitate the grinding of food, make their appear- 
 ance behind the bicuspids. The lower teeth erupt before 
 the corresponding teeth of the upper jaw; the first or an- 
 terior molars about the sixth year ; the central incisors at 
 the seventh; the lateral incisors at the eighth; the first 
 bicuspids at the ninth, and the second at the tenth year ; 
 the canines from the eleventh to the twelfth year ; the sec- 
 ond or middle molars at the thirteenth, and the third or 
 posterior molars, the wisdom teeth, as they are called, from 
 the seventeenth to the twenty-first year, or later. Some- 
 times young soldiers suffer considerably from pain and 
 
THE TEETH. 125 
 
 swelling about the back part of the alveolar arch, due to 
 the incoming of a wisdom tooth. When the swollen gum 
 overlying the crown of the tooth is cut across, the symp- 
 toms will speedily subside. 
 
 207. Each tooth is divided anatomically into the crown, 
 which is visible in the mouth ; the neck, which is embraced 
 by the gum; and the root, hidden by the gum and socketed 
 in the jawbone. The root of each of the incisors, canines, 
 
 Second molar of Wisdom tooth of Section of lower molar : a, 
 
 . upper jaw. upper jaw. dentine; 6, enamel; c, crusta 
 
 petrosa; d, pulp cavity. 
 
 and bicuspids is single and conical, the canine fang being 
 longer than the others. Each lower molar has two roots, 
 one in front and one behind, and each upper molar three 
 roots, two toward the outer and one toward the inner aspect 
 of the jaw; but the fangs of each wisdom tooth are usually 
 consolidated into one which presents grooves or markings of 
 a division into three in the upper and two in the lower jaw. 
 
 208. The teeth are composed of a substance called den- 
 tine, somewhat harder than bone. This is crowned with a 
 dense white' enamel and coated on the fangs with a thin 
 layer of true bone, which is here called crusta petrosa. In 
 the interior of each tooth is a cavity containing the dental 
 pulp, which consists of nerves and blood-vessels that enter 
 by an aperture at the end of the fang. 
 
 209. Decay takes place by the softening and breaking 
 
126 THE STOMACH. 
 
 down of the dentine, at first into superficial cavities, which 
 afterward lay open the dental pulp and, undermining the 
 enamel, permit the caving in of the crown and the total 
 destruction of the tooth. The teeth may be preserved for 
 many years by the use of the tooth brush and by having all 
 cavities filled with gold or other durable filling at the hands 
 of a dentist. Speedy decay follows neglect in all cases, 
 although some teeth and some individuals are more liable 
 to suffer than others. The anterior molars give way soon- 
 est, and are frequently decayed before the posterior molars 
 have erupted. The pain associated with this decay is 
 sometimes so severe in its paroxysmal exacerbations as 
 to call for emergency treatment [346]. A crust of tartar 
 accumulates on those parts of the teeth that are not sub- 
 jected regularly to the use of the tooth brush. This de- 
 posit, which consists of a cement of lime and organic mat- 
 ter, adheres so firmly that it has occasionally to be scaled, 
 off by a sharp steel instrument [350]. The margin of the 
 gum behind the front teeth of the lower jaw and the outer 
 surface of the posterior molars are favorite sites for its 
 accumulation. 
 
 210. The saliva contains a fermentative principle, ptya- 
 lin, which, when mixed with starch, changes that substance 
 first into dextrin and then into glucose [564]. The change 
 is immediate, so far as regards a small percentage of the 
 starch, but the fermentation is brought to an end as soon 
 as the mouthful reaches the acid liquids of the stomach. 
 
 211. The stomachy when distended, is a somewhat pear- 
 shaped bag occupying the epigastrium, its large end on the 
 left under the diaphragm, its smaller or pyloric extremity 
 on the right under the liver. [See illustration on page 
 99.] Its walls consist of flattened bundles of longitu- 
 dinal, oblique, and circular muscular fibres, with an exter- 
 
THE STOMACH. 127 
 
 nal peritoneal [161] covering and an internal mucous lin- 
 ing. Embedded in the last are many minute tubular follicles 
 from which, when required for digestion, the gastric juice, 
 an acid liquid containing a ferment, pepsin, oozes into the 
 stomach, as the perspiration sometimes oozes from the pores 
 of the skin or the saliva into the mouth during mastication 
 [262]. When a meal is taken, the gastric juice is freely 
 secreted and incorporated with the masticated food by the 
 contraction of the muscular walls of the stomach. Starch 
 and fat are unchanged in the stomach except for mechani- 
 cal division, but albuminous materials become dissolved 
 into a sour-smelling liquid called pepton, which is in part 
 absorbed by the veins of the stomach and in part escapes 
 at the pylorus along with the chyme or grumous liquid 
 which the stomach transfers to the intestine as the result 
 of its digestion. 
 
 212. The process of liquefying the albuminoids, which is 
 the object of gastric digestion, occupies from one to four or 
 five hours, according to the quantity and digestibility of the 
 food and the efficiency of the preliminary mastication. It 
 can easily be understood why a mass of tough gluten and 
 unbroken starch cells, such as exists in sodden, unraised 
 bread will cause a sense of heaviness or oppression in the 
 stomach for some time after it has been eaten. Meats that 
 have been preserved in brine become hard and difficult of 
 digestion. An excess. of fat also interferes with the action 
 of the gastric juice and prolongs the stay of the food in the 
 stomach. Veal and lamb require more time than beef or 
 mutton. Peas and beans, on account of their large propor- 
 tion of nitrogenous elements, make a greater call on the 
 powers of the stomach than the cereal grains. Poultry, 
 fish, and oysters are quickly digested. 
 
 213. The contractile walls of the stomach keep it in close 
 
128 THE INTESTINES. 
 
 contact with the food during the progress of digestion. 
 The pyloric end, leading into the intestine, is guarded by 
 a circular band of muscular fibres which permits liquids to 
 drain away, but prevents the passage of undigested food. 
 In the healthy condition there is no tendency to regurgita- 
 tion through the cesophageal opening, but in certain mor- 
 bid states of the stomach its contents are thrown out by 
 vomiting. 
 
 214. The small intestine is a long narrow tube in which 
 the chyme is treated after its passage from the stomach. 
 It measures about twenty -five feet from its commencement 
 
 at the pylorus, under the cartilages of 
 the ribs of the right side, to its ter- 
 mination in the large intestine in the 
 right iliac region just above the fold 
 of the groin. [See page 99.] It is 
 gathered up into coils which are held 
 in position by folds of a membrane 
 called the mesentery. The walls con- 
 Foids of the mucous sist of a muscular layer, covered with 
 ^o^venL Tito P eritoneiim externally, and lined with 
 small intestine. a thick mucous membrane, arranged 
 
 loosely in many pleats or folds to ex- 
 pose a greater surface to the material which passes over it. 
 The mucous membrane, besides secreting mucus for the 
 protection of itself against matters of an acrid nature, is 
 provided with many small follicles which aid the liver and 
 pancreas in the digestion of starchy substances [218]. 
 
 215. The spleen lies under the lower ribs of the left 
 side, close to the stomach. It is about the size of the fist ; 
 but as it is elastic and distensible its size depends chiefly on 
 the quantity of blood which it contains. One of its func- 
 tions is that of acting as a safety valve to the blood current 
 
THE LIVER AND PANCREAS. 129 
 
 for the supply of the digestive organs. When full and 
 actively engaged these organs require a larger blood sup- 
 ply than when empty; and as the spleen is always smaller 
 when the stomach is full than when it is empty, it is sup- 
 posed to be a distensible cistern which serves to accommo- 
 date the blood when that liquid is not required for active 
 operations in the stomach and intestines. 
 
 216. The liver [page 99] secretes a dark-greenish liquid, 
 the bile, which is stored, when not required for use, in a 
 small pear-shaped receptacle, the gall-bladder, opening into 
 the intestine near the pylorus. This secretion acts as a 
 stimulant to the muscular coat of the intestines, inducing 
 those contractions which carry the contents onward from 
 the upper to the lower end, a movement known as the peri- 
 staltic or vermicular motion of the intestine [262]. The 
 bile is strongly alkaline, saponifying fatty substances, as 
 when oil is shaken up with liquid ammonia or caustic soda, 
 and rendering them soluble and susceptible of absorption. 
 It is also an antiseptic, preserving the chyme from putre- 
 faction during its sometimes slow progress through the in- 
 testinal canal. 
 
 217. The pancreas or sweetbread secretes an alkaline 
 liquid containing a ferment, trypsin, which has the same 
 influence on starch that is possessed by ptyalin [210]. The 
 pancreatic juice operates also on the liquid albuminoids that 
 have escaped the action of the stomach, transforming them 
 into pepton ; and by its alkalinity aids the bile in reducing 
 the fats to a soluble condition. 
 
 218. The chyme diminishes in quantity as it approaches 
 the lower end of the small intestine. The pepton, dextrin, 
 glucose, and emulsified fats are absorbed by the veins of 
 the intestine, but chiefly by a set of vessels called lacteals. 
 The mucous membrane of the small intestine is so beset 
 
 9 
 
130 ABSORPTION. 
 
 with minute processes or villi as to resemble velvet. Each 
 of these processes contains a special absorbing vessel in its 
 centre. The vessels from adjoining villi unite, forming 
 larger vessels, which may be detected as whitish lines on 
 the intestine if digestion is in progress at the time of the 
 examination. The white color is due to minute globules 
 of emulsified fat in the chyle or liquid which the vessels 
 absorb. These vessels enter the folds of the mesentery, 
 where they pass through the substance of a number of 
 small bodies, each about the size of an almond. In these, 
 the mesenteric glands, a change takes place in the chyle. 
 It becomes capable of coagulating and many white corpus- 
 cles like those of the blood are found in it. After leaving 
 the glands, the vessels unite into two or three trunks, which 
 terminate in a large vessel, the thoracic duct, by which the 
 chyle is led upward along the front and left side of the 
 vertebral column to the left subclavian vein near the junc- 
 tion of the internal jugular. 
 
 219. Digestion and absorption take place in the large 
 intestine, for nutrient enemata are changed and taken up 
 by the vessels even from its lower part the rectum. Dur- 
 ing the passage of the intestinal contents along the upper 
 part of the large intestine, the secretions that were con- 
 cerned in their digestion in the small intestine are absorbed, 
 leaving only a semi-solid mass of refuse and undigestible 
 material called faces, which is excreted. A valve, the ileo- 
 ccecal [page 99] , guards the entrance to the large intestine 
 and prevents backflow into the small intestine by any move- 
 ment of compression. Attached to the head of the large 
 intestine near this valve is the appendix, a small rudi- 
 mentary organ which is sometimes the seat of dangerous 
 inflammations. 
 
 220. The blood is thus seen to be supplied with its nutri- 
 
THE LYMPH VESSELS. 131 
 
 tive material from the albuminoids, starches, fats, sugar, 
 and salts of the food, the crude results of the digestive 
 process finding their way into the circulation by the hepatic 
 vein after filtration through the liver, or by the lacteal ves- 
 sels after filtration through the mesenteric glands. The 
 lacteals are, however, only a part of a larger absorbent 
 system which pervades the whole body. This, the lym- 
 phatic system, consists of minute vessels which ramify in 
 the tissues, often following the track of the veins in their 
 junction one with another to form larger vessels. They 
 absorb from the tissues those matters that have been ex- 
 uded or formed during the nutritive or reparative processes, 
 and return them to the blood for further use as nutritive 
 material, or to be carried to the proper organ for elimina- 
 tion as refuse. Owing to the thinness of their walls and 
 the transparency of the lymph, as the liquid which they 
 contain is called, they are made out with difficulty unless 
 injected for the special purpose of displaying them. Some- 
 times, when inflamed, their tracks may be observed in the 
 living body, as when from a poisoned or festering sore on 
 the hand their red lines are found to extend along the fore- 
 arm and arm to the armpit. The flow of the lymph is oc- 
 casioned by muscular movements and valves which, as in 
 the case of the veins, direct the current onward to the 
 heart. The vessels anastomose freely with each other, and 
 at certain parts of their course are connected with small 
 glandular bodies which are usually aggregated in particular 
 localities, as the groin, armpit, neck, etc. The glands 
 effect a change in the character of the lymph, increasing 
 its coagulability, providing it with white corpuscles^ and 
 preparing it for readmission into the blood by way of the 
 thoracic duct. Matters which would poison the blood, if 
 admitted into its current, are retained in the glands, in 
 
132 RESPIRATION. 
 
 which they often set up a suppurative inflammation, which 
 leads to their own extrusion from the system. 
 
 EXCRETION. 
 
 221. EESPIRATION. The lungs fill the cavity of the chest 
 with the exception of that part in the centre and toward 
 the left occupied by the heart. [See illustrations on pages 
 99 and 119.] Each is enveloped in a serous membrane, the 
 pleura, which lines also the interior of the walls of the chest 
 and the upper surface of the diaphragm, to facilitate the 
 motion of one part on the other. The space between the 
 pleura covering the lung and that lining the walls is called 
 the pleural sac or cavity ; but in health there is no pleural 
 cavity, for the lung lies in close contact with the walls 
 which protect it. 
 
 222. Each lung is composed of the branchings of an air 
 tube and the associated divisions of the pulmonary arteries 
 and veins which carry the blood to and from the organ. 
 The air tube or trachea divides behind the sternum into 
 two branches or bronchial tubes, one for each lung. To 
 prevent its closure during movements of the neck, the walls 
 of the trachea are formed of narrow cartilaginous rings 
 closely set in a strong fibrous membrane. The ultimate 
 branches of the bronchial tubes end in minute air cells, 
 like grapes on the terminal twig of a vine, each cell sur- 
 rounded with a network of capillary vessels in which the 
 pulmonary arteries end and the pulmonary veins find their 
 origin. The air passages are lined with mucous membrane 
 covered with cells surmounted on their free ends with, mi- 
 croscopic filaments, or cilise, which, by a constant swaying 
 motion prevent the secreted mucus from backing into the 
 air cells. 
 
 223. An upward and outward movement of the ribs, with 
 
RESPIRATION. 133 
 
 a concurrent downward movement of the diaphragm [161], 
 creates a partial vacuum in the lungs, which is immediately 
 filled by inflow of air through the larynx and trachea, con- 
 stituting the act of inspiration. No sooner is this com- 
 pleted than the diaphragm relaxes, the ribs fall, and the 
 capacity of the chest being thereby lessened, some of the 
 contained air is thrown out, constituting the act of expira- 
 tion. The alternation of these two movements constitutes 
 the act of respiration, which, in the normal condition of the 
 system, is performed from fifteen to eighteen times per 
 minute, or at the rate of one respiration for every five beats 
 of the heart. The motive power in quiet respiration is 
 mainly furnished by the action of the diaphragm; when 
 the breathing is more active the muscles which elevate and 
 depress the lower ribs become engaged ; in forced respiration 
 every muscle bearing on the thorax is called into action, 
 and even those of the face participate in the movement, 
 dilating the nostrils visibly to facilitate the ingress of the 
 air. 
 
 224. The organ of voice or larynx is situated in the upper 
 part of the air tube. Its walls are here strengthened by 
 large cartilages which increase its size on its outer aspect ; 
 but internally, opposite the prominence of the cartilages, 
 the tube is narrowed to a triangular chink, the rima glot- 
 tidisj by two folds of mucous membrane, the vocal cords, 
 which vibrate in the passage of the- air current between 
 them and produce the voice. 
 
 225. The lungs have a capacity of over three hundred 
 Cubic inches, but ordinarily the air movement into and out 
 of the chest does not exceed thirty cubic inches. This 
 quantity at each inspiration enters the lungs, mixing with 
 that already there, and at expiration the same quantity of 
 the mixed air is thrown out, the removal and replacement 
 
134 RESPIRATION. 
 
 sufficing to keep the contained air pure enough to oxygenate 
 or arterialize the current of the circulation. The diffusion 
 of the inflowing air throughout the air cells occasions a 
 faint respiratory murmur, which may be heard by laying the 
 ear on the chest. It is rougher or coarser over the trachea 
 and larger bronchial tubes than over the pulmonary tissue. 
 The sound in the one case is sometimes called bronchial 
 breathing, in the other vesicular breathing. 
 
 226. The inspired air, if fresh, contains only a trace of 
 carbon dioxid, rarely amounting to .04 per cent., or 4 parts 
 in 10,000 of the air. The expired air is warmer than the 
 inspired air; it is saturated with moisture, as may be seen 
 by breathing on some cold condensing surface; and it con- 
 tains about 4. 3 per cent, of carbon dioxid. 
 
 227. The act of respiration may be suspended volun- 
 tarily for a time ; but the necessity for breathing speedily 
 overcomes any voluntary restraint by spasmodic gasping 
 efforts. When, notwithstanding these, aeration fails to 
 take place, the blood tends to stagnate in the lungs, and 
 is thrown back on the right ventricle, causing the veins to 
 become distended and the surface congested and dusky. 
 Meanwhile the circulation of venous blood in the brain 
 benumbs the consciousness of the individual, whose strug- 
 gles for breath become proportionately weaker. A person 
 thus affected is said to be asphyxiated. When the lungs 
 are sound and the deficient aeration of the blood is due to 
 some mechanical interference with the inflow of air or some 
 narcotic influence on the brain, the continuance of respira- 
 tion by artificial means [417] is often of value in saving 
 life. But difficulty of breathing is frequently due to causes 
 which affect the integrity of the lungs or air passages, and 
 which cannot be favorably affected by any method of arti- 
 ficial respiration. In pneumonia the air cells become filled 
 
RESPIRATION. 135 
 
 with exudation [173] from the capillary vessels, and the 
 patient, in fatal cases, is to all intents and purposes drowned 
 in the plasma of his own blood. In diphtheria the air tubes 
 are narrowed and perhaps occluded by the formation of false 
 membrane within them. In bronchitis the mucous mem- 
 brane becomes swollen and blocks up the tubes, or an excess 
 of secretion may produce the same effect. A slight inflam- 
 matory tumefaction of the lining membrane of the larynx 
 has frequently caused death, for the air passage between 
 the vocal cords [224] is so narrow as to be easily closed up. 
 In pleurisy, or inflammation of the pleura, the pain of the 
 inflamed surfaces rubbing against each other makes the 
 breathing shallow, and later the lung may become com- 
 pressed by an accumulation of effused serum in the pleural 
 cavity. A punctured wound of the chest admits air into 
 the cavity, and the lung becomes collapsed by the pressure 
 of the atmosphere; during respiratory efforts air enters 
 and escapes, as in the case of a leaky bellows, by the leak 
 rather than by the regular passages. 
 
 228. When the same air has been breathed and rebreathed 
 a number of times, it becomes unfit for respiratory use. 
 Those who inhale it suffer from headache, heaviness of 
 mind, and general discomfort. These effects are attributed 
 rather to the organic emanations of the used air than to the 
 carbon dioxid, for the latter, when derived from other 
 sources than human respiration, may be inhaled in large 
 proportions without harmful manifestations. 
 
 229. Fresh air contains about four volumes of carbon 
 dioxid in 10,000; but as the average man throws out 
 from his lungs .01 cubic foot per minute, or .6 cubic 
 foot per hour, the quantity in an occupied room is speed- 
 ily increased unless it be diluted and carried away by in- 
 termixture with a steady flow of fresh incoming air. The 
 
136 HESPtRATIOK* 
 
 air of bed-rooms, barrack-rooms, and hospital wards be- 
 comes oftentimes exceedingly foul at night. Instead of 
 four volumes in 10,000, the air may be charged with 
 twenty, forty, or more volumes. The quantity of carbon 
 dioxid found in breathed air gives a definite expression 
 to its vitiation. If half a fluidounce of lime water be in- 
 troduced into a clean, dry, eight-ounce bottle containing 
 the air to be examined, and shaken up vigorously for a 
 minute or two, the appearance of a turbidity from insol- 
 uble carbonate of lime in the liquid will indicate the pres- 
 ence of eight or more volumes of carbon dioxid in 10,000 
 volumes of the air examined. If no turbidity be mani- 
 fested, the air contains less than eight volumes in 10,000. 
 Keady methods of air analysis, such as that just indicated, 
 have not come into general use because they convey no 
 more information than may be gathered by the sense of 
 smell. A wholesome room should not have more than six 
 parts per 10,000 of the air. When the carbon dioxid 
 amounts to seven volumes, a want of freshness is observed 
 on entering from the outer air ; and when nine or more vol- 
 umes are present, the organic odor becomes perceptible. 
 
 230. The inflow of fresh air to take the place of air viti- 
 ated by human occupancy is known as ventilation. Its ob- 
 ject is to so dilute the products of respiration that the carbon 
 dioxid of the air of the room shall not exceed six volumes in 
 10,000; and to effect this 3,000 cubic feet of external air 
 are required hourly per man. An aperture of seventy-two 
 square inches would furnish the needful supply if the inflow 
 proceeded at the rate of two feet per second ; but if the 
 aperture were considerably smaller, ventilation could be 
 effected only by the introduction of the air at such a rate 
 as would cause danger from draughts. A corresponding 
 aperture of exit must be provided. 
 
CUTANEOUS EXHALATION. 13? 
 
 231. By natural ventilation is understood that which 
 takes place through doorways, windows, transoms, and the 
 seams of imperfect woodwork, and, if there be an open fire- 
 place, by the draught up the chimney. Heat is a powerful 
 aid to ventilation. As warm air is lighter, bulk for bulk, 
 than cold air, the warm air of a room rises to escape while 
 colder air seeks to enter below. Even when there is no fire 
 in the room the tendency of air vitiated by respiration is 
 upward, because it comes from the lungs warmer than the 
 surrounding air. When there are no special currents to 
 deflect it, the puff of tobacco smoke from the lips of a 
 smoker rises toward the ceiling. The natural exit for foul 
 air is in the upper part of a room. To ventilate satisfac- 
 torily by windows, the sashes should be lowered from the 
 top as well as raised from the bottom. But when ventila- 
 tion is effected by artificial means, the air may be drawn 
 off from any suitable point. 
 
 232. CUTANEOUS EXHALATION. The body is enveloped 
 in a tough, close-fitting elastic covering, continuous at the 
 mouth, nostrils, and other apertures with the mucous mem- 
 brane of the interior. This covering consists of the skin 
 and an underlying layer of fatty tissue. Over the flexures 
 of the joints, in the eyelids, and other parts the layer of 
 fat is thin, that motion may not be impeded, while over the 
 abdomen a thickness of several inches acts as a protection 
 to the contained organs against injury from either violence 
 or cold. 
 
 233. The skin consists of two layers : The corium, derma 
 or true skin, which overlies the fat, is composed of closely 
 interlaced elastic fibres, with vessels, nerves, hair follicles, 
 small glands and channels for the passage of matters that 
 are to be thrown out of the system. The upper layer, 
 cuticle or scarf skin, consists of microscopic cells which 
 
138 CUTANEOUS EXHALATION. 
 
 grow from the surface of the true skin, and are shed in a 
 dried up or shrivelled condition from its own free surface. 
 The cells of the cuticle are composed of an albuminous 
 material, like the nails or hair, which are indeed out- 
 growths from its structure. Their horny nature may be 
 observed on the palms of the hands after unusual labor, 
 which by intermittent pressure has excited the cutaneous 
 growth. 
 
 234. The skin is well supplied with nerves, which are 
 distributed to small processes or papillce, projecting from 
 
 Perpendicular section of the skin, showing, a, the epidermis, cuticle, or scarf 
 skin; 6, a layer of dark-colored cells; c, the papillae on the surface of d, the 
 corium, derma, cutis vera, or true skin, and e, the fat cells underlying it ; /, a 
 perspiratory pore or aperture, g, the duct, and ft, the coiled substance of a 
 sudoriparous gland ; i, the shaft of a hair, fc, its root, and I, sebaceous glands 
 communicating with the interior of the hair follicle. 
 
 the surface of the true skin like the villi [218] from the 
 mucous membrane of the small intestine. These papillae 
 are particularly numerous on the ends of the fingers, where 
 their arrangement in lines may be observed as parallel and 
 sometimes concentric ridges. The sense of touch is pro- 
 
CUTANEOUS EXHALATION. 139 
 
 portioned to their size and number. The points of a com- 
 pass, separated only one-twelfth of an inch, will be recog- 
 nized as two distinct objects by the tips of the fingers; yet 
 when separated two inches they will be felt to make but 
 one impression on the middle of the forearm, thigh, or 
 back. The cuticle gives protection to the sensitive papillae 
 by covering or sheathing them with an insensitive layer. 
 
 235. The skin is beset with hairs; each rooted on a small 
 papilla at the bottom of a follicle. From this root it rises 
 through the follicle to the surface and beyond. Small se- 
 baceous glands are packed in the interstices of the true 
 skin, their ducts opening usually into the hair follicles. 
 They secrete an unctuous matter, to prevent the skin from 
 being dried and cracked by exposure to the sun and air. 
 On the face, and particularly on the nose, their ducts some- 
 times become choked and their apertures, soiled by expo- 
 sure, appear as black points on the surface. Cautious pres- 
 sure will liberate the retained secretion in the form of a 
 tallowy cast of the duct. 
 
 236. But the elements in the structure of the skin by 
 which the purification of the blood is mainly effected are 
 the sudoriparous glands. These are small coiled tubules 
 which reach from beneath the true skin to the surface of 
 the cuticle, where their ducts terminate in minute pores. 
 They are surrounded by a vascular network from which 
 certain constituents of the blood are drawn off and trans- 
 mitted to the surface to be dissipated as insensible perspira- 
 tion or poured forth as a visible transudation. Condensed 
 perspiration or sweat is a sour-smelling liquid, containing 
 traces of saline and organic matter. The quantity of liquid 
 eliminated daily from the blood by means of these glands 
 depends on varying conditions as to exercise and external 
 temperature; but its average is about two pounds. The 
 
140 EXCRETION BY THE KIDNEYS. 
 
 process is regulated by the nervous system; for in disorder 
 of the latter perspirations may occur in the absence of the 
 conditions which are ordinarily required for their produc- 
 tion, as when the skin is pale and cold in the prostration 
 of syncope [302] or approaching death. 
 
 237. Although the removal of water from the blood is 
 one of the prime functions of the skin, the cuticle performs 
 an important duty in -preventing the general drying up 
 of the tissues by evaporation. Moreover, when the water 
 supply of the system is deficient, the skin may become an 
 absorbing instead of an eliminating organ. Immersion in 
 a bath of tepid water allays thirst. Even when the cir- 
 culation is almost at a standstill, and the patient uncon- 
 scious from a deficiency of water in the blood, he may be 
 rallied from his dangerous condition by the absorbing power 
 of the skin [405]. Nor is this power restricted to the ab- 
 sorption of water, for mercury may be taken up and the 
 system brought under its influence by means of vapor baths 
 or inunction. Absorption takes place readily from the sur- 
 face of the true skin; and before hypodermic medication 
 [502] came into use, the method of dusting or dressing a 
 blistered surface with the medicine to be absorbed was oc- 
 casionally practised. 
 
 238. URINARY EXCRETION. The kidneys are two elon- 
 gated organs situated on the wall of the abdominal cavity, 
 one on each side of the vertebral column. The tissue of 
 the kidney consists of the ramifications of blood-vessels in 
 and around a series of fine tubes which drain the urine 
 from them. These tubules unite on the inner aspect of 
 each kidney into an elastic tube, the ureter, by which the 
 liquid to be thrown out is conveyed to the bladder. 
 
 239. The bladder [161] is a strong muscular sac, coated 
 in part with peritoneum and lined with mucous membrane. 
 
EXCRETION BY THE KIDNEYS. 141 
 
 Its discharge tube, the urethra, passes from its lower and 
 fore part downward and forward beneath the pubic arch, 
 and then along the under surface of the penis. In passing 
 under the arch, the urethra penetrates a strong fibrous 
 membrane which closes in the bottom of the pelvis ; and 
 this membrane it is which forms the impediment some- 
 times encountered in passing the catheter [294]. 
 
 240. The urine consists of water holding in solution cer- 
 tain nitrogenous substances and inorganic salts. When the 
 muscles are used up by exercise they are repaired by the 
 albuminous principles of the blood, while their old and 
 degenerated material is absorbed in the form of complex 
 organic substances, which are finally converted into urea 
 and filtered off through the kidneys. Some of the transi- 
 tion products in the decomposition of albuminous substances 
 are occasionally found in traces in the urine ; one of these, 
 uric acid, is constantly present. On the other hand, in 
 morbid states not only uric acid, but many of the less oxi- 
 dized products of the decomposition of the albuminoids may 
 be found in considerable quantities in the urine. 
 
 241. The inorganic salts of the urine, consisting of chlo- 
 rids, sulphates, and phosphates of the alkalies and of lime 
 and magnesia, are derived in great part from the food [198]. 
 Chlorids are constant constituents of most articles of food. 
 Sulphates originate in the decomposition -of albuminous tis- 
 sues, the sulphur of which becomes oxidized in the body. 
 Phosphates exist naturally in both animal and vegetable 
 foods; they are derived also from the reparation of the 
 bony tissues and the oxidation of phosphorus in the dis- 
 integration of the nerves and nervous masses. 
 
 242. The average quantity of urine secreted daily is about 
 fifteen hundred cubic centimeters, or fifty fluidounces. It 
 is decreased in warm and dry weather, when cutaneous and 
 
142 ANIMAL HEAT. 
 
 pulmonary transpiration is active, for there is then less 
 water left in the system for elimination by the kidneys; it 
 is decreased also in diseases characterized by profuse watery 
 evacuations from the bowels. It is increased in cold and 
 damp weather, when exhalations from the skin and lungs 
 are at a minimum, and in morbid conditions associated 
 with dryness of skin, excepting those inflammatory or 
 febrile diseases which tend to the suppression of all the 
 secretions. Normal urine removes from the system daily 
 about an ounce each of urea and salts and eight or ten 
 grains of uric acid in the form of urates. When freshly 
 passed it is slightly acid, but after a time becomes alkaline 
 from the transformation of its urea into carbonate of am- 
 monia. 
 
 243. ANIMAL HEAT. When oxygen combines with car- 
 bon, carbon dioxid is produced, and heat is evolved during 
 the process, which is called oxidation or combustion. The 
 union of oxygen with carbon is followed by the same re- 
 sults, whether it takes place in the kitchen range or the 
 human system. In the ordinary fireplace much of the heat 
 that is produced passes off by the flue; so in the tissues 
 much of the heat produced passes from them into the cur- 
 rent of venous blood, and is thrown out by the lungs- 
 Water takes a prominent part in the regulation of the ani- 
 mal heat. When -a flame is applied to water in a flask, the 
 heat is communicated to the water and its temperature rises 
 until it reaches 212 F., when it boils; but after this its 
 temperature rises no more, although the water still receives 
 accessions of heat from the flame. Instead of becoming 
 hotter it becomes converted into watery vapor or steam, 
 and heat is absorbed during the process. Hence we can 
 understand that every breath which sends out watery vapor 
 into the atmosphere carries with it a certain amount of heat. 
 
ANIMAL HEAT. 143 
 
 This is a cooling influence which is in constant operation to 
 offset the continual heating influence of the oxidation which 
 takes place in the tissues. The water evaporated from the 
 skin is another cooling influence constantly in operation, but 
 susceptible of augmentation or decrease in accordance with 
 associated conditions. When, on account of exercise, an 
 excess of heat is generated in the tissues, the breathing 
 becomes deeper that more watery vapor may be thrown out 
 at each expiration, and the perspiration is increased to cool 
 the body by its evaporation. When, on the other hand, the 
 vital actions are conducted so gently that there is no excess 
 of heat generated, the water which would otherwise be ex- 
 haled from the skin is drawn off without loss of heat by the 
 kidneys. These two organs supplement each other and 
 keep the temperature of the body at a normal of 98.4 F. 
 If, from any cause, as a chill to the surface, the perspira- 
 tory pores are closed, the heat of the body ceases to be dis- 
 sipated and in a little while the condition which we call 
 fever is developed. The influence of a diaphoretic, such 
 as Dover's powder, in reducing fever by inducing perspira- 
 tion, is thus understood. When a particular organ becomes 
 inflamed, the active changes going 011 in its substance aug- 
 ment its heat, and a symptomatic fever [322] is established. 
 When the action of the skin ceases because of a deficient 
 supply of water in the system, the blood becomes heated 
 and the circulation disturbed, leading to a condition which 
 has been called thermic fever, but which is generally known 
 as sunstroke [404]. 
 
CHAPTER III. 
 
 THE ADMINISTRATIVE SYSTEM. 
 
 244. The ADMINISTRATIVE SYSTEM consists of the brain, 
 spinal cord, nerves, and ganglia. The brain is the nervous 
 matter contained in the cranium ; it is connected directly or 
 intermediately with every organ and tissue as the headquar- 
 ters of the body to which all the reports called sensations are 
 rendered, and from which all orders for motion or action 
 based on those reports are issued. The spinal cord extends 
 downward through the vertebral canal, giving off branches 
 or nerves at intervals from its sides. The ganglia are small 
 fragments of nervous tissue found at intervals near the 
 spinal column, or in protected situations, as behind the 
 heart and around the large arteries of the abdomen. They 
 communicate freely with each other by branches called sym- 
 pathetic nerves, and with branches of the. cerebro-spinal 
 system ; and their distribution is along the tracks of the 
 arteries, going where the blood goes. 
 
 245. A large nerve consists of minute tubules enclosed 
 in a strong protective sheath, as the insulated wires of a 
 telegraph cable are enclosed in a non-conducting covering. 
 The branching of a nerve is like the splitting up of the 
 cable for the proper distribution of its contained wires. 
 Each tubule, representing a wire, ultimately reaches its ter- 
 minal station, where by its means messages may be con- 
 veyed to and from the brain. 
 
 246. The brain is a somewhat egg-shaped, pulpy body, 
 divided from before backward into two contiguous hemi- 
 
THE NERVOUS SYSTEM. 
 
 145 
 
 spheres ; but the line of division does not extend all the 
 way down, for about its middle there is a broad bridge of 
 communication between the two sides. The surface presents 
 also grooves called sulci, and as these give the brair. the ap- 
 pearance of consisting of a packed mass of irregular coiled 
 
 THE HEMISPHERES OF THE BRAIN: A, the right; B, the left, divided from be- 
 fore backward by a, b, the longitudinal fissure, and connected by c, the bridge 
 of transverse fibres called the corpus callosum. On the right side the convolu- 
 tions and sulci are shown ; on the left the upper part of the convexity of the 
 hemisphere has been cut away to show the gray matter d, d, dipping into the 
 sulci and appearing as islands, e, e, in the interior of the white matter; the 
 elongated cavity with curved extremities is the lateral ventricle of that side. 
 
 tubing, the seeming coils are spoken of as the cerebral convo- 
 lutions. The exterior of the brain consists of gray, cineri- 
 tiousj or vesicular matter, the interior of white or medullary 
 matter. The latter is a compact mass" of nerve tubules con- 
 necting various parts of the gray matter with each other 
 and with all parts of the body. There are several cavities, 
 called ventricles, in the interior of the brain, their walls 
 10 
 
146 THE NERVOUS SYSTEM. 
 
 lined with gray matter. The brain weighs about fifty 
 ounces, but the quantity of vesicular matter varies with 
 the number of the convolutions and the depth of the sulci. 
 The intelligence appears to be proportioned to the quantity 
 of gray matter which envelops the white matter of the 
 brain. 
 
 247. The interior of the cranium is lined with a strong 
 fibrous membrane, the dura mater, which sustains and sup- 
 ports the brain, and supplies the nerves with a protective 
 covering as they pass through the bony apertures. Inter- 
 nally it is faced with a serous layer, the arachnoid, which 
 is reflected loosely over the convolutions, the two smooth 
 surfaces lessening the risk of injury from jolting, just as 
 the peritoneum [161] protects the abdominal organs from 
 injury by friction. Beneath the arachnoid and in close 
 contact with the brain matter is the pia mater, composed 
 of a fine network of nutrient blood-vessels. 
 
 248. The spinal cord is protected by a strong sheath, 
 which is lined like the dura mater. It consists chiefly of 
 nerve tubules, but a curved streak of gray matter extends 
 throughout its length on each side of its middle line. The 
 nerves which emerge in the cervical region divide on each 
 side into two sets, an upper and a lower. The former are 
 distributed to the head, neck, and interior of the chest, one 
 of them, the phrenic, being the medium by which the re- 
 spiratory movement of the diaphragm [161] is sustained. 
 The latter form an interlacement of large cords, called the 
 brachial plexus, which crosses the upper part of the armpit 
 with the axillary vessels, and is distributed to the upper ex- 
 tremity. The dorsal nerves supply the walls of the chest 
 and abdomen. The lumbar and sacral nerves are distrib- 
 uted to the pelvis and hips, but several of them unite on 
 each side into one large cord, the great sciatic nerve, which 
 
THE NERVOUS SYSTEM. 147 
 
 extends along the back of the thigh, and breaks up into 
 branches for the supply of the lower extremity. 
 
 249. There are two kinds of nerve tubules: Nerves of 
 sensation, or sensory nerves, convey information to the gray 
 matter of the brain ; nerves of motion, or motor nerves, trans- 
 mit from the gray matter the influence by which the mus- 
 cles are brought into action. When a sensory nerve is cut 
 across, the area of its distribution loses its feeling because 
 the information concerning its condition does not reach the 
 gray matter of the brain. When a motor nerve is severed, 
 the muscles which it supplied become paralyzed, because the 
 orders emanating from the gray matter do not reach them. 
 Most of the nerves contain both motor and sensory fila- 
 ments ; but some are purely motor, as the facial, a cerebral 
 nerve, which supplies the muscles of the head and face. 
 On its way out of the cranium it traverses the middle ear 
 [259], and when it becomes involved in certain destructive 
 diseases of that organ, the corresponding side of the face 
 loses the power of motion, becoming blank and expression- 
 less, but retains sensation, for the sensory filaments are de- 
 rived from another nerve. The motor filaments of the 
 spinal cord are aggregated in its anterior part ; the sensory 
 filaments in its posterior part. Hence the lower limbs 
 of a patient may be paralyzed and yet retain their sensa- 
 tion, because the posterior part of the cord has not suf- 
 fered from the disease or injury so much as the anterior 
 part. 
 
 250. The nerves from certain organs bring special in- 
 formation to the brain. The optic nerves transmit impres- 
 sions as to light or shade, color, form, size, distance; the 
 auditory nerves bring impressions of sound; those of taste 
 and smell guard the entrance to the alimentary and respira- 
 tory tracts ; and from certain parts, as the tips of the fin- 
 
148 THE KERYOUS SYSTEM. 
 
 gers, come sensations giving definite ideas as to certain 
 properties of external objects. 
 
 251. The eye is protected by its deep situation in the 
 socket, by the projecting ridge of the frontal bone and the 
 quick movement of its upper lid. It is a small, globular- 
 shaped camera, covered in front by mucous membrane, the 
 conjunctiva. The rays of light enter through the cornea, 
 which is set into the front of the eyeball like a watch-glass 
 
 The rays from the object A B are brought to a focus on the retina at C D t 
 where an inverted image is formed as in the camera of the photographer. 
 
 over the dial plate. Behind the cornea is a colored curtain 
 of muscular fibres, the iris, with a central aperture, the 
 pupil, which becomes contracted or dilated, according as 
 the light is strong or v weak. The crystalline lens, situated 
 behind the iris, brings the rays to a focus on the retina, a 
 delicate expansion of the optic nerve. The whole is en- 
 closed, except on the corneal front, in a strong casing of 
 white fibrous tissue, the sclerotic coat. 
 
 252. When a camera is out of focus the lens is moved 
 forward or backward by a screw until the image is clearly 
 outlined on the ground-glass screen. In the eye a small 
 muscle increases the refracting powers to bring the rays 
 from near objects to a focus on the retina. This is called 
 the power of accommodation of the eye. 
 
 253. An individual should see distinctly at six hundred 
 yards a black centre, three feet in diameter, on a white 
 
THE NERVOUS SYSTEM. 149 
 
 ground, or at twenty feet a circular spot, four-tenths of an 
 inch in diameter, ou a white card. An eye which responds 
 to this test is emmetropic or normal. 
 
 264. In elderly people vision for distant objects remains 
 normal, but that for near objects is impaired. In reading, 
 the sight has to be aided by convex glasses. This condition 
 is called presbyopia. 
 
 255. When the lens is too convex or the refracting media 
 of the eye too powerful, the rays from distant objects are 
 brought to a focus before they reach the retina. The spot 
 on the card must be brought nearer than twenty feet to be 
 clearly distinguished, or a concave glass must be placed 
 before the eye to diminish its refracting power. This is 
 the condition of myopia, or short-sightedness. 
 
 256. When the lens is too flat or the refracting media 
 too weak, the parallel rays from a distant object fail to 
 reach a focus until they have passed behind the retina; and 
 bringing the object nearer increases the difficulty. This, 
 the condition of hypermetropia or long-sightedness, requires 
 convex glasses to aid the eye in focussing the rays. 
 
 257. When the cornea is irregular in its curvature, a 
 vertical line may be seen clearly, while a horizontal line 
 crossing it is blurred or indistinct. This defect, astigma- 
 tism, cannot be remedied if the corneal surface is so faulty 
 as to distort the outlines of objects like a piece of poorly 
 made window-glass; but if there is merely a bulge or a 
 flattening at some particular point, special glasses may be 
 fitted. 
 
 258. Color-blindness is an inability to recognize certain 
 colors. When a man who is green-blind is presented with 
 a skein of worsted of that color and desired to pick from a 
 stock of various colors the skeins which correspond with it 
 in color, irrespective of shade, he will select and add to his 
 
150 THE NEBVOUS SYSTEM. 
 
 green samples skeins of other colors, mostly neutral tints, 
 as grays, drabs, etc,, which seem to him to have the same 
 depth of shade as his test skein. When he is presented 
 with a roseate skein one having a tinge of purple in its 
 redness he will match it with shades of green or gray; 
 and when tested with a bright-red skein he will bring for- 
 ward light greens and browns as corresponding with it in 
 color. A red-blind man can see the purple but not the red 
 in the roseate test skein, and so selects light shades of blue 
 and violet as samples of the roseate color. When presented 
 with a bright-red skein, he matches it with shades of green 
 and brown that seem to the normal eye to be darker than 
 the test skein. 
 
 259. The external ear consists of a framework of pliant 
 cartilage bound to the bony parts by strong fibrous tissue. 
 At the bottom of the shell, or concha, is the opening of the 
 external auditory canal, which conveys the vibrations of the 
 air to the tympanum or drum of the ear. Its entrance is 
 beset with hairs to exclude insects, and its sebaceous folli- 
 cles [235] secrete a bitter waxy substance. This canal 
 extends inward and forward for about an inch, curving 
 slightly, so that its middle part is somewhat higher than 
 its ends [430], The middle ear consists of a small cavity 
 in the interior of the temporal bone. It is lined with a 
 delicate mucous membrane, and any mucous secretion that 
 may gather in it drains off by a tubular passage, the Eu- 
 stachian tube, into the back part of the throat. Ordinarily 
 the walls of this tube are in apposition, but during swal- 
 lowing they become separated. In blowing the nose, air is 
 sometimes forced into the tympanic cavity, giving rise to a 
 feeling of distention in the middle ear, which is, however, 
 immediately relieved by the movement of swallowing. 
 When the Eustachian tube is obstructed, as frequently 
 
THE NERVOUS SYSTEM. 151 
 
 happens from the swelling of an ordinary sore throat, a 
 temporary deafness may be developed because air cannot 
 get into the tympanic cavity to support the drum of the 
 ear on its inner side against the pressure of the external 
 air on its outer side. The internal ear is a complex ar- 
 rangement of the nervous tissue by which the vibrations of 
 the tympanum are conveyed to the brain. 
 
 260. The olfactory nerve is distributed to the mucous 
 membrane covering the upper part of the interior of the 
 nose. It enters from the brain through apertures in a thin 
 plate of bone which forms part of the floor of the cranium 
 and the roof of the nasal cavity. 
 
 261. The tongue is the organ of taste, but some special 
 nervous filaments are distributed to the palate and fauces. 
 It is supplied also with nerves of common sensibility, which 
 enable it to detect extraneous matters in the food during 
 mastication. It consists of longitudinal and transverse 
 muscular fibres, which by their contraction enable it to 
 assume almost any form. Its surface is roughened with 
 close-set papillae which are covered with mucous membrane. 
 A longitudinal furrow on its upper surface ends behind in 
 a depression near the base of the tongue; and from this 
 point some large papillae project outward and forward, in 
 the form of a V. To impress the nerves of taste a sub- 
 stance must be in solution or soluble in the liquids of 
 the mouth. If the substance is insoluble it is recognized 
 only by the nerves of common sensation as insipid, gritty, 
 etc. 
 
 262. In the government of the army only such matters 
 as affect the general welfare are forwarded for the action 
 or decision of the War Department; minor and routine 
 matters are disposed of by subordinate commanders. So 
 in the human system, many sensations or reports are trans- 
 
152 THE NERVOUS SYSTEM. 
 
 mitted by the nerves, which are not of sufficient importance 
 to call for special action by the INTELLIGENCE at headquar- 
 ters ; these are disposed of by what is called reflex action. 
 When the toes of a patient are tickled or pinched, the mus- 
 cles of his thigh and leg are brought into action, and the 
 foot is drawn away. This may be a voluntary act. The 
 sensation may be received and appreciated by the brain, 
 and in consequence a motor influence may be sent out to 
 effect the withdrawal of the foot from the cause of the irri- 
 tation. But, on the other hand, it may be involuntary and 
 independent of sensation, as when it occurs in a paralyzed 
 limb. In such a case the gray matter of the spinal cord 
 takes note of the sensation, recognizes it as being not of 
 sufficient importance to be forwarded to the brain, and it- 
 self sends out orders to meet the needs of the case. Most 
 of the routine acts of life are regulated by this action of the 
 gray matter of the spinal cord. When an individual walks, 
 the pressure of his weight on the sole of the foot is trans- 
 mitted to the cord, and elicits the motor influence for the 
 continuance of the movement. Separate acts of volition 
 are not required for the various motions that make up each 
 step of a prolonged walk. But it is in the regulation of the 
 functions of the various organs that reflex action has its 
 greatest field of operation. The whole of the business of 
 organic life is conducted by the nervous matter of the gan- 
 lia [244], and the gray matter of the brain receives intel- 
 ligence only when something goes wrong. When the ven- 
 tricles of the heart become filled with blood the sensory 
 filaments report the fact to the cardiac ganglion, and orders 
 are issued for immediate contraction. When there is an 
 insufficiency of oxygen in the lungs the ganglionic nervous 
 matter is informed, and, according to the necessities of the 
 case, a deep or shallow inspiration is taken [223]. When 
 
THE NERVOUS SYSTEM. 153 
 
 masticated food reaches the fauces the muscles of degluti- 
 tion are called into action. When food enters the stomach 
 its presence is announced and, from a special ganglion, the 
 standing orders for the needful increase in the supply of 
 blood and the prompt secretion of the gastric juice [211] 
 are carried out. Contact of the chyme with the intestinal 
 lining produces the vermicular or peristaltic movements 
 [216], which carry the alimentary mass onward from coil 
 to coil. The functions of the kidneys, liver, skin, etc., are 
 all thus regulated and co-ordinated by reflex influence. 
 This system is sometimes called the sympathetic nervous 
 system, because by means of its connection with the cere- 
 bro-spinal nervous filaments the organs which it regulates 
 are to a certain extent brought into relation or sympathy 
 with the mind or will. The cheeks, for instance, flush or 
 pale, and the heart palpitates or fails under the influence 
 of mental emotions, and the will exercises a limited con- 
 trol over the respiratory movements. 
 
 263. Eeflex action from ganglionic or spinal nervous 
 matter relieves the gray substance of the brain from the 
 care of supervising the normal action of the organs and the 
 routine movements of the body, leaving its energies to be 
 expended in the exercise of the mind and will. That the 
 INTELLIGENCE finds enough to do in this way is shown by 
 the necessity for sleep. The brain is well supplied with 
 blood to repair its waste, part of which appears in the urine 
 as phosphates [241]; yet the rapidity of the waste is such 
 that a certain number of hours in every twenty-four must 
 be given up wholly for recuperation. Nothing manifests 
 the independent character of the reflex acts so clearly as 
 their continuance during sleep, when the intelligence is pro- 
 foundly suspended. The heart beats, the chest heaves, the 
 arterialized blood circulates, the liver, kidneys, skin, etc., 
 
154 THE NERVOUS SYSTEM. 
 
 perform their various functions under the controlling influ- 
 ence of the ganglionic system, and if the position of the 
 body or limbs be in any way uncomfortable, the gray mat- 
 ter of the spinal cord intercepts the message, and rectifies 
 the position without disturbing the sleeping INTELLIGENCE. 
 
PART III. 
 
 THE SPECIAL DUTIES OF THE HOSPITAL 
 CORPS. 
 
 CHAPTER I. 
 
 MANAGEMENT OF ACCIDENTS, ETC. 
 
 264. A seriously wounded or sick man must be removed 
 to hospital without delay, except when immediate treat- 
 ment offers the only hope of saving life. 
 
 If the patient be insensible, place him on his back with 
 a support under his head; remove his neckwear and un- 
 button the clothing on his chest. Then sprinkle cold water 
 on his head, face, and chest, and put some to his lips to 
 ascertain if he has the power of swallowing. The nature 
 of the case should be made out, with a view to relieving 
 urgent symptoms and preventing injury during transpor- 
 tation. 
 
 265. If the injury be obvious, ascertain its characters; 
 if obscure, inquire of the bystanders what is known con- 
 cerning its history or cause. Personal examination of the 
 patient must be made with the utmost gentleness, lest harm 
 be done to some undiscovered injury. When facilities are 
 available, the case should be treated as at the first dressing- 
 station of field service [41, 365] . All symptoms observed 
 during this examination should be noted mentally for the 
 information of the medical officer, because some change 
 
156 MANAGEMENT OP ACCIDENTS, ETC. 
 
 may take place in the condition of the patient before he 
 comes under medical supervision. 
 
 266. When there is much prostration, the patient's head 
 must be kept low ; and if he has lost so much blood as to be 
 notably weak or faint, efforts should be made to revive 
 him before removing him to hospital. In no case while in 
 this exhausted state should he be placed on his feet or re- 
 quired to make exertion, however slight, in his own behalf 
 lest he fall into the condition of. syncope. If the case is 
 one of external hemorrhage, an ounce of brandy or whis- 
 key, with .020 morphine, should be administered before 
 placing him on the litter; but if the hemorrhage is inter- 
 nal, faintness should be relieved by small doses, twenty or 
 thirty drops, of aromatic spirit of ammonia at short inter- 
 vals in a spoonful of water. 
 
 267. In moving a case of fractured thigh or leg, one per- 
 son should support the fractured parts; and before trans- 
 porting the patient on the litter the foot of the injured limb 
 should be tied to the other, to prevent its rolling outward 
 by its own weight ; and support, as by a blanket rolled into 
 a cylinder, should be applied along the outer side of the 
 limb. 
 
 268. At the hospital the patient is prepared for bed by 
 removing his clothes, ripping the seams, if necessary, 
 cleansing soiled surfaces, and applying dressings. When 
 the patient is unconscious or paralyzed, the mattress should 
 be protected by rubber or gutta-percha cloth under the 
 sheets, and a folded blanket, covered with a draw-sheet, 
 should be placed under the hips. 
 
 269. The private of the hospital corps on ward duty 
 should be an intelligent, careful, and even-tempered man. 
 His duties as relating to the routine work of the ward are 
 easily learned ; but a long experience is needful to fit him 
 
QUALIFICATIONS OF A NURSE. 157 
 
 for those pertaining to the treatment of the sick. He is 
 responsible for the ventilation, heating, cleanliness, and 
 discipline of his ward. He stands by the bedside during 
 the visit and listens attentively to the instructions of the 
 surgeon. He obtains the medicines from the dispensary, 
 and administers them as directed; and in special cases 
 feeds the patients and attends to all their personal wants. 
 These duties require tact and gentleness, for sick men are 
 often irritable and difficult to please. He should note care- 
 fully all changes in the symptoms for the information of 
 the steward and medical officer. Changes in the pulse, 
 temperature, and respiration are recorded in most of the 
 serious cases; the frequency and character of the dis- 
 charges, the occurrence of cerebral disturbance, the times 
 and duration of sleep, and any complaint of pain or any 
 abnormal sensation felt by the patient should also be care- 
 fully recorded. The more a nurse knows of the condition 
 of a patient the greater is his value, for inexperience and 
 want of knowledge will often call unnecessarily for assist- 
 ance, while, on the other hand, they may consider as un- 
 important some change which is of vital interest. 
 
 270. Ordinarily the patient should have a bath before 
 being put to bed. A warm bath, from 85 to 98 F., 
 soothes the system, predisposing to sleep, while it cleans 
 the skin and promotes its activity. A tepid bath, from 65 
 to 85, has little value in hospital practice. A cold bath, 
 below 65, and a hot bath, above 98, are powerful influ- 
 ences : the former, when the immersion is short, is followed 
 by warmth and tingling of the surface ; the latter quickens 
 the pulse and respiration, congests the surface, and may in- 
 duce faintness. When the hot bath is followed by free per- 
 spiration its action is salutary ; but when it occasions ful- 
 ness in the head, throbbing, and giddiness, its influence is 
 
158 SURGICAL OPERATIONS. 
 
 harmful. Cold baths are seldom used for the sick, as a cer- 
 tain vigor of constitution is needful to enable reaction [304] 
 to take place. The hot-air bath is often conveniently sub- 
 stituted for the hot bath, as it may be given by the bedside, 
 the patient sitting on a cane-bottomed chair, with a spirit- 
 lamp beneath, and blankets draped around him from the 
 neck to the floor to confine the heated air. 
 
 272. Preparations for the performance of a surgical oper- 
 ation can be made only by one who has a knowledge of 
 what is to be done. Preliminary to operation the surgical 
 staff and nurses, the dressings, instruments, and patient, 
 must undergo a systematic preparation. 
 
 Disinfection of the Hands. All rings are removed, and 
 the hands and forearms are scrubbed for five minutes with 
 soft soap and hot water, particular attention being given to 
 the nails ; after drying, the parts are washed with alcohol 
 and then in a solution of bichlorid, 1 to 2,000, in warm boiled 
 water. Some surgeons, after washing with soft soap, make 
 the skin mahogany brown with permanganate of potassium, 
 subsequently decolorizing with oxalic acid solution, and then 
 lessening the irritation of the skin by washing in boiled lime- 
 water. 
 
 Disinfection of Dressings. These are steamed in a steri- 
 lizer for twenty minutes, after which they are removed with 
 aseptic hands to jars which have been scrubbed with soft 
 soap and afterward with bichlorid solution. The contents of 
 the jars are covered with sterilized towels soaked in bichlorid. 
 
 Disinfection of Instruments. Every knife or sharp-edged 
 instrument is wrapped in gauze, to preserve its edge from 
 injury, and boiled for five minutes in a one-per-cent. soda 
 solution. Each is then removed with aseptic fingers, and 
 all are arranged in pans containing sterilized water and 
 covered with sterilized towels. 
 
SURGICAL OPERATIONS. 159 
 
 The needle of a hypodermic syringe is boiled with the in- 
 struments ; but the barrel and piston are soaked an hour in 
 carbolic acid, five per cent., in alcohol. 
 
 Silk thread or silver wire is wound on glass rods or spools, 
 and boiled with the instruments or steamed with the dress- 
 ings. Rubber drainage-tubes and catheters are boiled or 
 steamed j silkworm gut is boiled five minutes in alcohol ; 
 and catgut is soaked in ether for two days and then put in 
 alcohol in a firmly corked bottle, which is boiled in water 
 for two hours. 
 
 Disinfection of the Patient. If possible, on the day be- 
 fore the operation the patient is given a bath ; the area of 
 operation is shaved, washed with soft soap and water, 
 rinsed off with boiled water, washed with alcohol, and 
 scrubbed with bichlorid solution, after which the part is 
 covered with aseptic gauze, secured with a bandage. On 
 the day of the operation the patient is bathed and given a 
 clean flannel shirt. The area of operation is then treated 
 as on the previous day, and the patient placed on the oper- 
 ating-table and covered with a sterilized sheet. All persons 
 assisting should wear sterilized linen gowns, the hair cov- 
 ered with a sterilized towel, and the hands disinfected; 
 and whenever an object not aseptic has been touched, the 
 hands should be bathed in bichlorid again. 
 
 273. A table of suitable height and length should be 
 covered with two or three folds of blanket, overlaid by a 
 disinfected rubber cloth, and provided with a low pillow 
 for the head. Chloroform or ether [276] is then adminis- 
 tered. The limb, if an amputation is intended, is then 
 elevated and emptied of blood by pressure with the hands 
 in the direction of the trunk, after which the tourniquet 
 [387], which has already been placed in position, is screwed 
 up to stop the circulation. Esmarch's bandage [275] may 
 
160 
 
 SURGICAL OPERATIONS. 
 
 be used to empty the limb, and his hollow rubber cord to 
 control the inflow of blood. The surgeon now cuts the soft 
 parts to the bone, and the flaps, or incised tissues, are in- 
 
 Amputation of the thigh. 
 
 stantly gathered up in the hands of an assistant, who draws 
 them in the direction of the trunk, out of the way of the 
 saw. Sometimes, instead of his fingers, the assistant uses 
 
 A bone-cutting forceps. 
 
 for this purpose a retractor, a piece of muslin two feet 
 long, and as wide as the diameter of the limb operated on. 
 This is torn for half its length down its middle, and the 
 
 A spring or artery forceps. 
 
 two strips are made to embrace the bone at their point of 
 junction, so that by traction on the muslin the soft parts 
 are protected. During the application of the saw the as- 
 sistant in charge of the limb is careful to do no more than 
 support its weight j if he do more than this he will lock the 
 
SURGICAL OPERATIONS. 161 
 
 saw between the freshly sawn surfaces, and if he do less 
 the unsupported part of the weight may splinter off the 
 under part of its upper fragment. On. the removal of the 
 limb the surgeon smoothes the edges of the bony stump 
 with a scraper or strong-backed, blunt scalpel, and may 
 have to use a bone-cutting forceps to round off sharp an- 
 gles. The prominent arteries are then picked up by for- 
 ceps or tenaculum, and tied [389] ; and the tourniquet is 
 gradually relaxed to permit those that remain unligatured 
 to indicate their position by their leakage. When these 
 are secured, the tourniquet is removed and the cut sur- 
 faces are well washed with sterilized water until all oozing 
 has ceased, after which they are carefully bathed with an 
 antiseptic lotion, united by sutures [356], and dressed. 
 
 274. The provision for such an operation includes, there- 
 fore, a suitable operating-table ; an anaesthetic, and handker- 
 chief, or cone and sponge, for its administration ; hot and 
 cold water supplies, basins, gauze, and towels; disinfecting 
 solutions j amputating knives, among them a double-edged 
 
 c 
 
 A tenaculum. A scalpel. 
 
 one, or catlin, if the forearm or leg be concerned in the oper- 
 ation; scalpels, for incidental use, and one with a strong 
 back as a bone-scraper ; a bone-cutting forceps ; several ar- 
 tery forceps, tenacula, and ligatures, with needles and pre- 
 pared silk or gut for sutures ; dressings, and ' brandy or 
 whiskey for use in case of need. 
 
 275. Esmarch's bandage is a broad elastic roller, applied 
 from the toes or fingers upward, to compress the soft parts 
 and drive the blood before it toward the trunk. When the 
 bandage has reached a point three or four inches above the 
 
 11 
 
162 SURGICAL OPERATIONS. 
 
 site of the intended operation, a piece of strong elastic tub- 
 ing or flat band, with hook and chain attachment, is wound 
 several times around the limb to cut off its circulation, after 
 which the bandage is removed and the limb is ready for 
 operation. The removal of the strong tubing, which acts 
 the part of tourniquet in this method, is often followed by 
 profuse oozing. To prevent it, some operators close the 
 wound and elevate the stump before entirely removing the 
 tubing ; others attempt to control it by the application of 
 hot water, 150 to 180 F. ; but perhaps the best method is 
 that which shortens the period of pressure by the substitu- 
 tion of the ordinary tourniquet for the tubing as soon as the 
 principal arteries have been tied. 
 
 276. Anaesthetics produce insensibility to pain. Chloro- 
 form, ether, and nitrous oxid or laughing-gas are the anaes- 
 thetics chiefly employed. The last-mentioned is used by 
 dentists in the extraction of teeth ; the evanescent nature 
 of its effects renders it unsuitable for operations that re- 
 quire time for their performance. The two others are used 
 in general surgery. They induce a condition of excitement 
 which is followed by insensibility. After a few inhalations 
 the face becomes flushed, and the pulse and breathing are 
 excited; the patient may be talkative and noisy, jovial or 
 quarrelsome, but is always incoherent, and often straggling 
 in his delirious fancies. Afterward muscular power and 
 sensation are lost, as evidenced by the inability of the pa- 
 tient to sustain the weight of his arm when it has been 
 raised by the surgeon, and his failure to wink when the 
 conjunctiva is touched. His breathing is quiet, and his 
 pulse full and regular, but perhaps somewhat slower than 
 natural. The object of the administrator is to prolong this 
 condition to the close of the operation ; if he give too little, 
 the patient may begin to struggle; if he give too much, 
 
SURGICAL OPERATIONS. 163 
 
 stupor with stertorous breathing is developed. Usually the 
 movements incident to dressing the wounds arouse the pa- 
 tient ; failing this, consciousness is recalled by slapping the 
 forehead and chest lightly with a cold, wet towel. 
 
 277. A larger quantity of ether than of chloroform is re- 
 quired to produce the anaesthetic effect ; its vapor is more 
 irritating, causing cough, feelings of suffocation, and dis- 
 inclination on the part of the patient to continue the in- 
 halation; it is highly inflammable, and hence dangerous 
 under certain conditions; the excitement produced is more 
 violent, and its period more protracted, particularly if the 
 vapor be much diluted. The respiration under ether is less 
 regular, being often shallow and spasmodic. Its after- 
 effects headache, confusion of mind, nausea, and general 
 malaise are of greater intensity, and last longer than those 
 which follow the use of chloroform. The latter, therefore, 
 has many points in its favor ; but these are counterbalanced 
 by the greater risk of death : many more deaths from chlo- 
 roform than from ether have been reported. 
 
 278. Chloroform is best administered from a conical 
 sponge, or a soft handkerchief folded to a square of some- 
 what more than four inches. One or two drachms are 
 poured on, and the patient is told to breathe deeply, while 
 the sponge or handkerchief is held over his mouth and nos- 
 trils at such a distance as will permit a mixture of atmos- 
 pheric air with the indrawn current of anaesthetic vapor. 
 As soon as the handkerchief loses the freshness of the chlo- 
 roform odor, another similar quantity is sprinkled over it. 
 As the vapor is much heavier than air, there is no need of 
 oiled silk or other impervious covering to the upper surface 
 of the sponge or handkerchief. During the period of ex- 
 citement, the quantity of entering air should be diminished ; 
 but as soon as the patient sinks, with a deep breath or sigh, 
 
164 SURGICAL OPERATIONS. 
 
 into a condition similar to that of quiet sleep, the handker- 
 chief should be raised to admit of a freer entrance of air. 
 The free admission of air is important; a small quantity of 
 chloroform vapor permeating the system to the exclusion of 
 air is far more dangerous than a larger quantity adminis- 
 tered with proper precautions. If the patient show any 
 sign of returning consciousness, a freshening of the chloro- 
 form supply, or a lowering of the handkerchief to increase 
 the percentage of vapor inhaled, is required; and, on the 
 other hand, if the breathing begin to be stertorous, the 
 handkerchief may be laid aside for the time being. But 
 meanwhile the administrator must permit nothing to inter- 
 fere with his guard over the pulse and respiration of the 
 patient. The slightest irregularity in either dictates the 
 temporary withdrawal of the vapor. When chloroform 
 proves dangerous, it is usually by a stoppage of the heart, 
 sometimes of the breathing. When this happens, the oper- 
 ation must be suspended, fresh air admitted into the room, 
 the patient placed with his head considerably lower than 
 his body, his tongue pulled forward, and breathing encour- 
 aged by slapping the chest lightly with a cloth wet with 
 cold water, or artificial respiration must be employed. 
 The danger of vomiting is lessened by the administration 
 of thirty cubic centimetres of whiskey before beginning the 
 inhalation. In case vomiting occurs, the patient should be 
 rolled over on his side, that the vomited matters may have 
 free exit from his mouth. Death may occur from suffoca- 
 tion if these matters find their way into the trachea. If 
 the stomach of the patient is comparatively empty at the 
 time of the administration, the risk attending vomiting is 
 materially lessened. 
 
 279. Ether is administered from a sponge covered on its 
 tipper surface with a layer of oiled silk. Sometimes a folded 
 
NECESSITY FOR CLEANLINESS, ETC. 165 
 
 towel is rolled into the shape of a hollow cone, open at the 
 base for application over the mouth and nostrils ; the ether 
 is sprinkled over its interior. A cone of stout packing-paper 
 is also occasionally used, with a sponge fastened in its apex. 
 A half ounce or more is poured on the sponge at a time, and 
 the patient watched as in the case of chloroform. Danger 
 in the case of ether usually arises from failure of the res- 
 piration ; less frequently from stoppage of the heart. 
 
 280. Low/, ana'sthesia for subduing the pain in minor 
 operations is produced by throwing a spray of ether on the 
 part. The cold resulting from the evaporation of the atom- 
 ized ether benumbs the skin, and, if not too prolonged, is 
 not followed by undesirable results. 
 
 281. The hydrochlorate of cocaine, in a four or five per- 
 cent, solution, is used in operations on mucous surfaces. 
 It is often used in operations on the eye. A few drops 
 paralyze the terminal branches of the nerves of sensation, 
 the effect lasting only five or ten minutes. It is used also 
 in operations on the mouth and throat, rectum, vagina, and 
 urethra; twenty-four grains injected into the rectum have 
 proved fatal. It has no value as an anaesthetic when ap- 
 plied to the skin. 
 
 282. NECESSITY FOR CLEANLINESS IN THE TREATMENT 
 OF WOUNDS, OPEN SORES, ETC. The discharges from 
 wounds, ulcerations, abscesses, etc., have always a putre- 
 factive or septic tendency ; and this should be constantly 
 borne in mind by those who are concerned in the manage- 
 ment of surgical cases, that the most perfect cleanliness, 
 combined with antiseptic precautions and free ventilation, 
 may effectually prevent one wound from' being injured by 
 the less favorable conditions of another. Hospital attend- 
 ants have, indeed, to make perfect cleanliness their guid- 
 ing principle even for their own welfare, for the discharges 
 
166 DIET, TONGUE, TEMPERATURE. 
 
 from mucous surfaces and cutaneous or other ulcerations 
 have, in certain diseases, a contagious quality. Gonor- 
 rheal matter coming in contact with the eyes, as from a 
 tainted towel or finger, will light up a most violent and 
 destructive inflammation [425], and a hangnail or other 
 trifling abrasion on the hand may permit the introduction 
 of the syphilitic virus. 
 
 283. The diet of invalids is based on our knowledge of 
 the action of the stomach on food. As starchy and saccha- 
 rine articles, when properly prepared in a semi-liquid con- 
 dition, do not make any call on the powers of the stomach 
 for their digestion [211], they are largely used in the sick 
 chamber. Arrowroot, barley, corn-starch, farina, and tap- 
 ioca are invariably found in the list of hospital stores. 
 Nitrogenous substances, when used for the sick, are re- 
 duced to the liquid form, as beef tea, mutton, or chicken 
 broth, etc. The patient takes wine whey until he is able 
 to digest the casein of milk, and eggs beaten up with wine 
 or brandy until the stomach can digest more solid forms of 
 nutriment. Jellies lead on to custards, light puddings, and 
 various farinaceous dishes, and these to fish, chicken, and 
 carefully cooked meats. 
 
 284. The appearance of the tongue often gives important 
 information concerning the condition of the digestive organs 
 and the general system. Naturally the tongue is clean, red, 
 and pliant. In malarial disease it is large, flabby, coated 
 with a bluish or grayish film, and. indented on the margin 
 as if with the impression of the teeth. In disordered diges- 
 tion it is cream-coated or covered with a yellowish fur. 
 When notable fever is present it becomes dry; a moist 
 tongue is always an improvement on a dry one. In ty- 
 phoid fever it is narrow, elongated, dry, with a dark stain 
 on the centre of its dorsum, and of a deep red color at its 
 
TEMPERATURE. 167 
 
 tip and edges. Sometimes it cracks and bleeds, and the 
 blood dries into dark crusts, called sordes, on the tongue, 
 lips and teeth. Medicines that are unpleasant to the taste 
 may be deprived of much of their flavor by closing the nos- 
 trils while swallowing them. 
 
 285. Free vomiting is less distressing than dry retching. 
 A patient suffering from. the latter condition should be liber- 
 ally supplied with tepid water or demulcent drinks, the 
 more so as their subsequent ejection facilitates the removal 
 of obnoxious matters from the stomach. 
 
 286. The natural temperature in man is usually said to 
 be 98.4 F., but it varies a little, being more frequently 
 above than below that point. When it falls below 97, the 
 patient is in a state of collapse [303] ; when it rises above 
 99.5, he is feverish. Up to 102 the fever is said to be 
 moderate; above that degree it is high. Death is immi- 
 nent when the temperature reaches 106. 
 
 287. Bodily temperatures are sometimes recorded in de- 
 grees of the Centigrade scale. The zero or freezing-point 
 of this scale corresponds with 32 F. ; and the boiling-point, 
 212, of the latter with 100 Centigrade. Hence 180 
 Fahrenheit degrees = 100 Centigrade, or 1 = |. To change 
 Centigrade statements into the Fahrenheit scale, multiply 
 by -f- and add 32. To change Fahrenheit into Centigrade, 
 subtract 32 and multiply the remainder by f . 
 
 288. The clinical thermometer is a mercurial column, 
 self-registering by a detached portion of the mercury, and 
 accurately graduated for the short range of temperature 
 likely to be observed above or below the normal. A sud- 
 den jar communicated to the hand which holds the instru- 
 ment, bulb downward, will send the index down when 
 required. When the patient is conscious and intelligent, 
 the temperature is taken by placing the bulb of the ther- 
 
168 
 
 TEMPERATURE. 
 
 mometer under the tongue, and having him close his lips 
 around the stem and breathe gently through his nose for 
 two or three minutes, or until the mercury ceases to rise. 
 The temperature may also be taken by placing the bulb in 
 the armpit and pressing the arm close to ihe chest during 
 the time of the observation. The rectum is a good situ- 
 ation for obtaining the temperature in unconscious patients. 
 289. The normal temperature is subject to a daily fluc- 
 tuation of about a degree of Fahrenheit's scale. It is high- 
 
 TSbwrriber 
 
 105" 
 
 104-' 
 
 10 y 
 
 102' 
 
 lot? 
 
 100* 
 
 99' 
 
 15 16 
 
 17 
 
 IS 
 
 19 
 
 21 
 
 V\ 
 
 105 
 
 [01 
 
 (03 
 
 100 
 
 99 
 
 Temperature chart, showing the morning and evening observations in a case 
 of malarial fever; quinine was given at the times marked*, and its influence i& 
 manifested in the succeeding fall of the temperature. 
 
 est in the evening, at from five to eight o'clock; lowest 
 during the night or early morning, from two to six o'clock. 
 The hours of low temperature enhance the danger in cases 
 of low vitality. When fever is present, these fluctuations 
 are often distinctly marked. In the evening the patient 
 becomes manifestly worse ; the flush deepens on his cheek, 
 the skin becomes hotter, and the cerebral disturbance aggra- 
 vated. These are called evening exacerbations. The sub- 
 sidence of this excess of fever after midnight is spoken of 
 as a remission. Evening exacerbations occur in all fevers, 
 
PARALYSIS. 169 
 
 even in those which, like typhoid, are regarded as contin- 
 ued fevers. When the remission is strongly marked or 
 occurs daily at an unusual hour, the fever is a remittent; 
 and when, during the lull, the temperature drops to the 
 normal or below it, the fever is said to intermit. The tak- 
 ing of the temperature in febrile cases is an important duty. 
 It not only shows the progress of the fever and the influ- 
 ence of quinine or other anti-febrile remedies upon it, but 
 often enables the physician to prognosticate the result. A 
 line drawn across a ruled scale so as to show the morning 
 and evening temperature daily during the course of the dis- 
 ease is called a temperature chart. 
 
 290. When the lower limbs are paralyzed, the condition 
 is called paraplegia ; this is occasioned by disease or injury 
 of the lower part of the spinal cord. Fracture or displace- 
 ment of the vertebrae may have severed the cord or caused 
 pressure upon it, or the pressure may be the result of in- 
 flammatory effusion or exudation [173]. If the lesion be 
 somewhat higher in the loins, there will be involuntary pas- 
 sage of urine and faeces. When the lesion is high in the 
 dorsal region, respiration becomes oppressed from paralysis 
 of the muscles concerned in expanding and contracting the 
 chest. When in the lower cervical region, the upper ex- 
 tremities participate in the paralysis. When above the 
 origin of the phrenic nerves, death follows immediately from 
 paralysis of the respiration. 
 
 291. When paralysis is due to disease or injury of the 
 brain, as concussion or compression [401], apoplexy [403], 
 etc., the loss of motion and sensation is one-sided, hemi- 
 plegia ; but as the respiratory nerves of the unaffected side 
 carry on the vital movements, death does not follow so 
 promptly as when the upper part of the cord is involved. 
 In hemiplegic cases the paralysis of the limbs is on the side 
 
170 BBDSOBES. 
 
 opposite to that which is diseased or injured, for the nerves 
 from each side of the brain cross over to the opposite side 
 as they leave the cranium to enter the spinal canal ; but as 
 the nerves which supply the head and face are cerebral 
 nerves issuing above this crossing of the tubules, the side 
 of the face which is paralyzed is that in which the lesion 
 exists. An apoplectic clot in the right side of the brain 
 paralyzes the right side of the face and the left side of the 
 body. 
 
 292. To change a soiled sheet under a paralyzed or help- 
 less patient: Turn him on his side; roll the uncovered 
 half of the soiled sheet up lengthwise until the cylinder lies 
 close to his back. Have one-half of the fresh sheet rolled 
 into a similar roll and place its cylinder alongside of the 
 other, smoothing the unrolled half over the bed and tuck- 
 ing it away properly. Turn the patient on his other side 
 so as to bring him on the clean sheet; remove the soiled 
 sheet, and unroll and smooth out the fresh one. 
 
 293. Bed-sores are usually found in patients who have 
 been confined to bed for a long period by exhausting dis- 
 eases, paralyses, compound fractures, etc. ; and their site is 
 the tissues subjected to pressure between the mattress and 
 some bone that is not well padded with soft parts, as the 
 sacrum and the prominences of the hip-bones, spine, or ribs. 
 The treatment consists of regularly inspecting the back and 
 other points of possible injury in a patient likely to become 
 affected in this way, and frequently changing his position 
 to relieve the threatened parts from continued pressure. 
 The skin should be kept dry and clean by washing with 
 soap and water, or bathing with alcohol, or a solution of 
 corrosive sublimate, 1 to 1,000, and afterward dusting with 
 fine starch. The sheet on which the patient lies should be 
 kept free from creases and crumbs, and be replaced by 
 
USE OF CATHETER. 171 
 
 fresh linen as soon as it becomes soiled or damp. Benefit 
 may also be derived from the protection of a piece of soft 
 leather, spread with soap plaster, and the judicious use of 
 pillows. In unconscious or paralyzed patients, the skin 
 should be kept free from the irritating contact of discharges 
 from the bowels or bladder ; but when this is impossible, it 
 should be protected by simple cerate or petrolatum. When 
 a sore has formed it should be relieved from all pressure by 
 air cushions or other suitable rings or pads, poulticed if 
 sloughing, and antiseptically dressed if discharging only 
 molecula'rly. When paralysis is due to fracture of the 
 spine [449], bed-sores may be looked for in the course of 
 a few days, as in addition to the pressure there is a loss of 
 preservative nerve power in the parts. Such cases require 
 every care in nursing to prevent the sores from themselves 
 becoming the active agent in causing the death of the 
 patient. 
 
 294. For the introduction of the catheter the patient 
 should be on his back, head and shoulders slightly raised 
 by pillows, knees drawn up and separated from each other 
 to relax the muscles of the abdomen. The operator stands 
 on the left side of the bed, and, supporting the penis with 
 the fingers of his left hand, inserts the point of the instru- 
 ment, previously warmed and oiled, into the mouth of the 
 urethra. In doing this the body of the instrument is almost 
 horizontal, its concavity looking to the left groin. As the 
 point passes down the urethra the handle is swung round 
 horizontally from the groin to the middle of the abdomen 
 and is then gradually raised to the perpendicular and de- 
 pressed between the thighs of the patient as the urine 
 begins to flow through it. A suitable vessel should be 
 placed to receive the discharge and prevent unnecessary 
 soiling of the bedding. A piece of rubber tubing fitted to 
 
172 CHARACTERS OF URINE. 
 
 the mouth of the catheter and leading into the vessel is 
 sometimes useful. No force should be used in the opera- 
 tion, the catheter being guided rather than pushed into the 
 bladder. Sometimes an impediment is offered by the point 
 of the instrument to the movement which brings the handle 
 to the perpendicular. This is best overcome by withdraw- 
 ing the instrument for an inch and letting it glide farther 
 into the canal before attempting to raise the handle. A 
 large-sized catheter should always be employed for catheter- 
 ization unconnected with a strictured urethra. 
 
 295. When the urine is passed in large quantity [242] it 
 is usually pale in color ; when scanty, high-colored. Blood, 
 when present, may be identified by the appearance of the 
 red corpuscles under the microscope. When in small quan- 
 tity and diffused throughout the urine, it probably comes 
 from the kidneys; when in larger quantity or in clots, and 
 when it escapes more freely during straining at the close of 
 urination, it probably comes from the ureters or bladder; 
 when it comes before the flow of urine, which afterward 
 becomes clear, its source is probably the lining of the ure- 
 thra. In some acute malarial attacks the urine is of the 
 color of blood, although no red corpuscles can be discovered 
 by the microscope. Some substances, as rhubarb, beetroot, 
 logwood, etc., may give rise to an appearance as of blood in 
 the urine. 
 
 296. The specific gravity of urine is usually said to be 
 1.020; but as this depends on the quantity of dissolved 
 solids that pass off in the liquid, it necessarily varies ac- 
 cording as the urine examined was secreted after fasting or 
 after the ingestion of food or drink. In the absence of an 
 accurate urinometer the specific gravity may be taken by 
 balancing a small glass vessel on the dispensing-scales and 
 delivering into it from a pipette ten or more cubic centi- 
 
CHARACTERS OF URINE. 173 
 
 metres of the urine. The weight of the urine divided by 
 the number of cubic centimetres indicates the specific grav- 
 ity. If the contents of a 25 c.c. pipette weigh 25.500, the 
 specific gravity is 25.500-^-25 = 1.020. A notably low spe- 
 cific gravity is suggestive of albuminuria or Bright' s disease ; 
 a high specific gravity, of diabetes, a disease in which sugar 
 is present. 
 
 297. When urine is bloody it necessarily contains albu- 
 min ; but this substance in certain morbid states escapes 
 from the blood into the secreting tubules of the kidneys 
 along with the urea and salts which constitute the natural 
 excretion. Its presence in urine is suggested by the per- 
 sistence of air bubbles on the surface of the liquid after it 
 has been poured from one vessel into another. To detect 
 it: Boil ten or fifteen cubic centimetres of clear filtered 
 urine in a test-tube and add a drop or two of nitric acid. 
 Heat throws down phosphates, which are dissolved by the 
 nitric aci; the latter throws down urates, but these are 
 dissolved by the heat; when both reagents are applied, 
 nothing remains precipitated but the curdy flakes of albu- 
 minous matters. 
 
 298. Besides having a high specific gravity, as 1.040 or 
 over, urine which contains sugar is passed usually in in- 
 creased quantities. To ten or fifteen cubic centimetres in 
 a test-tube add a drop or two of a solution of sulphate of 
 copper and an excess of liquor potassse ; then boil the blue 
 solution thus formed, when, if sugar be present, a red sub- 
 oxid of copper will be precipitated. 
 
 299. Urine when freshly passed is clear, but after a time 
 a sediment may gather in it. Reddish crystals of uric acid 
 may be seen at the bottom of the containing vessel after 
 standing for twenty-four hours. Urates are more soluble 
 in warm than in cold water ; hence, when present in large 
 
174 CHARACTEKS OF URINE. 
 
 quantity, they may become deposited as a fawn-colored 
 powdery sediment after the urine has had time to cool. 
 The urates are in excess when the waste of tissue is great, 
 as in fevers and inflammations, or when the supply of ni- 
 trogenous food is greater than is required [240]. Phos- 
 phates are deposited as the urine becomes alkaline by de- 
 composition, because they are less soluble in an ammoniacal 
 than in an acid urine. They are whitish in color, and may 
 be distinguished from the urates by their failure to dissolve 
 on heating the liquid. They are usually present in excess 
 in cases of nervous depression or deficient vitality. The 
 gradual deposition of these insoluble or sedimentary mat- 
 ters under certain conditions within the bladder gives rise 
 to the formation of stone or gravel. 
 
 300. When a patient does not pass his urine the immedi- 
 ate cause may be either suppression or retention. Suppres- 
 sion of urine) in which the kidneys fail to secrete and 
 relieve the blood of urea and other refuse materials, is a 
 grave condition often seen when the secreting tissue is 
 disorganized; the blood becomes poisoned by the retained 
 matters, and, circulating in the brain, gives rise to urcemic 
 unconsciousness, convulsions, and death. In retention of 
 urine the kidneys continue to purify the blood, but from 
 some local cause the accumulated urine is not expelled 
 from the bladder. It may arise from injury to the spinal 
 cord above the origin of the nerves which supply the blad- 
 der, or from some stricture of the urethral passage, or even 
 from an overdistention of the bladder which temporarily 
 paralyzes its muscular coat. Relief in these instances is 
 afforded by the introduction of the catheter. Retention 
 may be present, although the patient's complaint is that of 
 passing water all the time in driblets. The bladder may be 
 so distended that it overflows through the urethra, yet can- 
 
CHARACTERS OF URINE. 175 
 
 not contract for the expulsion of the whole of its contents. 
 This condition is recognized by the tense swelling and feel- 
 ing of distress in the lower part of the abdomen. In such 
 cases it is better not to empty the bladder at once, but to 
 remove enough to give perceptible relief, and finish the 
 evacuation half an hour afterward. 
 
CHAPTER II. 
 
 SHOCK, REACTION, AND INFLAMMATION. 
 
 301. When the human body is injured without immedi- 
 ate loss of life, certain effects may usually be observed ; and 
 these are : 1, shock or collapse ; 2, reaction ; and 3, processes 
 of repair. 
 
 302. SHOCK is a condition of nervous depression following 
 severe injuries. A similar condition caused by mental im- 
 pressions is generally called syncope or fainting. The heart 
 beats slowly or quickly, but with so little power that it is 
 unable to force the blood to the brain, as is manifested by 
 sudden pallor of the face, with accompanying giddiness, 
 faintness, noises in the ear, indistinctness of vision, and 
 unconsciousness. The patient should be laid on the ground 
 with his head low ; recovery may be hastened by sprinkling 
 a little cold water on the face, offering diluted ammonia or 
 its carbonate for inhalation, and giving a few swallows of 
 cold water or some convenient stimulant. 
 
 303. But when shock is the result of injury, it is not so 
 readily controlled. When slight it is characterized by anx- 
 iety, tremors, pallor, and faintness, and is relieved by rest 
 in bed, reassuring words, and some mild stimulant, as beef 
 tea, coffee, weak toddy, or aromatic spirit of ammonia in 
 water. When severe, the patient is semi-conscious and 
 incoherent ; countenance pale, anxious, and shrunken ; sur- 
 face cold and bedewed with moisture; pulse weak, and res- 
 piration irregular and sighing. Recovery is promoted by 
 
SHOCK, REACTION AND INFLAMMATION. 177 
 
 placing the patient in bed with his head low, and applying 
 warmth to the extremities and pit of the stomach by hot 
 bottles and friction with warm flannels, while stimulants 
 are given in small quantities at short intervals. When 
 there is reason to fear the existence of internal hemorrhage, 
 as in injuries of the head, chest, and abdomen, alcoholic 
 stimulants should be given with caution. 
 
 304. Severe shock may end in insensibility and death by 
 syncope, or in a condition of abnormal excitement. As the 
 duration of this reaction, as it is called, is proportioned to 
 the previous depression, it is, of course, desirable to lessen 
 the intensity and duration of the collapse; but this must be 
 effected with caution lest the stimulants used should inten- 
 sify and prolong the subsequent reaction. This condition 
 is essentially one of fever, and is treated by the means 
 which tend to subdue fever [323] ; but as its cause is not 
 an abiding one, it usually subsides within twenty-four hours 
 or becomes merged in that fever which is an accompaniment 
 of the changes that are meanwhile taking place in the in- 
 jured parts. When, however, the system at the time of 
 the injury is debilitated, low delirium and muscular tremors 
 constitute the characteristic symptoms of a condition which 
 has been named prostration with excitement, and which re- 
 quires for its treatment careful stimulation, with opiates to 
 allay the nervous irritation. 
 
 305. REACTION AND INFLAMMATION. As soon as reaction 
 begins, a local process of repair is set up, which is neither 
 more nor less than an exaggeration of the ordinary nutri- 
 tive forces of the part. The vessels enlarge and become 
 engorged with blood,- making the part assume the local 
 characteristics of inflammation redness, swelling, heat, 
 and pain. It is red from the accumulated blood ; swollen 
 from the engorgement of the vessels and the presence of 
 
 12 
 
178 CONGESTION. 
 
 the transuded liquid; hot from the destructive oxidation 
 which the flow of oxygenated blood brings upon the injured 
 tissues ; and painful from compression of the nerves of sen- 
 sation by the tumefaction of the parts which surround them. 
 Should the capillary activity subside promptly, leaving no 
 trace of its presence, the part would be said to have been 
 congested , as when the ears or fingers suffer temporarily 
 from cold; but should the symptoms persist and a rapid 
 renewal of the deep-seated layers of the cuticle take place, 
 causing the older layers on the surface to crack and peel off, 
 or desquamate, an inflammation would then be said to have 
 existed. No well-defined line separates congestion from in- 
 flammation ; the one is the beginning of the other, and both 
 are essentially an increased activity of the ordinary pro- 
 cesses of nutritive change in the injured parts. During 
 congestion, coagulable lymph exudes from the vessels, con- 
 stituting the material of repair. This cements the surfaces 
 of a closed wound and fills up the vacuities of an open one 
 with its granulations. It has but little vitality, and its 
 power of resisting harmful agencies is correspondingly 
 small. When a wound becomes infected by bacterial organ- 
 isms, as by the introduction of splinters, fragments of 
 clothing, or other foreign matter, or by touching witfi. un- 
 clean fingers, or even by exposure to the air, the exuded 
 lymph becomes transformed into a liquid, pus, which is of 
 no use as a reparative material, and which drains away as a 
 fetid discharge or is collected in cavities called abscesses. 
 
 306. Manifestly, after the removal of the cause the in- 
 dications for treating a congestion are, first, to lessen the 
 quantity of blood in the engorged vessels ; and, second, to 
 promote the dispersion of the exudations that have escaped 
 into the injured tissues. 
 
 307. The engorged vessels may be relieved by position, 
 
INFLAMMATION. 179 
 
 by the application of cold or heat, or by the direct or in- 
 direct abstraction of blood. 
 
 308. The congested part should be kept at rest in an 
 elevated position ; those who have a felon on the finger 
 speedily discover that hanging the hand low aggravates the 
 suffering, and that raising it on the breast gives measurable 
 relief [344]. 
 
 309. Cold, applied by ice-bags, by evaporating lotions, or 
 by irrigation, acts by diminishing the size of the supplying 
 vessels. Sometimes a cooling astringent, as liquor plumbi 
 subacetatis, is added to the lotion to aid the cold produced 
 by evaporation. Pressure is sometimes useful, but usually 
 it is more likely to aggravate the evil by increasing pain, 
 and thus acting as an irritant. 
 
 310. Heat is applied by warm-water dressings, consist- 
 ing of lint or cotton thoroughly soaked, and covered with 
 oiled silk or gutta-percha cloth to prevent evaporation. 
 Poultices are made of bread-crumbs, oatmeal, linseed-meal, 
 or other farinaceous substances. These should be boiled for 
 a few minutes, to coagulate all their albuminous constitu- 
 ents and make the poultice lighter than it otherwise would 
 be. Heat, to be efficient, must act on the parts adjoining 
 the injury, relaxing them and preparing them to absorb 
 blood which, without their influence, would go to swell the 
 accumulation in the affected parts. An inflamed finger, for 
 instance, is relieved when the four other fingers and the 
 hand as a whole aid it in disposing of the blood that would 
 otherwise pulsate into its already-swollen tissues. 
 
 311. Blood is abstracted by leeches. These are placed 
 in a pill-box or wine-glass, which is inverted over the part 
 to which they are to be applied. If it is desirable that a 
 leech should bite on a particular spot, the part should be 
 covered with a piece of blotting-paper perforated at the 
 
180 INFLAMMATION. 
 
 spot, which should be touched with a drop of blood or milk 
 and water. Leeches fall off when sprinkled with salt, 
 which also makes them disgorge the blood they have swal- 
 lowed. Used leeches should be kept apart from the others, 
 as they frequently become sick and affect their compan- 
 ions injuriously. Bleeding from leech- bites may be kept 
 up by warm fomentations ; it may be stopped by touch- 
 ing the bites with collodion or with a point of lunar 
 caustic. 
 
 312. Cupping-glasses are also used for the abstraction of 
 blood, but the irritation caused by them necessitates their 
 application at some distance from the congested part. 
 They are most frequently used for the relief of internal 
 congestions, hence the patient must not be incautiously ex- 
 posed during their application. The surface must be mois- 
 tened with warm water, that the skin may slide freely under 
 the edge of the cup and rise within it. The cup is held in 
 the left hand, its mouth inclined downward and close to 
 the part on which it is to be placed. The flame of a spirit- 
 lamp is permitted to play in its interior for a second or 
 two; and as the right hand withdraws the lamp, the left 
 sets the cup on the selected spot. Immediately the skin 
 and subjacent tissues rise into the vacuum in a convexity 
 which momentarily becomes more and more turgid with 
 blood. The practice of putting a few drops of alcohol into 
 the cup should not be followed, as the skin may be injured 
 by the burning liquid; and even with the spirit-lamp flame 
 the patient will suffer if the edge of the cup be unneces- 
 sarily heated. The pressure of the atmosphere drives the 
 blood from the surrounding tissues into those covered by 
 the partial vacuum of the cups, and the congested spots 
 thus intentionally produced give more or less relief to the 
 congestion under treatment. This, which constitutes dry 
 
INFLAMMATION. 181 
 
 cupping, is sometimes all that is needful, the cups being 
 permitted to act for a given time ; but when wet cupping is 
 desired, the cup first applied is removed as soon as the 
 others are in position, the scarificator is used, and the cup 
 replaced, after which the other cupping-sites are treated, 
 in succession, in like manner. The cup is detached by 
 pressing with the finger on the skin near its edge. The 
 spring scarificator should be held firmly in position on the 
 skin when the trigger is pulled; cuts of one-eighth inch 
 generally yield better results than those that are deeper. 
 The operation is finished by cleaning the surface thor- 
 oughly, bathing the lancet wounds with an antispetic 
 liquid, and covering them with plaster so applied as to 
 counteract any tendency to gaping of their lips. 
 
 313. Counter-irritants act like cupping-glasses on parts 
 adjacent to the congested area. Turpentine stupes, mus- 
 tard, or ammonia are frequently used over the throat and 
 upper part of the chest in croup; and a large blister is 
 sometimes beneficial over the affected side in congestion of 
 the lung and on the back of the neck when the brain is 
 implicated. 
 
 314. Counter-irritants are called rubefacients when they 
 redden the skin ; vesicants when they raise the cuticle by 
 an underlying effusion. 
 
 315. The turpentine stupe is simply a flannel cloth wrung 
 out of hot water and sprinkled with turpentine. 
 
 316. Mustard, made into a soft paste with a little tepid 
 water, is spread on a piece of linen or cotton and applied 
 with a piece of tissue-paper, gauze, or fine cambric inter- 
 posed to prevent the irritant from adhering to the skin ; it 
 is kept in position until the surface is reddened, after which 
 a piece of soft lint is used as a protective. When left too 
 long in contact with the skin, mustard causes painful ulcera- 
 
182 INFLAMMATION. 
 
 tions. If mild rubefaction only is required, the paste should 
 contain one or two parts of wheat flour. 
 
 317. Ammonia is commonly employed in the form of the 
 official liniment ; or a wine-glass may be filled with pledgets 
 of lint soaked in diluted ammonia, and inverted for one or 
 two minutes over the selected part. 
 
 318. A fly-blister is made by spreading cerate of canthar- 
 ides on adhesive plaster, linen, or paper. The skin should 
 be sponged with vinegar before the blister is applied, and 
 there should be no tissue-paper facing such as is used in the 
 case of mustard. The application is removed as soon as 
 vesication takes place, or at the end of ten or twelve hours, 
 even in the absence of vesication. In the latter case, the 
 use of a bread poultice will usually raise the cuticle. In- 
 deed, in children and persons with delicate skins, the sub- 
 stitution of a poultice for the cerate at the expiration of 
 three or four hours is the better practice. If speedy heal- 
 ing be desired, the effused liquid is drained off by one or 
 two punctures and the part dressed with cotton or an anti- 
 septic ointment; if the blister is to be kept open, a circular 
 portion of the cuticle is cut out, but not removed, and the 
 surface dressed with an irritant ointment, as a petrolatum 
 dilution of the ceratum cantharidis. The immediate re- 
 moval of the cut portion is attended with much pain; it is 
 better, therefore, to permit it to be thrown off naturally. 
 
 319. For making small counter-irritant sores, technically 
 called issues, potassa or potassa cum calce is generally used. 
 A circular aperture the size of the portion of skin to be in- 
 flamed is cut in a piece of adhesive plaster, which is ap- 
 plied to the part. Potassa is rubbed on the unprotected 
 spot for a minute, after which the plaster is removed and 
 the part washed with vinegar. Potassa cum calce is made 
 into a paste with alcohol and applied for ten or fifteen min- 
 
INFLAMMATION. 183 
 
 utes over the aperture, vinegar being used, as in the other 
 case, to wash away the alkali that may be sticking to the 
 destroyed surface. These escharotics excite so much con- 
 gestive action in the skin as to cause its superficial layer to 
 be thrown off as a slough, leaving an ulcer which may, like 
 a blistered surface, be healed or variously irritated accord- 
 ing to the requirements of the case. 
 
 320. Hot water is readily available as a counter-irritant. 
 Its heat is best applied by means of the head of a hammer 
 or other smooth, metallic body. The hammer, immersed in 
 water at 120 F., dried and held in contact with the skin 
 for two or three seconds, acts as a rubefacient ; and if the 
 contact be prolonged for ten seconds, vesication will usually 
 be produced. Tincture of iodine, croton oil, and tartar 
 emetic ointment are frequently used for their counter-irri- 
 tant properties. 
 
 321. Besides these local applications for lessening con- 
 gestion and removing effusion, general measures are some- 
 times available and useful. Purgatives are valuable in 
 congestive conditions, particularly of the brain. They 
 stimulate the intestinal canal and the organs connected 
 with it; and the afflux of blood to these organs lessens by 
 just so much the engorgement of the blood-vessels in the 
 congested brain. The large watery evacuations produced 
 by Epsom, Glauber, and Rochelle salts relieve the turges- 
 cence of the vascular system by withdrawing part of the 
 liquid constituents of the blood, but without inducing that 
 extreme prostration which, in blood-letting, follows a loss 
 of the red corpuscles. The action of diaphoretics on the 
 skin and of diuretics on the kidneys operates advantage- 
 ously when the congestion to be relieved does not affect the 
 skin in the one instance or the kidneys in the other. In 
 both there is a temporary afflux of blood to these organs, 
 
184 SYMPTOMATIC FEVER. 
 
 which is relieved respectively by a free perspiration or a 
 profuse secretion of urine. Nauseants, as tartar emetic 
 and ipecacuanha, operate on the whole system and inci- 
 dentally only on the congested part. The vital energy of 
 every organ and tissue of the body is diminished that the 
 energy which threatens the congested organ with danger 
 may be lessened,, 
 
 322. SYMPTOMATIC FEVER. When an injury is severe, 
 reaction is usually associated with and aggravated by a 
 febrile condition, which is usually referred to as traumatic, 
 symptomatic, or inflammatory. The skin is hot and dry, 
 the face flushed, eyes injected, pulse quickened, breathing 
 accelerated, tongue white and coated, appetite impaired, 
 except for cooling liquids, bowels constipated, urine scanty 
 and high colored; and there are pains in the loins and 
 limbs, headache, restlessness, confusion of thought, and 
 sometimes delirium, particularly at night. At the onset 
 the patient may feel chilly, but there is never a decreased 
 temperature; on the contrary, even while chilliness is pres- 
 ent, the thermometer may show the bodily heat to be two 
 or more degrees above the normal. The febrile heat re- 
 sults from increased activity of the nutritive processes 
 going on in the injured part. The greater heat developed 
 there raises the average temperature of the blood, as the 
 heat of the water-back of a kitchen range raises that of the 
 contents of the hot-water cylinder connected with it. This 
 excess of heat distributed throughout the body stimulates 
 the oxidizing or destructive function of the blood, so that 
 all the tissues are wasted with unusual rapidity, thus add- 
 ing to the febrile heat and aggravating the abnormal con- 
 dition of the patient. 
 
 323. The measures which are of value in subduing this 
 febrile condition consist of rest, quiet, low diet, and the 
 
CHRONIC INFLAMMATION. 185 
 
 agencies already indicated as useful in quieting the local 
 action [306], such as purgatives, nauseants, and diapho- 
 retics, which depress the vitality of the whole system, and 
 certain remedies which reduce the temperature and pulse 
 without causing much general depression. 
 
 324. Rest has a powerful influence in quieting the heart's 
 action. The pulse is more rapid when one is standing than 
 when sitting ; more rapid when sitting than when at rest in 
 bed; and during exercise its rapidity is proportioned to the 
 exertion [186]. 
 
 325. Quiet, which may be regarded as a variety of rest, 
 implies the withdrawal of all stimulating impressions. The 
 patient should be kept in a cool, well- ventilated room, and 
 protected not only from glare, noise, and other physical in- 
 fluences, but as much as possible from all that would inter- 
 fere with tranquillity of mind. 
 
 326. By low diet is not meant a restriction to so many 
 ounces per day, for a fevered patient has usually but little 
 desire for food, but the careful avoidance in the diet of 
 everything of a stimulating nature. Milk, eggs, oysters, 
 tea, toast, beef tea, broths, farinas, and jellies constitute 
 its elements. 
 
 327. CHRONIC INFLAMMATION. Sometimes, and chiefly 
 in people of weak vitality, congestion does not entirely sub- 
 side after the healing of a wound, the filling up of an ab- 
 scess cavity, or the repair of an injury. The area remains 
 red and somewhat swollen ; but as the pressure is slight, 
 there is but little pain ; and as the nutritive changes in the 
 part are not active, there is neither local heat nor inflam- 
 matory fever. The fault in the constitution, which is the 
 main cause of the persistence of the congestive action, must 
 be remedied by tonics, stimulants, and diet, with appropri- 
 ate treatment when called for by a tubercular, rheumatic, 
 
186 CHRONIC INFLAMMATION. 
 
 syphilitic, or other specific taint in the blood. Local treat- 
 ment usually consists of stimulant applications to excite the 
 nutritive forces of the part to that energy of action which 
 will remove the exuded matters from a congested area, or 
 repair the damage that may have been caused by suppura- 
 tion or ulceration. 
 
 328. Active exercise promotes the nutritive changes in a 
 healthy part; the same end, in a chronically inflamed part, 
 is induced by what may be called passive exercise. Fric- 
 tion and massage or shampooing are the methods by which 
 this is attempted. The former is a misnomer, for the 
 manipulation intended is not a quick, superficial rubbing 
 that would speedily abrade the skin, but a firm, equable 
 pressure reaching to the deeper tissues and applied in the 
 direction of the circulation so as to aid the onward move- 
 ment of the blood. The latter adds to the so-called fric- 
 tion a pommelling, kneading, and slapping of the parts, 
 which should never be continued long enough to excite 
 pain. These methods of stimulation are used to remove 
 the exudations which, in sprains and contusions, interfere 
 with the natural movements of the affected parts. Pres- 
 sure enters into these manipulations as a part of the passive 
 exercise ; but it is sometimes applied continuously to pro- 
 mote absorption, as by means of a weight or compress on 
 an enlarged gland or bubo, or by strapping with strips of 
 plaster in the case of a swollen testicle. The oleaginous 
 substances which enter into the composition c f liniments are 
 of value mainly in lessening friction and preventing abrasion 
 during the rubbing which is associated with their use ; but 
 the turpentine, ammonia, and other stimulants that are fre- 
 quently employed have each a special value independent of 
 the method of their application. All the substances that 
 are used as counter-instants in acute inflammation [313- 
 
PATHOLOGY OF INFLAMMATION. 187 
 
 320] may be utilized as local stimulants in chronic cases ; 
 but while, as counter-irritants, the site of their application 
 is at some distance from the inflamed part, as stimulants 
 their site is the part itself, or so close to it as to involve it 
 in the stimulant action. Solutions of nitrate of silver, sul- 
 phate of zinc, sulphate of copper, and other irritant sub- 
 stances, so diluted as not to over-excite the parts, are in 
 constant use to change the character of the action in indo- 
 lent sores and in chronic inflammation of the mucous mem- 
 branes of the eye, throat, urethra, rectum, etc. Tincture 
 of iodine is frequently employed for the dissipation of the 
 effusions and exudations that impede motion after the in- 
 flammation which caused them has subsided, because, in 
 addition to its local stimulus, it is taken up into the sys- 
 tem, where it acts as a powerful excitant to the processes 
 of absorption ; and with the same view iodid of potassium 
 is often administered internally, particularly in scrofulous 
 and rheumatic swellings. In the chronic inflammations 
 and exudations of syphilitic disease mercury is frequently 
 prescribed in small doses to affect the system gradually 
 and gently. Gray powder, the chlorid, and iodids are 
 used internally for this purpose, with or without the ex- 
 ternal application of mercurial ointment or vapors. A 
 'mercurial vapor bath is administered by adjusting a blanket 
 around the patient from his neck to the floor as he sits un- 
 dressed upon a cane-buttoned chair under which, in a por- 
 celain or other suitable vessel, are twenty or thirty grains 
 of calomel. The heat of a spirit-lamp is made to volatilize 
 the calomel, forming a mercurial vapor which condenses on 
 and is absorbed by the skin. The bath lasts fifteen or 
 twenty minutes, and at its conclusion the patient is put to 
 bed wrapped in the blanket which was used to confine the 
 vapors. 
 
CHAPTER III. 
 
 SPECIAL INFLAMMATIONS. 
 
 329. BURNS. When heat is applied to the body by radi- 
 ation, as from a glowing fire, some of the minute scales that 
 form the cuticle have their vitality impaired. Congestion 
 follows and tho nutritive energies of the part become inten- 
 sified; but in the course of a few days the action subsides 
 with the completion of a new layer of cuticle and the scal- 
 ing off or desquarnation of the old one. This is known as 
 rubefaction the action produced on the skin by mustard, 
 liniment of ammonia, tincture of iodine, etc., when used as 
 counter-irritants. When produced thus intentionally rube- 
 faction requires no treatment except protection by some soft 
 material; but when it results from accident the congestive 
 reaction may go beyond rubefaction; and as it is undesir- 
 able that it should do so, means should be adopted to re- 
 strain it. Lead lotion is commonly used for this purpose, 
 with tincture of opium to allay the burning. Exposure to 
 the air increases the congestion and aggravates the pain; 
 hence the value of dusting the part with flour or starch, 
 covering it with cotton-wool, or smearing it with bland un- 
 guents, such as palm-oil, oxid of zinc ointment, or petrola- 
 tum, to which the addition of carbolic acid is of benefit, as 
 it tends, like opium, to benumb the sensibility; alkaline 
 liquids, as carron oil and strong solutions of carbonate of 
 soda, are also used for this purpose. 
 
 330. When the heat is greater, and generally in the in- 
 juries called scalds, the vitality of the surface layer of the 
 
BURNS. 180 
 
 skin is impaired as in rubefaction, bu the reactionary con- 
 gestion is so much more intense that the effused serum ac- 
 cumulates beneath the injured cuticle, raising it into a 
 blister. This is vesication the action of cantharides, am- 
 monia, acetic acid, etc., when applied for purposes of 
 counter-irritation. Every care must therefore be taken to 
 preserve the injured surface from influences that would in- 
 tensify the congestion. If the burned surfaces are numer- 
 ous or extensive they should be uncovered, one by one, or 
 part by part, to lessen exposure and prevent irritation. 
 Blisters, when flaccid, should not be opened, but when 
 distended they should be punctured to relieve tension 
 and lessen the risk of accidental rupture. They are then 
 protected by any of the applications mentioned as useful in 
 the case of rubefaction [329] except flour and starch, which 
 would become caked into an irritant by the exuding liquids ; 
 antiseptic absorbent cotton is probably the best; but what- 
 ever the application, it should be left undisturbed for sev- 
 eral days unless its removal is called for by excessive dis- 
 charge or putrescent odors. By the end of a week or ten 
 days a delicate new cuticle is formed, over which the old 
 shrivels up and peels off; but the entrance of putrefactive 
 germs from an inefficient protective or antiseptic dressing 
 will lead to suppuration if the degenerated matters drain 
 from the surface, to ulcer ution if they are absorbed, and to 
 sloughing if they are thrown off as a solid mass. In any 
 of these events the healing of the primary injury may be 
 delayed for weeks. If the whole thickness of the skin is 
 involved in a burn, protective or cooling applications should 
 be used at first to moderate the reactionary congestion ; next, 
 soothing poultices or warm-water dressings to promote the 
 ulceration which is to separate the slough; and lastly, the 
 applications called for by the characters of the granulating 
 
190 BURNS AND SCALDS. 
 
 sore. The cicatrix in burns of this depth becomes power- 
 fully contractile, so that it will in progress of time, and 
 according to its situation, evert the eyelids, distort the 
 features, draw the head to one side or the other, and flex 
 the joints, producing deformities and disabilities that are 
 as difficult to prevent as to cure. 
 
 331. In all burns except those of a trivial nature there 
 is more or less disturbance of the. general system. Shock 
 [302] is proportioned to the extent of the burn as well as to 
 its intensity ; thus, there may be as complete a collapse in 
 a case of scalding as in a case of charring, if the former in- 
 volve a larger extent of the surface. Sometimes shock ac- 
 companies very trifling burns, in which case it is usually 
 due rather to the circumstances attending the injury than 
 to the injury itself, and is easily removed by stimulants ; but 
 when due to the latter it is often prolonged, two or three 
 days elapsing in severe cases before reaction is established. 
 
 332. BURNS BY CORROSIVE ACIDS. The skin when 
 corroded by oil of vitriol, nitric or hydrochloric acid should 
 immediately be washed with a strong solution of carbonate 
 of soda or other alkali, and subsequently treated as a burn. 
 When the eyes are injured, the alkaline solution should 
 contain about ten grains of the carbonate to an ounce of 
 water. Olive or castor oil should afterward be used to 
 protect the disorganized conjunctiva. Stimulants and opium 
 are called for if there is much shock. 
 
 333. SCALDS, ETC., OF THE THROAT. Children are 
 sometimes scalded or burned in the mouth and throat by 
 steam or boiling water, acid, or strongly alkaline liquids, as 
 solutions of ammonia or washing soda. Usually the 
 mucous membrane of the lips and mouth only is injured ; 
 but occasionally the larynx is involved. Kedness and 
 swelling of the mouth and throat, with difficulty in 
 
FROST-BITE. 191 
 
 swallowing, hoarseness, and accompanying fever, follow 
 the accident. The immediate danger in such cases arises 
 from closure of the rima glottidis [224]. If the local symp- 
 toms are due to acids or alkalies, the appropriate antidote 
 [500] should be used as a mouth- wash, and taken into the 
 stomach if there is reason to suppose that any of the dan- 
 gerous liquid has been swallowed. 
 
 334. FROST-BITE. The frost-bitten part is cold, 
 shrunken, bloodless, and without sensation. The immediate 
 object of treatment is to restore the circulation in the affected 
 region; but the reaction must be cautiously induced lest 
 the subsequent congestion run into gangrene or sloughing. 
 The frozen part should be thawed out by friction with a 
 mixture of snoiv or ice and water. Only when reaction is 
 fairly established should the patient be moved into a warm 
 room. 
 
 335. After reaction is established, the lighter grades of 
 frost-bite require no treatment except protection. In cases of 
 greater severity, increasing congestion should be restrained 
 by cooling lotions ; but if sloughing threatens, these should 
 be replaced by soothing poultices, with stimulants of resin 
 and turpentine when the action becomes indolent, and 
 charcoal or other deodorizing antiseptics when called for 
 by the gangrenous condition. When the toes, fingers, or 
 larger portions of the extremities are destroyed, they do not 
 become separated from the living parts in such a manner as 
 to leave the latter in good condition for the formation of a 
 rounded stump ; on the contrary, as the interior parts suffered 
 less than the exterior from the killing influence of the cold, 
 more of them are preserved ; and when the separation takes 
 place they, including the bones, project beyond the level of 
 the superficial tissues that remain. This necessitates sur- 
 gical interference. 
 
192 CHILBLAINS AND CONTUSIONS. 
 
 336. CHILBLAINS are chronic congestions produced by 
 cold in constitutions of impaired vitality. The patient 
 should be well fed and exercised to give vigor to the sys- 
 tem. This, with the protection of the congested parts from 
 changes of temperature, will alone effect a cure; but local 
 applications, as of camphor, turpentine, or tincture of iodine, 
 are called for, chiefly by the intolerable itching. When 
 sloughing takes place, poultices with resin cerate or turpen- 
 tine should be used until the surface is ready to granulate. 
 
 337. A CONTUSION or bruise is the injury that results 
 from a sudden crushing of the parts. There is swelling, 
 with numbness, dull aching pain, and shock. The swelling 
 results from exudation and extravasation [173], the dark 
 color of the bruise being due to the latter. Where the tis- 
 sues are lax, as about the eyelids and scrotum, the swelling is 
 greater, in proportion to the injury, than where they are less 
 distensible. Evaporating lotions or ice should be applied to 
 restrain the outflow from the vessels. Ordinarily, in a few 
 days the swelling decreases and the discoloration fades. 
 Absorption is promoted by rubbing equal parts of tincture of 
 arnica and water, with equable pressure, over the contused 
 parts ; or soap liniment with tincture of opium may be used 
 if there be much pain. Contusion of the testicle is accom- 
 panied with much shock and tendency to syncope. Con- 
 tusion of the abdomen, as from blows, the kick of a horse, 
 or passage of a wheel over the body, is sometimes followed 
 by nausea, vomiting, and great prostration, although there 
 may be no laceration of the abdominal viscera. In cases 
 of suspected internal injury stimulants should be given 
 with caution, lest hemorrhage be increased. A full opiate 
 dose, the careful removal of the patient to hospital and per- 
 fect rest afterward, constitute the treatment of the emer- 
 gency; purgatives are contraindicated. 
 
SPRAINS. 193 
 
 338. A SPRAIN is a stretching or tearing of the fibrous 
 bands and expansions that surround a joint or of the mus- 
 cular and tendinous tissues concerned in the movements of 
 the body. When a sprained joint is examined immediately 
 after the injury, the absence of dislocation or fracture is 
 readily discovered; but if some hours have elapsed, there 
 may be so much pain, swelling, and interference with mo- 
 tion as to render the diagnosis uncertain until the inflamma- 
 tory action has been to some extent controlled. Evapo- 
 rating, lead, opiate, arnica, and other lotions have a value 
 only when acting in concert with immobility. Splints and 
 slings should be applied when needful to restrain the joints 
 of the upper extremity ; but when the ankle or knee is 
 injured, the patient should be put to bed with the limb 
 elevated on pillows; -and after the subsidence of the inflam- 
 mation, the utmost caution must be exercised in resuming 
 the use of the injured limb. Sprains of the ankle often 
 disable for months on account of chronic inflammation 
 kept up in the joint by its unadvised use. A sprain seems 
 a minor injury, and patients fail to recognize the necessity 
 for absolute rest until they learn by experience that it 
 would perhaps have been better for them if there had been 
 a dislocation or fracture, as they would then have submitted 
 to the necessary confinement. Slight sprains of the ankle 
 or knee, associated with little inflammatory action, are some- 
 times put up in an immovable dressing, as the starch, sili- 
 cate, or gypsum bandage [440443], and the patient per- 
 mitted to move about on crutches ; but when the injury is 
 at all severe, the acute inflammation should be controlled 
 before having recourse to these dressings. Stiffness of the 
 joint during convalescence from sprain of the ankle is re- 
 moved by friction or massage, and effusion by tincture of 
 iodine or other counter-irritants [328]. 
 13 
 
194 ABSCESSES. 
 
 339. Sprains of the loins are sometimes so severe as to 
 simulate more dangerous injuries, as fracture of the spine; 
 but the patient is usually able, with more or less difficulty, 
 to straighten himself up, and the spinous processes present 
 no irregularity. Blood in these cases sometimes appears 
 in the urine, indicating an injury to the kidneys; but this 
 is not often followed by any inflammation of that organ. 
 Hemorrhage may also take place into the spinal canal, 
 occasioning paralysis of the lower extremities and increas- 
 ing the resemblance to fracture. Paralysis may also super- 
 vene from effusion of serum into the canal, due to the 
 spread of the inflammation from the sprained tissues to the 
 membranes of the cord. The necessity for perfect rest in 
 severe sprains of the loins is therefore imperative. This is 
 aided by suitable measures to allay inflammation [323] in 
 the early period, and counter-irritants and resolvents after- 
 ward. 
 
 340. ABSCESS. When the degenerated matter of an exu- 
 dation accumulates in a liquid form in the interior of a 
 tissue it constitutes an abscess. The walls of the cavity 
 which contains the matter are thickened from exudation, 
 and external to this there is usually a swelling from effusion 
 of serum, and, if the skin be implicated, a redness from 
 congestion. Superficial abscesses are seen in connection 
 with minute punctured wounds from splinters, the presence 
 of which gives rise to the suppuration which eventually 
 casts them out. During the hard stage of the inflammatory 
 swelling, the progress of suppuration should be promoted by 
 large poultices, but as soon as a fluctuating spot is detected, 
 that is, a soft spot which feels to pressure with the finger 
 as if it contained liquid, an incision should be made to lib- 
 erate the matter. If no incision is made, the abscess cavity 
 becomes enlarged by absorption until the surf ace is reached; 
 
BOILS AKD CARBUNCLES. 195 
 
 but in this case the patient has to suffer for a longer period, 
 and owing to the larger size of the cavity more time is 
 required for its healing, and the* likelihood of scarring is 
 increased. Granulation is conducted under stimulant, anti- 
 septic, or such other dressings as may be called for by its 
 condition. 
 
 341. BOILS. A boil is a hard, knobby, painful swelling 
 developed under the skin, which is more or less congested. 
 It enlarges, and at the end of a week its centre becomes 
 pointed and ruptures, giving issue to a liquid oozing, and 
 showing through the aperture a yellowish slough which is 
 too soft to be pulled out by a forceps, even if it were free 
 from all adhesions to the interior. In a few days the 
 slough breaks down and is discharged, the cavity granu- 
 lates, and in progress of time the coagulable lymph which 
 formed its walls becomes absorbed. Boils usually come in 
 crops. The treatment for abscess is not suitable here, 
 because the matter cannot be cast out by incision, and poul- 
 tices increase the size of the interior slough. The boil is 
 best treated by merely protecting it from injury by adhesive 
 plaster, and dressing with resin ointment when the slough 
 is separating. 
 
 342. Some large and flat boils are called blind because 
 they do not open to discharge a slough. After increasing 
 for a week or ten days they slowly subside, leaving a hard- 
 ness at their site for a long time ; or, at the period of their 
 culmination, a small purulent point may be discovered, 
 which, instead of opening for the discharge of a slough, 
 dries into a yellowish scale. Poultices and incision are of 
 no benefit. The part should be simply protected by plas- 
 ter. Any discoverable errors in diet or mode of life should 
 be corrected. 
 
 343. CARBUNCLES are large and tedious boils which occur 
 
196 WHITLOW. 
 
 generally on the back of the neck in debilitated constitu- 
 tions. The subcutaneous tissues are involved in the con- 
 gestion, which is of a livid color and attended with much 
 pain and constitutional irritation. The local treatment 
 consists of poultices or warm-water dressing, with after- 
 ward a free crucial incision and applications of resin or 
 turpentine to promote the evacuation of the cavity. Some- 
 times the opening is made by potassa [319]. If left to 
 itself, the carbuncle is opened by ulceration at two or more 
 places, which uncover the underlying slough as they increase 
 in size. A nutritious diet is always, and stimulants gener- 
 ally, required to effect the cure. 
 
 344. In a WHITLOW or FELON, which is usually occasioned 
 by a prick on the end of a finger, the exudation is bound 
 down by the strong membrane covering the bone or the 
 fibrous tissues which hold the tendons of the finger in their 
 place. The consequent pressure is a source of severe throb- 
 bing pain even when there is but little redness or swelling. 
 The patient is deprived of sleep, and his whole system dis- 
 turbed, by the intensity of his suffering. The hand should 
 be enveloped in a large poultice, and kept in an elevated 
 position; opium or Dover's powder should be given to allay 
 pain and promote the subsidence of the congestion; but if 
 the symptoms are not favorably impressed within twenty- 
 four hours, a free cut should be made down to the bone to 
 relieve alike the tension in the part and the suffering of the 
 patient. To wait until the accumulated matter reached the 
 surface by ulcerative action would be to invite the destruc- 
 tion of the part and many weeks of disability, as the matter 
 finds it easier to spread upward into the palm of the hand 
 along the tendons than to come to the surface. 
 
 345. A GUMBOIL is a suppuration connected with the 
 fang of a tooth. A congestion with a slight exudation of 
 
GUMBOILS. 197 
 
 lymph occurs at the deep end of the fang. As this lymph 
 is locked in on all sides by bone, there is intense pain, which 
 soon becomes throbbing. If at this stage the tooth be 
 extracted, the matter escapes and the trouble is at an end ; 
 but it is not always advisable to sacrifice a tooth on account 
 of the temporary inflammation at its root. Occasionally 
 the matter finds its way between the fang and the socket, 
 and escapes gradually at the neck of the tooth. The usual 
 course, however, is for the matter, by its pressure, to cause 
 absorption of the bony tissue in which it is confined, until 
 an aperture is made which permits it to escape and accumu- 
 late between the surface of the jaw-bone and the gum. 
 Accordingly, when any soft, boggy swelling is observed on 
 the gum, it should be immediately incised to permit the 
 matter to escape. For the time being the gumboil is at an 
 end ; the swelling subsides and the incision heals ; but very 
 frequently the healing is not perfect. There often remains 
 a minute aperture on the site of the incision, and from it 
 matter occasionally exudes. Sometimes the aperture be- 
 comes blocked up, and there may be a little pain and swell- 
 ing before the accumulated matter finds its way through 
 the fistulous opening. To effect a cure in this instance, 
 the decayed root must be removed. If the matter of the 
 original gumboil be not liberated when it has penetrated 
 through the bone and reached the gum, it will generally 
 cause much swelling, and finally break within the mouth by 
 the thinning of the walls of the abscess cavity ; but some- 
 times the matter dissects its way into the tissues of the 
 cheek, causing much swelling of the face and subsequent 
 disfigurement by the scar of its opening. This should be 
 avoided by the liberation of the matter while it is yet con- 
 fined between the gum and the bone. 
 
 346. Ulceration of a bone is called caries. The same 
 
198 TOOTHACHE. 
 
 term is applied to the softening and absorption by which 
 cavities are formed in the dentine [208] of the teeth. 
 Toothache is one of the symptoms of this decay. When 
 the cavity is small and does not penetrate to the dental 
 pulp, it should be carefully cleaned out with absorbent cot- 
 ton on the end of a suitable instrument, and then plugged 
 with cotton moistened with carbolic acid, to allay sensitive- 
 ness. Afterwards, when the cavity has lost its tenderness, 
 it should be dried and filled with gutta-percha, softened by 
 a heat which should not be greater than the skin of the 
 wrist or back of the hand can bear without pain. When 
 the cavity is large and the pulp exposed, as evidenced by 
 the extreme sensitiveness of the bottom of the cavity, the 
 relief of the toothache requires the extraction of the tooth or 
 the killing of the nerve. To effect the latter purpose, a 
 mixture of equal parts of laundry soap and arsenious acid 
 is used. The cavity having been carefully dried, a small 
 piece, about the size of a pin-head, of the arsenical soap is 
 introduced into it and held in position for twenty-four 
 hours by a rilling of cotton-wool. This intensifies the pain 
 for several hours, but afterward relief is experienced. 
 Care should be taken that the action of the arsenic is con- 
 fined to the cavity. Carbolic acid on cotton-wool is used 
 to allay any remaining tenderness, after which the cavity 
 may be plugged with gutta-percha, as a preservative, until 
 the services of a dentist are obtained. 
 
 347. When a tooth has to be sacrificed because of a gum- 
 boil or a large cavity of decay, a suitable tooth-forceps 
 should be selected. Forceps are made of different sizes and 
 shapes ; but every one should be strong and unyielding in 
 its jaws and handles, and should move easily at its joint, 
 without being in the slightest degree loose-jointed; the 
 jaws should fit accurately to the neck of the tooth to be 
 
TOOTH EXTRACTION. 199 
 
 extracted, and should flare out toward their joint, so as to 
 cap the crown of the tooth without compressing it. The 
 jaws of an upper-tooth forceps are usually in line with the 
 handles, while those of the lower-tooth forceps are set at a 
 considerable angle. Forceps for single-fanged teeth [207] 
 have the extremity of their jaws gently curved and plain ; 
 those for the upper molars have a ridge on the face of the 
 outer blade for catching hold of the crotch between the outer 
 fangs ; those for the lower molars have a similar ridge on 
 both blades to fit on each side into the crotch; a pointed 
 cow-horn forceps is designed for lifting out the lower molars. 
 The various forceps at the command of the intending oper- 
 ator should be carefully studied as regards their adjustment 
 to the teeth and the direction of the traction to be employed. 
 The operating-chair should be solid, with a convenient grasp 
 for the hands of the patient, and a low neck-rest, that his 
 head may be thrown well back. 
 
 348. The operator stands on the right side when an upper 
 tooth is to be extracted ; on the left when a left lower tooth 
 is the subject; and behind, operating over the face of the 
 patient, when a right lower tooth is to be removed. The 
 fingers of his left hand should steady the jaw near the 
 affected tooth and afford counter-force during the extrac- 
 tion. In laying hold, the blades are closed lightly on the 
 tooth and the points are pushed well home on the neck 
 beneath the gum, keeping their long axis in line with that 
 of the tooth. The blades are then closed firmly on the 
 tooth so as not to slip, yet not to crush in the sides of a 
 hollowed tooth. A steadily increasing pull is then made, 
 with a slight rotary movement if the tooth is single-fanged, 
 and an equally slight lateral or forward and back movement, 
 when the tooth will come away. In extracting molars, the 
 traction is combined only with an outward and inward 
 
200 TOOTH EXTRACTION-. 
 
 movement; any attempt at rotation would break the fangs. 
 Care should be taken that the extracted tooth do not slip 
 from the forceps into the throat of the patient. 
 
 349. If the tooth break during the attempt at extraction 
 an effort may be made to remove the stump, but it should 
 not be prolonged if not promptly successful. The patient 
 may be solaced with the information that his toothache will 
 subside, as the dental pulp has now been removed, or, if 
 the relief of a gumboil was intended, that the matter will 
 now find exit by the central canal and sides of the fang. 
 Stumps rarely call for extraction save at the hands of a 
 dentist to prepare the gums for artificial teeth. As the 
 dental nerve is destroyed, they are seldom the subject of 
 toothache. A steel lever is useful in their extraction, as is 
 also a shorter gouge-like instrument ; these, which are called 
 elevators, are inserted between the socket and the stump ; 
 but the greatest care must be taken lest they slip and injure 
 the mouth, tongue, or throat. 
 
 350. A small dental case is provided by the Medical De- 
 partment for use at military posts where the services of a 
 qualified dentist cannot be obtained. By its means a care- 
 ful and neat-handed operator can insert a stopping that will 
 last for years. It contains a mirror for examinations, a 
 sealer for removing tartar, an explorer for examining cavi- 
 ties, chisels for trimming their edges, and excavators for 
 cutting out decayed dentine, with forceps for handling 
 absorbents, etc., and a supply of prepared gutta-percha. 
 Heavy socket-handles are provided for holding the instru- 
 ments. A spatula is used in filling large cavities, and 
 burnishers when the cavities are small. The gutta-percha 
 stopping requires to be cut into pellets proportioned to the 
 size of the cavity to be filled. These are warmed on a 
 piece of porcelain over a lamp-flame, taking care not to 
 
fORNS, BUNIONS, ETC. 201 
 
 Overheat them. They are then worked into the cleaned 
 and dried cavity with warm instruments. Moisture in the 
 cavity will defeat the intention of the operation. 
 
 351. CORNS. Continued pressure causes absorption and 
 ulceration ; intermittent pressure stimulates growth. Corns 
 are an illustration of the effects of intermittent pressure ; 
 but it often happens that the stimulation induces inflamma- 
 tion and suppuration. When acutely inflamed, the part 
 should be poulticed or treated with water dressing, covered 
 with oiled silk, and subsequently punctured to liberate the 
 matter, removing the corn at the same time, if this can be 
 readily accomplished. The proper treatment for uninflamed 
 corns, whether hard, as over the prominences of the toes, 
 or soft, as on their contiguous surfaces, is to keep them 
 closely trimmed, particularly toward the centre, and to 
 wear shoes that do not chafe or press upon the part or crowd 
 the toes together. Care of the feet is of greater benefit in 
 the cure of corns than more energetic and painful methods 
 of eradication. 
 
 352. BUNIONS are caused by the pressure of narrow-toed 
 shoes. Naturally, the toes spread away from each other, 
 but the narrow -toed shoe crowds them on the middle toe as 
 a centre, the great toe being deflected outward and the 
 little toe inward, while the root of each forms a prominent 
 angle on the side of the foot. This angle, unsupported by 
 adjacent structures, receives the pressure of the boot or 
 shoe, and its skin becomes first thickened by the stimula- 
 tion, and then painfully congested by its continuance. If 
 this protest against the unsuitable footgear be disregarded, 
 effusion takes place beneath the skin and forms a water-pad, 
 as it were, for the protection of the joint. Under a contin- 
 uance of the pressure the effused serum becomes replaced 
 by purulent matter, which escapes by the ulceration of a 
 
202 BLISTERS ON THE FEET, CHAFINGS. 
 
 small aperture through the overlying cuticle. The cure of 
 the bunion requires the removal of the cause, the relief of 
 the congestion by a poultice, the absorption of the effusion 
 by iodine paint, or the granulation of the suppurating cavity 
 under appropriate dressings soothing, if the granulations 
 be unprogressive from inflammation, and stimulating, if 
 unprogressive from indolence. 
 
 353. BLISTERS ON THE FEET. In the early days of a 
 march soldiers sometimes suffer from blistering of the feet, 
 particularly the heel, developed by chafing in ill-fitting 
 shoes or such as have not been broken in to the form of the 
 feet. The blister should be drained and protected next day 
 by a piece of rubber plaster. 
 
 354. CHAFING IN THE GROINS is also a frequent annoy- 
 ance on the march. It should be treated in camp by wash- 
 ing the excoriated surface and applying a lotion of acetate 
 of lead, and on the march by the use of oxid of zinc oint- 
 ment. 
 
CHAPTER IV. 
 
 WOUNDS. 
 
 355. A WOUND is an injury inflicted by mechanical vio- 
 lence on the living body hence a bruise is a wound ; but 
 the term is usually restricted to a separation of parts. An 
 incised wound is one made by a cutting instrument; in a 
 lacerated wound the tissues are torn apart ; and in a contused 
 wound they are broken by some irregularity on the surface 
 of the bruising instrument or by the violence of its appli- 
 cation. Sometimes a contused wound presents the appear- 
 ance of an incision, as when the scalp is split open by a 
 club. A punctured wound has great depth as compared 
 with its other measurements. A bayonet wound is a char- 
 acteristic punctured wound; a sabre cut is a contused 
 incision ; gunshot wounds are contused lacerations. 
 
 INCISED WOUNDS. 
 
 356. The requirements of treatment in the case of wounds 
 are: To arrest hemorrhage; to remove shock; and to 
 adjust the separated surfaces and to so retain them until 
 the exuded lymph or granulations have acquired strength 
 enough to withstand the separating tendencies of the ordi- 
 nary movements of the part. Close contact cannot be 
 effected if any foreign matter, such as splinters of the 
 weapon, sand, or earthy particles, fragments of clothing, 
 or even coagulated blood be lodged in the wound. These 
 must be picked away by the forceps or fingers, or washed 
 
204 INCISED WOUNDS. 
 
 off with a plentiful supply of water. The skin of the 
 neighboring surface should also be cleaned, and, if necessary, 
 shaved. The part is then placed in that position which 
 will relax the injured tissues and permit the sides of the 
 wound to be brought together, and the edges are stitched at 
 half-inch or other suitable intervals if plaster alone will not 
 hold them in position. A slightly curved needle is pushed 
 through the skin at about one- fourth of an inch from the 
 edge of the wound, and thence through the opposite tissues, 
 
 Closing a wound by suture. Securing apposition by plaster 
 
 strips. 
 
 drawing after it the suture thread, which is then tied in a 
 reef or surgeon's knot [389] and cut off short. 
 
 357. Strips of plaster are applied across the line of the 
 wound at short intervals or between the sutures, if any have 
 been inserted. They should be long enough to extend sev- 
 eral inches on each side of the wound, and they hold better 
 when slashed two or three times with the scissors for half 
 an inch longitudinally at each end. In applying each, and 
 particularly the first one, which should be across the centre 
 of the line of wound, one-half of the strip should be placed 
 in position on one side of the wound ; and when it adheres 
 firmly, traction should be made on the unapplied half with 
 one hand while the other draws toward the wound the tis- 
 sues on which the plaster is to be laid, that it, when applied, 
 
LACERATED WOUNDS. 205 
 
 may the better retain the sides of the wound in apposition. 
 A very good way of applying plaster strips is shown in the 
 accompanying illustration. When a clean incised wound 
 has been drawn together by plaster or sutures, the only 
 dressing required is a protection from the air and from 
 changes of temperature. Some folds of lint or sublimated 
 gauze may be laid over it and retained by a bandage; and 
 if the wound is situated near a joint, the occasional move- 
 ment of which would tend to draw the edges apart, a suit- 
 able splint should be applied to restrain its motion. A 
 cradle or light curved framework is sometimes placed over 
 a wound to relieve it from the weight of the blankets. The 
 sides of such a wound will in forty-eight hours be so firmly 
 united that each suture may be snipped at the side of its 
 knot and removed by seizing the knot between the points of 
 a dressing forceps ; but the plaster and splint should be 
 left until the union is strong enough to sustain the ordinary 
 strain incidental to their situation. In removing the strips 
 of plaster, each should be raised from one end to the line of 
 the wound, then from the other end to the same line, after 
 which its middle may be detached; in a large wound the 
 centre strip should be replaced by a fresh one before the 
 support of the others is withdrawn. Wounds which prog- 
 ress thus favorably are said to heal by primary union or by 
 the first intention. 
 
 LACERATED WOUNDS. 
 
 358. It is sometimes difficult to bring the sides of a 
 lacerated wound into that close contact which is needful to 
 primary union. When the edges are brought together, 
 there may be interstices and cavities in the interior which 
 the most carefully arranged compresses will fail to obliter- 
 ate. Moreover, there may be loss of substance, not only in 
 
206 LACERATED WOUNDS. 
 
 the interior, but of the surface, which will prevent the ed^s 
 from coining together. Such a wound does not bleed so 
 much as an incised one, but it requires the exercise of 
 greater care to secure the freedom of its irregular surfaces 
 from the presence of foreign matter. After it has been 
 thoroughly cleaned the wound should be closed by stitches 
 and slips of plaster, with small pads or compresses of folded 
 lint to preserve its sides in contact, and a splint, if needful, 
 to restrain motion. The object is to obtain primary union 
 of as much of the wound as possible. 
 
 359. The presence of lymph or of a thin layer of coagu- 
 lated blood between the surfaces does not interfere with 
 this union ; but when there are considerable cavities within 
 the wound, union in this adhesive way does not take place. 
 The lymph lying next to the living surface becomes con- 
 verted into living granulations, and that which is more 
 remote, lying in the centre of the cavity or interstice, breaks 
 down into a liquid which drains from the wound. The 
 formation of granulations progresses gradually, until ulti- 
 mately the two sides come into apposition, and adhesion 
 takes place by what is called secondary union in contradis- 
 tinction to that by primary adhesion. 
 
 360. When the loss of tissue involves the superficial 
 parts, constituting what is called an open wound, repair is 
 effected by granulation ; and when this process has brought 
 the reparative material in the wound up to the level of 
 the surrounding surface, a delicate skin, soon becoming 
 thicker and stronger, spreads from the edges over the sur- 
 face and completes what is called the cicatrization of the 
 wound. 
 
 361. If, however, the granulations be in judiciously treated 
 by warm, moist, and relaxant applications, such as poul- 
 tices, they may lose their fresh red color and their power 
 
LACERATED WOUNDS. 207 
 
 of exuding adhesive material ; so that, when opposite sur- 
 faces come together in the interior, they are unable to unite, 
 and when the proper level in the open wound is reached, they 
 fail to cicatrize, rising, instead, above the level as a fungous 
 growth, constituting what has been called proud flesh. The 
 sluggish granulations must be touched freely with lunar 
 caustic or sulphate of copper. This destroys their super- 
 ficial parts, and the action set up in the capillaries of the 
 deeper parts in order to throw off the cauterized slough 
 leaves them in fitter condition for adhesion or cicatrization, 
 as the case may be. 
 
 362. When a wound is infected, owing to imperfect 
 cleansing at first, to subsequent injudicious handling, or to 
 exposure, it becomes red, hot, swollen, and painful, and the 
 discharge from it profuse and acrid in fact, it festers ; and 
 if the swelling should block up the track by which the dis- 
 charges escape, or if the wound itself be of such a character 
 that the generated matter tends to become bagged in some 
 cavity or infiltrated in the subcutaneous or intermuscular 
 cellular tissue, a dangerous inflammation will result. The 
 wound should be freed from all putrefying matters ; and if 
 this cannot be accomplished by flushing it with disinfecting 
 solutions, a special opening should be maie to facilitate 
 their escape. When it has been thoroughly cleaned it may 
 be again dressed with antiseptics, which are to be renewed 
 as soon as materially contaminated with the discharges. 
 Irrigation, which was formerly employed as a method of 
 continuously cooling an inflamed wound, is one of the means 
 by which the putrefactive tendency may be neutralized. 
 It is effected by placing a vessel containing a supply of the 
 liquid to be used on a plane a foot or two higher than the 
 wound and siphoning its contents through a rubber tube, 
 delivering in or on the wound. The flow through the tube 
 
208 CONTUSED AND*. GUNSHOT WOUNDS. 
 
 must be regulated by a clip or some extemporized means of 
 pressure. 
 
 CONTUSED WOUNDS. 
 
 363. A part which has been severely contused may be 
 several days or weeks before the discoloration consequent 
 on extravasation of blood is effaced and the tissues return 
 to their healthy condition [337]. So in a contused wound 
 time must elapse before the severed surfaces are in a condi- 
 tion to unite. There can therefore be no union by first in- 
 tention, and sutures are useless in view of the swelling that 
 would necessitate their removal in the course of a few 
 hours as reaction progresses. Plaster strips suffice to pre- 
 serve adjustment after the wound has been cleaned. On 
 account of the lowered vitality of the injured tissues it is 
 of importance to thoroughly disinfect and protect a severe 
 contused wound. Without an efficient antiseptic treatment, 
 the germs of putrefaction would find in the extravasations 
 and exudations of the injured tissues the most favorable 
 conditions for their growth and propagation, and, as a 
 result, a violent action would be set up, attended with 
 much loss of substance by sloughing, a rapid spread of the 
 inflammation by the acrid products, and the danger of con- 
 stitutional infection by their absorption into the blood. On 
 the other hand, with an efficient antisepsis the injured tis- 
 sues break down and are absorbed or drain away, leaving 
 the wound free to granulate and heal like the cavities and 
 interstices of a wound that is merely lacerated. 
 
 GUNSHOT WOUNDS. 
 
 364. Gunshot wounds are treated like other contused 
 lacerations ; but the battlefield produces them in such num.- 
 
FIRST AID IN GUNSHOT WOUNDS. 209 
 
 bers as to render imperative the adoption of a system for 
 their satisfactory management. 
 
 365. FIRST AID concerns itself with shock, hemorrhage, 
 and the application of protective dressings. 
 
 366. SHOCK is, as in other wounds, usually proportioned 
 to the severity of the injury ; but sometimes the excitement 
 of victorious battle counteracts the depressing influences of 
 a serious wound, while, when the mind is affected by defeat 
 and the body exhausted by fatigue, a comparatively trivial 
 injury may exercise a powerful impression. When shock 
 is severe, place the patient on his back with his head low ; 
 check hemorrhage, if it exists; loosen belts and clocking, 
 and give 5 c.c. of aromatic spirit of ammonia or 20 c.c. of 
 whiskey, with cheering words before removal from the field. 
 
 367. BLEEDING. Oozing is usually restrained by the 
 dressing which is intended for the protection of the wound. 
 Venous bleeding is suppressed by graduated compresses [384] 
 on the wound ; and if from a limb, by a bandage applied 
 firmly from the toes or fingers up to and over the compresses. 
 Arterial bleeding is controlled by compresses, in wounds of 
 the head, hand, and foot; but when the jet comes from the 
 thigh, leg, arm, or forearm, a tourniquet or rubber bandage 
 should be applied to the main arterial trunk [387]. If the 
 blood springs from the neck or the walls of the chest or 
 abdomen, torsion [386] or the ligature [388] is used; fail- 
 ing this, efficient pressure with the fingers must be employed 
 until the hospital is reached. The common carotid is reached 
 by pressing the finger deeply into the neck in a backward 
 and inward direction at the anterior margin of the sterno- 
 mastoid muscle ; the facial as it curves from the neck to the 
 face over the base of the lower jaw about an inch in front 
 of its angle; the subclavian may be flattened against the 
 first rib by pressing the thumb downward into the hollow 
 
 H 
 
210 FIKST AID IN GUNSHOT WOUNDS. 
 
 behind the collar-bone ; the axillary by placing the thumb 
 in the armpit and pressing outward against the humerus; 
 the brachial in the upper part of its course by a similar 
 outward pressure, but immediately above the elbow the pres- 
 sure must be from before backward; the radial and ulnar 
 arteries are reached by the fingers along the outer and inner 
 sides of the forearm near the wrist; and bleeding from 
 the palmar arches is controlled by graduated compresses 
 backed by wooden splints. The femoral artery is reached 
 below the middle of the groin by pressure with the thumb 
 backward against the femur ; the popliteal by pressure from 
 behind against the knee-joint; the anterior tibial in the 
 lower part of its course by pressure along a line drawn from 
 the head of the fibula to midway between the malleoli; the 
 dorsal artery of the foot along the outer side of the extensor 
 tendon of the great toe ; the posterior tibial in the hollow 
 between the inner ankle and the heel. 
 
 368. When the hemorrhage has been very great, the 
 patient is completely prostrated. His face and lips are 
 pale, countenance shrunken, skin cold and bedewed with 
 drops of perspiration ; his pulse is rapid, small, weak, and 
 fluttering, perhaps almost imperceptible; his breathing 
 quiet, but frequently interrupted by a long, sighing expira- 
 tion; his voice is weak and whispering, and his limbs pow- 
 erless or at times tossed about in sudden, aimless move- 
 ments. If he is conscious, he calls for water to allay his 
 thirst ; but he is often unconscious or unobservant of what 
 is passing, muttering occasionally to himself in a low deli- 
 rium. A case of this kind, occurring in the field, must be 
 carried with the utmost care by hand-litter to the hospital, 
 administering stimulants by the way, and continuing the 
 treatment on the litter until the returning strength of the 
 patient authorizes his removal to bed, 
 
FIRST AID IN GUNSHOT WOUNDS. 211 
 
 369. The object of a PRIMARY or FIELD DRESSING is to 
 protect the wound. The contents of a first-aid packet 
 should be used in accordance with its printed directions, or 
 the wound should be covered with layers of sublimated lint, 
 cotton, jute, etc., and secured with plaster or the triangu- 
 lar bandage; but if the wound is already soiled it should be 
 freed from foreign matters and be made antiseptically clean 
 before being dressed. 
 
 370. The proper size for a triangular bandage is from 
 forty to fifty inches along the base and twenty to twenty - 
 four inches from the centre of the base to the apex. A 
 piece of linen, muslin, or other suitable material of this 
 shape and size fulfils many of the requirements of first aid 
 in surgical emergencies. It may be folded in the form of a 
 cravat for application to the head, neck, or limbs, as well 
 as for fixing splints or other protective appliances. In 
 bandaging the hand, the injured member is laid upon the 
 open triangle, the fingers toward the apex, and the wrist 
 or forearm over the middle of the base ; the apex is then 
 turned upward over the hand, and held in position by cross- 
 ing the ends of the bandage over it, and tying them around 
 the wrist. The foot is bandaged in a similar manner, the 
 ends being secured around the ankle. On the same princi- 
 ple the stump after the amputation of a limb may be treated 
 or dressings retained upon any part of the head. It may 
 be applied to the chest by fastening the ends around the 
 body and drawing the apex over one or the other shoulder 
 down in front or behind to be made fast to the girdle formed 
 by its base ; to the pelvis by encircling the body and bring- 
 ing the apex up between the thighs in front or behind to be 
 fastened to the girdle. For the shoulder a strip may be 
 torn lengthwise from the base of the triangle, passed around 
 the neck on the injured side, and fastened in the uninjured 
 
212 FIRST AID IN GUNSHOT WOUNDS. 
 
 armpit; the small triangle remaining is made fast by its 
 base around the arm of the injured side, and its apex is 
 carried up over the shoulder to be secured to the strip 
 already applied. For wounds of the hip or thigh two tri- 
 angles are required one is folded and applied as a girdle 
 around the body, the base of the other is 
 passed around the thigh, and its apex 
 brought up aiid made fast to the girdle. 
 As a sling for an injured upper ex- 
 tremity one-half is laid over the breast 
 and shoulder of the uninjured side, so 
 as to bring the midlength of its base 
 under the hand and its apex beyond the 
 elbow to be supported; the other half 
 is carried up over the shoulder of the 
 
 Sling for forearm. *- 
 
 injured side and its ends are tied on the 
 nape of the neck. The point or apex of the triangle is 
 then smoothed out, folded snugly around the elbow, and 
 made fast. 
 
 371. When bones are fractured, place the limb in as 
 natural and easy a position as possible and apply a bandage 
 or padded splints for comfort during transportation. Rifles, 
 swords, scabbards, pieces of wood, lath, or shingles, branches 
 or twigs, may be used as splints, and clothing, blankets, 
 hay, straw, grass, or moss as padding. Collar-bone or 
 shoulder-blade : put the forearm and hand in a sling and 
 bind the arm to the body. Humerus : apply two splints, 
 one in front and one behind, when the break is in the lower 
 part; otherwise, on the inner and outer sides; and support 
 the arm in a sling, forearm : place thumb up and apply a 
 splint along the outer surface to the wrist and along the 
 inner surface to the ends of the fingers ; support by sling. 
 Bones of leg and thigh : apply splints on each side. For 
 
INFECTED WOUNDS. 213 
 
 the thigh the outside splint should extend from the armpit 
 to beyond the foot. A blanket made into two rolls, with a 
 trough for the limb between them, is useful. Bind the 
 injured limb to the sound one. 
 
 INFECTED WOUNDS. 
 
 372. Wounds are occasionally assailed by germs of great- 
 er virulence than those of putrefaction, particularly when 
 many patients are crowded together under the same roof. 
 ERYSIPELAS and HOSPITAL GANGRENE both result from the 
 infection of the wound by specific germs through the medium 
 of a foul atmosphere, tainted fingers, instruments, sponges, 
 etc. Each of these germs produces its respective disease : 
 the one a violent inflammation, which spreads far from the 
 original wound along the skin and its underlying tissues, 
 causing the accumulation of purulent matters at various 
 points, with much disorganization of the affected parts and 
 a corresponding amount of febrile action; the other an 
 equally violent inflammation which, although spreading 
 with less rapidity, exercises a more deadly action 011 the 
 parts involved, causing their mortification or death, and is 
 associated with a low or typhoid form of fever. To avoid 
 these infections, the wounded should be treated in the open 
 air or in tents rather than in crowded rooms. 
 
 373. ARROW WOUNDS are punctured wounds with more 
 or less of contusion, but they differ from bullet penetrations 
 in being always infected with germs. Both the arrow- 
 head and its shaft are always unclean ; the former is often 
 made fast with animal fibres, and the latter painted with 
 blood or vegetable juices. Wounds penetrating the cranium, 
 chest, or abdomen are therefore exceedingly dangerous. The 
 head of the arrow should be removed, if possible ; but the 
 projecting flukes make this difficult. First aid is restricted 
 
214 ARROW WOUNDS. 
 
 to cutting away the shaft a few inches outside the entrance 
 and taking care that no movement of the patient shall bury 
 the head deeper in the tissues. But the sooner the effort 
 is made to remove the arrow-head the greater will be the 
 chances of success, for the fastenings of many arrow-heads 
 become loosened in the moist tissues, so that traction on the 
 shank removes it, leaving the head within. If needful, the 
 wound must be enlarged for the passage of a long-limbed 
 forceps, and only when the head has been secured between 
 the blades should traction be made on the shank and forceps 
 as a whole. Cases may occur when the best, if not the only 
 possible, way of removing the missile is to push it onward 
 in its line of direction, meeting it, for extraction, with an 
 incision through the tissues which it must of necessity pen- 
 etrate. Sometimes, in the excitement of battle with Indian 
 foes, the wounded man will seize the shaft of the arrow 
 and drag it from the wound, in which case the head is usu- 
 ally left in the tissues, and the difficulties attending its 
 removal are much increased. 
 
 374. Wounds which become infected with the germs of 
 erysipelas or hospital gangrene [372] are in truth POISONED 
 WOUNDS; but this title is usually reserved for those that 
 are inoculated with the poisonous agent by the instrument 
 which inflicted them. The scratches or punctures acci- 
 dentally received in examining or dissecting the dead body, 
 or in operating on the living, are often poisoned as well as 
 those caused by the sting of a hornet or nettle, the bite of 
 a rabid dog, or the fangs of a venomous serpent. The grav- 
 ity of these depends on the nature of the virus or germ 
 introduced. The wound in itself is generally a minor con- 
 sideration a mere abrasion often proving more dangerous 
 than a free laceration, as the oozing of blood from the lat- 
 ter tends to the removal of the infectious material. 
 
INFECTED WOUNDS. 215 
 
 375. DISSECTION WOUNDS sometimes heal as readily as if 
 uninfected ; in other cases the scratch inflames and suppu- 
 rates, leaving an ulcer which heals by granulation or by 
 forming a thick scab, as in the case of the vaccine virus; 
 in a third set of cases the inflammatory action is not con- 
 fined to the wound, but involves all the neighboring tissues, 
 as of the finger and hand, while red lines of inflamed 
 lymphatic vessels reach upward to the armpit, the glands 
 of which become implicated in the swelling and suppura- 
 tion. Dissection wounds are especially dangerous when the 
 virus implanted is derived from a patient who has died of 
 blood-poisoning, erysipelas, or inflammation of the peri- 
 toneum or pleura. The fever which accompanies them is 
 usually of a low or typhoid type. The treatment of dissec- 
 tion, as of all poisoned wounds, looks to the removal or 
 destruction of the poison before it has time to be absorbed. 
 Prompt action is therefore essential. A constriction should 
 be placed around the finger or hand above the injured 
 point, which should be immediately washed in a germicidal 
 liquid, incised to promote bleeding, and sucked vigorously 
 to remove the septic matter. After this, if the matter is 
 known to be of a specially dangerous character, lunar caus- 
 tic should be freely applied and the part wrapped up in a 
 large soothing poultice. In the absence of nitrate of silver, 
 any powerful escharotic may be employed, as the caustic 
 alkalies, sulphuric or nitric acid applied by means of a 
 wooden probe, a drop of boiling oil, or a small fragment of 
 chlorid of zinc paste made by moistening and mixing one 
 part of the salt with two of flour. 
 
 376. The BITE OP A RABID DOG should be treated as a 
 dangerous dissection wound. When lunar caustic is not at 
 hand, the wound, after laceration, free bleeding, and vigor- 
 ous suction, should be cauterized with a steel rod, probe, or 
 
216 INFECTED WOUNDS. 
 
 other suitable instrument, at a dull red heat. Experience 
 has shown the efficiency of solid nitrate of silver, when 
 promptly and freely applied ; but the terrible and deadly 
 nature of hydrophobia has begotten a distrust of any but 
 the most heroic measures. Hence a thorough excision of 
 the bitten part is by some recommended, to be followed by 
 caustic or the actual cautery. 
 
 377. SERPENT BITES must be promptly sucked, excised, 
 and cauterized, an encircling ligature meanwhile having 
 been placed on the cardiac side of the wound ; some prac- 
 titioners have used alcohol, ammonia, or tincture of iodine 
 locally to neutralize or decompose the virus. The effect of 
 the poison depends on its virulence in the individual case. 
 Sometimes the part inflames, the inflammation spreading 
 like erysipelas along the subcutaneous cellular tissue, and 
 affecting the glands by way of the lymphatic vessels. The 
 patient may die after several weeks of suppuration and 
 suffering, or recover after many months with a limb more 
 or less impaired by destructive inflammation. In the most 
 virulent cases, the patient dies in a few hours from disor- 
 ganization of the blood, the body becoming swollen, ecchy 
 mosed, and undergoing rapid decomposition. If there is 
 much depression during and after the local treatment, alco- 
 holic stimulants should be freely administered. 
 
 378. The BITES OF TARANTULAS and the STINGS OF SCOR- 
 PIONS, CENTIPEDES, ETC., are frequently spoken of in the 
 Western service of our army, but are rarely seen. When 
 they occur, they must be treated on the same general prin- 
 ciples as other wounds of this class. The application of 
 diluted ammonia or liquor potassse to the injured point is 
 recommended by some for the neutralization of the poison. 
 
 379. The trifling wounds caused by the STINGS OF BEES 
 OR WASPS are best treated by suction, which usually with- 
 
GLANDERS. 217 
 
 draws the sting, or touching with diluted ammonia, after 
 which the local inflammation is subdued by means of lead 
 lotion or cold-water dressings. 
 
 380. GLANDERS. The inflammatory discharges from a 
 glandered horse or mule produce disease in man when they 
 come in contact with a wound, an abraded skin, or even 
 with the unbroken mucous membrane of the nose or lips. 
 The contagious nature and the invariable fatality of the 
 disease call for the utmost care in dealing with its sus- 
 pected occurrence in the horse. The earliest sign consists 
 of a steadily flowing watery or slightly mucous discharge 
 from the nostrils, with swelling of the glands under the 
 jaw of the affected side. This may continue unchanged for 
 several months, the mucous membrane being dark purplish 
 instead of faintly pink as in health or bright red as in ordi- 
 nary catarrhal inflammation; but usually the discharge 
 becomes thick, viscid, discolored, bloody, and offensive, the 
 mucous membrane ulcerated, and the lymphatic glands of 
 the face tumefied or transformed into putrid sores. The 
 glands on the inside of the thighs are next involved, and 
 speedily the whole body is converted into a mass of putre- 
 faction. In some cases the disease begins by swelling and 
 ulceration of a few of the glands of the extremities ; the 
 lymphatic vessels connected with these become swollen and 
 corded, and implicate the other glands with which they 
 communicate. These knots of enlarged glands, called farcy 
 buds, ulcerate in their turn, and the matter discharged from 
 them is as infectious and dangerous as that from the glan- 
 dered mucous membrane. In man, the two modifications 
 of the disease are usually combined; whether the disease 
 begins as glanders or as farcy, the other modification is 
 speedily developed. 
 
 381. When a suspicious case appears in a stable, the 
 
218 GLANDERS. 
 
 affected animal should be isolated and cared for until expert 
 testimony has decided upon its destruction as a dangerous 
 focus of infection, or its treatment, for farcy in its early 
 stages has been successfully treated. Those having care of 
 the animal should not sleep under the same shelter with their 
 charge ; all unnecessary contact should be avoided, and after 
 unavoidable contact, either with the animal or surrounding 
 objects which might be infected, the greatest care should be 
 given to washing away every trace of such contact j the dan- 
 ger in the breath of the animal should be fully appreciated, 
 and exposure to its impetus during the sneezing or cough- 
 ing, which frequently occurs, should especially be shunned. 
 Disinfectant solutions [536] should be freely used. 
 
CHAPTER V. 
 
 HEMORRHAGE FROM WOUNDS. 
 
 382. CAPILLARY HEMORRHAGE consists of a general ooz- 
 ing of red blood from the surface of the wound. It is con- 
 trolled by clearing away all clots, freely exposing the part 
 to the air, and elevating it ; by affusion with cold or hot 
 water [275] or the application of ice; by the use of styp- 
 tics, which coagulate the blood in the cut ends of the ves- 
 sels, and by bringing the sides of the wound together when 
 they can be so bandaged as to prevent the bagging of ac- 
 cumulating blood. 
 
 383. Liquor ferri subsulphatis, or MonsePs solution, is 
 the styptic commonly used ; the persulphate is too irritant 
 for this purpose. It is applied locally by means of a dossil 
 of lint ; it is inhaled from an atomizer in bleeding from the 
 lungs, and administered in 3 to 6 minim doses in hemor- 
 rhage from the stomach or bowels. Tannin is applied 
 locally in solutions of suitable strength ; dissolved in alco- 
 hol and ether and mixed with collodion, it forms a styptic 
 collodion used for sealing the edges of wounds. Alum in 
 solution, turpentine, tincture of catechu, tincture or infu- 
 sion of matico, and other astringents are also frequently 
 employed by mopping the bleeding sufrace with a pledget 
 of lint or cotton which has been soaked in the styptic 
 liquid. Epistaxis or bleeding from the nose is treated by 
 any of these methods aided by compression of the facial 
 artery [367]. Ordinarily in full-blooded individuals nose- 
 
220 HEMORRHAGE. 
 
 bleeding is salutary and easily stopped ; but in broken-down 
 constitutions and in heart disease it is sometimes persistent 
 and dangerous. Bleeding from the socket of an extracted 
 tooth may be controlled by removing all clots from the cav- 
 ity, packing into it, bit by bit, a long strip of dry lint, a 
 quarter of an inch wide, placing a small-folded compress 
 over this, and keeping the jaws tightly closed on the whole 
 for several hours. 
 
 384. VENOUS HEMORRHAGE is dark-colored, and flows in 
 a steady stream. Pressure with the finger or with gradu- 
 ated compresses is the best means of controll- 
 ing this species of hemorrhage. Graduated 
 compresses consist of small pads of folded 
 
 A graduated lint, cotton, or other suitable material. The 
 smallest is placed on the bleeding-point; 
 others are laid over it, the outermost being the largest, 
 so that when the whole is bound in position by means of 
 a bandage the pressure is transmitted to the bleeding 
 vessels. If the bleeding is from a limb, a bandage should 
 be applied from the toes or fingers to the level of the 
 wound, prior to placing the compresses in position. A 
 tight bandage around the limb above the wound increases 
 venous bleeding. 
 
 385. ARTERIAL HEMORRHAGE is florid red in color and 
 escapes from the wound in spurts or jets. A small arte- 
 rial point may be recognized on a profusely oozing surface 
 by the impulse of the escaping blood and the bright- 
 ness of its color. Nature operates in three ways to pre- 
 vent fatal consequences from the division of these vessels : 
 by the contraction of the divided ends, the coagulation of 
 the blood, and the influence of the injury on the heart and 
 nervous system. When an artery is divided its muscular 
 coat contracts on the instant, narrowing and withdrawing 
 
HEMORRHAGE. 221 
 
 its cut end into the tube of the outer coat, and carrying the 
 interior lining along with it. A gash with a sharp knife is 
 followed by a spirt of blood which escapes before the inner 
 coats have had time to contract; but this immediately sub- 
 sides to a capillary oozing unless some comparatively large 
 vessel has been wounded. When the cutting instrument is 
 blunt the bleeding is relatively less, because the irritation 
 caused by the coarse edge stimulates the vessels to contract. 
 Some vascular tumors which could not be excised on account 
 of hemorrhage have been successfully removed by the 
 ecraseur, a strong wire cord which is looped over the tumor 
 and made to cut its way through. Contused and lacerated 
 wounds bleed less than incised wounds : an arm has been 
 torn off by machinery without notable hemorrhage from 
 the lacerated axillary artery. The closing of the divided 
 vessels, which is begun by the contraction of the interior 
 coats, is completed by the formation within them of a plug 
 of coagulated blood; for the retracted and roughened ends 
 favor the deposition of coagulum. The tendency to faint- 
 ing [302] which follows a wound conduces to the suppres- 
 sion of bleeding by diminishing the force of the heart's 
 action. 
 
 386. Artificial means for arresting hemorrhage are based 
 upon those employed by nature. Douching with cold or 
 hot water, or exposure to the air, stimulates the cut vessels 
 to greater contraction, and is suitable to the cases of small 
 vessels that do little more than ooze. Continued pressure 
 with the finger upon a bleeding-point will restrain hemor- 
 rhage until the vessel becomes plugged with coagulum ; this 
 pressure may be combined with the use of styptics. When 
 the spurting vessels are small, bleeding may often be stopped 
 by torsion, by which is meant seizing the bleeding-point 
 between the blades of a forceps and twisting it three or 
 
222 HEMORRHAGE. 
 
 four times, thus converting that particular part of the wound 
 into a laceration, which does not bleed. When the vessel 
 is larger and yields a dangerous jet, the finger must be 
 placed upon it to prevent loss until better means of control 
 have been adopted. These consist either of placing a 
 tourniquet or elastic bandage [275] on the limb above the 
 wound as a temporary expedient, or of applying a ligature 
 around the open mouth of the vessel as a permanent 
 measure. 
 
 387. The field tourniquet consists of a pad to be placed 
 over the artery and a strap and buckle to secure it in posi- 
 tion. This may be extemporized by 
 a roller for a pad, fastened by a loop- 
 bandage [438]; or by encircling the 
 limb with a handkerchief over a 
 smooth stone for a pad, and tighten- 
 ing the handkerchief by giving seve- 
 ral turns to a short stick which has 
 been slipped between it and the skin 
 on the opposite side of the limb to the 
 stone. The latter was the original of 
 
 The screw tourniquet. 
 
 the screw tourniquet that is yet in use, 
 and which consists of an encircling band that may be tight- 
 ened by the separation of two metal plates consequent upon 
 the turning of a screw. The screw and plates are usually 
 placed over the artery, with a large roller beneath the lower 
 plate, to give a -trustworthy pressure along the arterial 
 track. 
 
 388. But the tourniquet is merely a provisional arrest, as 
 during transportation to hospital or while awaiting the 
 arrival of expert assistance or the needful instruments. 
 Permanent closure of the bleeding vessel must be effected 
 by the ligature ; and when an artery of some size is divided 
 
HEMORRHAGE. 223 
 
 it is not enough to tie its upper or bleeding end its lower 
 end should also be secured to prevent hemorrhage from it 
 after \he establishment of the collateral circulation [187]. 
 When an artery is tied firmly with a small round cord of 
 ligature silk or carbolized catgut, its inner coats are cut 
 across at the point of stricture and retract on account of 
 their contractility, leaving only the tough external tunic in 
 the grasp of the ligature. In the course of one or more 
 
 Ligation of an artery: The ligature has cut the middle and internal coats 
 which are retracted on each side within the arterial tube ; a conical plug of co- 
 agulum has been formed on the side towards the heart. 
 
 days, depending on the quantity of tissue devitalized by the 
 pressure of the ligature, the whole of this tissue becomes 
 absorbed and the loop is free to be withdrawn by traction ; 
 but this does not usually happen until the cellular coat on 
 the upper side of the ligature has been sealed by exuded 
 lymph and the canal of the vessel closed for some distance 
 by a fibrinous coagulum. There is, therefore, no recur- 
 rence of the bleeding when the ligature is withdrawn as 
 in the case of silk, or when it is liquefied and absorbed as in 
 the case of catgut. Ordinary catgut is too readily softened 
 and absorbed when imbedded in the living tissues; but 
 when specially prepared, as by soaking for a long time in 
 carbolized oil, it becomes harder, and resists the action of 
 the tissues until time has been afforded for the consolidation 
 of the artery. 
 
 389. In operating, the bleeding mouth of the vessel is 
 transfixed with a tenaculum or seized with a spring or 
 artery forceps [273], and drawn out from the mass of tissue 
 
224 HEMORRHAGE. 
 
 in which it is imbedded, after which an assistant passes the 
 ligature around it and ties it firmly in a reef knot or that 
 modification of a reef knot sometimes called the surgeon's 
 knot. In tying the reef knot, the middle of the ligature is 
 applied to the artery immediately in advance of the points 
 of the forceps or curve of the tenaculum, and its free ends 
 are brought loosely around on the other side of the artery 
 and crossed from one hand to the other, forming a ring 
 through which one end is passed to form a single knot. 
 This knot is drawn tightly on the artery, the traction on the 
 
 The reef knot. The surgeon's knot. 
 
 ligature on both sides being made as close to the vessel as 
 possible in order not to drag it out of its position. The 
 inner coats give way under the pressure of the tightened 
 ligature ; but as the single knot would speedily slip, it must 
 be guarded by a second, made as before by crossing the 
 ends to form a ring, slipping one end through the ring and 
 drawing on the ends; but in crossing the ends for this sec- 
 ond single knot, that which lies in front of the first knot 
 must be placed in front of the other, else the second knot 
 will not hold securely. Sometimes, in tying the second, 
 the first knot will become relaxed, to prevent which the tip 
 of the finger of an assistant should be pressed upon it until 
 the second is about to be run home ; but the first may be 
 made to hold better until the second is tied by passing the 
 end through the ring twice, constituting the surgeon's knot, 
 instead of once, as in casting the sailor's or reef knot. If 
 
HEMORRHAGE. 225 
 
 the ligature is of catgut, both ends are cut off short at the 
 knot, which is left in the wound to be absorbed; if of silk, 
 one of the ends is cut short off and the other is brought out 
 at the lowest part of the wound, so that it may act as a drain 
 for the passage of liquids exuded after the lips of the wound 
 have been brought into position and sutured. 
 
 390. The hemorrhage which takes place from a wound at 
 the time of its infliction and ceases spontaneously or with 
 the aid of surgical art, as described above, is called primary. 
 This hemorrhage, whether arterial, venous, or capillary, 
 must always be completely stopped before a wound is closed, 
 lest it should continue and become infiltrated between the 
 muscles or penetrate into neighboring cavities, forming a 
 clot which would give rise to extensive inflammation by its 
 subsequent disintegration and decomposition. The greater 
 the shock attending the injury, or the greater the faintness 
 from blood already lost, the greater must be the care given 
 to this point, because, as the patient rallies from the shock 
 or syncope and the impulse of the heart becomes stronger, 
 there is greater danger of a recurrence of the bleeding. It 
 is well, therefore, when there is much nervous prostration, 
 to wait for marked indications of returning strength before 
 finally closing the wound. 
 
 391. The bleeding which occurs during reaction, when 
 the clots which have formed in the mouths of the vessels 
 are driven out by the increased force of the circulation, is 
 called intermediary hemorrhage. When care has been taken 
 in the first instance, this seldom amounts to more than a 
 mere oozing which may stain the overlying dressings. 
 
 392. But danger from hemorrhage has by no means 
 ceased when reaction has been established, for at the end of 
 several days the establishment of a collateral circulation 
 [187] may give rise to bleeding if the lower end of the 
 
 15 
 
226 HEMORRHAGE. 
 
 divided artery was left unguarded by a ligature [388]; 
 ulceration or sloughing may lay open an artery or vein the 
 coats of which have been contused ; or a ligature may come 
 away, leaving the vessel imperfectly guarded by coagulum 
 and exuded fibrin, so that what is called secondary hemor- 
 rhage may occur, and be even more dangerous than the 
 primary bleeding, on account of the greater difficulty of 
 securing an injured vessel in a wound that has been more or 
 less altered by adhesions and granulations than in one that 
 is recently inflicted. Secondary hemorrhage, if slight, may 
 be controlled by pressure or the injection of styptic solu- 
 tions ; but if profuse it must be temporarily restrained by 
 the application of a tourniquet or other pressure to the main 
 trunk above the wound until competent surgical assistance 
 has been obtained to open the wound and secure the bleed- 
 ing vessels. 
 
CHAPTER VI. 
 
 WOUNDS OF THE HEAD, NECK, AND TRUNK. 
 
 393. The gravity of WOUNDS OF THE HEAD depends on 
 the amount of injury sustained by the nervous masses. 
 Contused wounds should be treated, as in other parts of the 
 body, to moderate inflammation and promote the absorption 
 of extravasated blood or exuded inflammatory products. 
 Incised wounds sometimes bleed freely, and require a com- 
 press. Plaster strips, not sutures, should be used to retain 
 the edges in apposition, even when the wound is lacerated 
 and the scalp torn from the underlying bone. Preliminary 
 to this, the hair must be removed by close cropping and 
 shaving. 
 
 394. Dressings are retained on the scalp in various ways. 
 In applying a single roller or bandage for this purpose, the 
 end is placed on the forehead and one or two firm horizontal 
 turns are made, ending on the temple, where the superim- 
 posed layers are fastened together by a pin or stitches ; the 
 bandage is then carried from this fixed point over the vertex 
 and under the chin as often as may be required, and the 
 end and crossings stitched for greater security. The double 
 rotter is made by stitching together the free ends of two 
 single rollers. In applying it to the head, horizontal turns 
 are made to fix in their place those turns that are carried 
 over the cranium to cover its dome. This, the recurrent or 
 capelline bandage, is a relic of the olden time, when to do a 
 thing secundem arlem was considered of more importance 
 than to do it so that it should fulfil the indications in the 
 
228 
 
 WOUNDS OF THE HEAD. 
 
 case under treatment. A simpler retentive appliance is 
 the four-tailed bandage. This is a piece of muslin a yard 
 long and six or eight inches wide which has been torn 
 lengthwise into two strips of equal width, except in about 
 
 Single roller for the head. 
 
 Four-tailed bandage on chin. 
 
 six inches of its middle part. The untorn portion is applied 
 to the vertex; the posterior tails are tied under the chin 
 and the anterior tails under the occiput. 
 
 395. A narrower four- tailed bandage than that for the 
 head is useful on the chin; the upper tails are tied on the 
 back of the neck, or crossed there and tied under the chin, 
 and the lower ones are carried to the vertex. The six- 
 tailed bandage for the head is made on the same principle. 
 The central part is applied to the vertex, the middle tails 
 are made fast under the chin, the anterior tails beneath the 
 occiput, and the posterior ends on the forehead. But a 
 handkerchief used as a triangular bandage is the simplest 
 and often the best form of retentive appliance. The centre 
 of the base or long side of the triangle is applied to the 
 forehead, the apex or opposite corner falling over the occi- 
 put, where the ends of the base meet and are tied firmly 
 
WOUNDS OF THE KECK AND CHEST. 229 
 
 together, or are brought forward after crossing, and made 
 fast on the forehead. 
 
 396. In cases of CUT-THROAT there is often much bleed- 
 ing, which should be controlled by continued compression 
 with the finger if the bleeding is venous, by torsion or the 
 ligature if arterial. When the cut is below the larynx, the 
 head, neck, and chest may become swollen from the escape 
 of air into the cellular tissue (emphysema] ; this is not usu- 
 ally a dangerous complication. The wound should be closed 
 by many stitches, and its lips supported by long strips 
 of plaster, stretching downward and outward toward the 
 collar-bone and shoulder; but if the patient is unable to 
 breathe through the natural passage the wound should be 
 left open, with its sides approximated by a forward inclina- 
 tion of the head. When the pharynx is involved, nourish- 
 ment must be administered by means of the stomach-pump 
 [502]. 
 
 397. WOUNDS OF THE CHEST penetrating the cavity and 
 injuring the lung are usually attended with shock; and 
 when there is serious internal hemorrhage the patient sinks 
 into a condition of great prostration and final collapse ; but 
 however desirable it may be to ascertain the full extent of 
 the injury, the finger or probe should not be used in the 
 examination. Penetration of the wall is usually associated 
 with the entrance of air through the wound, distending the 
 cavity and preventing the filling of the lung during inspi- 
 ration. Blood in the pleural cavity, hcemothorax, gives a 
 dull sound on percussion over the collected extravasation ; 
 air in the pleural cavity, pneumothorax, gives a tympanitic 
 or drum-like sound over the intruded air When the lung 
 is penetrated, blood appears in the sputa, and an admixture 
 of air gives a frothiness to liquids that escape from the 
 wound; the cellular tissue of the chest often becomes infil- 
 
230 WOUNDS OF THE ABDOMEN. 
 
 trated with air, constituting the condition called emphysema. 
 If the penetration is small, as a stab, and inflicted with a 
 clean instrument, it may heal as readily as a simple non- 
 penetrating wound, even although there may be extravasated 
 blood within the pleura and an injury to the lung; but if 
 the wound become infected by injudicious handling, by the 
 exposure incident to its open or gaping character, or by the 
 lodgment of any foreign matter, as a bullet or fragment of 
 clothing, a violent inflammation of the pleura and lung will 
 result. 
 
 398. The treatment of the non-penetrating wound is that 
 of flesh wounds in any other situation; and that of pene- 
 trating wounds differs only in the addition of precautions 
 to restrain internal hemorrhage and moderate the subse- 
 quent inflammation. During collapse, stimulation must be 
 attempted with caution, lest it aggravate the hemorrhage; 
 during reaction, perfect rest and quietude must be enjoined. 
 
 399. WOUNDS OF THE ABDOMEN which do not penetrate 
 into the abdominal cavity require greater care in their 
 management than corresponding wounds of the chest. This 
 arises from the greater likelihood of foreign bodies escaping 
 detection among the muscular tissues, the greater difficulty 
 of obtaining coaptation of the deeper parts of the wound, 
 the greater danger of extravasated blood burrowing between 
 the muscles, and, corresponding with all this, the greater 
 tendency of such wounds to suppurate and occasion con- 
 stitutional disturbance. In treating them, foreign matter 
 should be carefully removed; bleeding should be entirely 
 stopped before the edges are approximated, and this should 
 be effected by the ligature if the flow is copious, or by 
 torsion, styptics, cold or local pressure if slight; on no 
 account should the wound be closed and compresses applied 
 with the view of controlling hemorrhage, lest the blood find 
 
WOUNDS OF THE ABDOMEN. 231 
 
 its way into the intermuscular spaces ; compresses should 
 be used, however, to insure coaptation of the deeper parts, 
 and the edges should be closed by sutures or strips of plaster 
 while the body is retained in that position which most facil- 
 itates closure. In punctured wounds it is often difficult to 
 decide whether the cavity has been penetrated; in such 
 cases, exploration by the finger or probe is not advisable. 
 Hemorrhage must be stopped before the wound is closed, 
 as otherwise blood, if the wound penetrated, would collect 
 in the peritoneal cavity. When penetration is evidenced 
 by protrusion of the viscera, the case must be brought 
 immediately to the attention of the surgeon. 
 
CHAPTER VII. 
 
 THE CAUSATIVE CONDITIONS OF INSENSIBILITY. 
 
 400. Insensibility may arise from : Injury to the brain by 
 external violence ; apoplectic conditions, or those connected 
 with congestion of the brain; and syncopic conditions, or 
 those connected with a diminished circulation of blood. 
 
 401. CONCUSSION OF THE BRAIN varies in intensity from 
 a momentary stunning, which leaves the patient temporarily 
 confused, weak, and tremulous, to a state of continued in- 
 sensibility with feeble but easy breathing, an almost imper- 
 ceptible pulse, pale countenance, and cold, clammy skin. 
 The occurrence of vomiting in a case of severe concussion is 
 accounted a favorable sign, as the patient usually rallies 
 after it. The patient should be put to bed and be warmly 
 covered; warmth should also be applied to the extremities; 
 and should the power of swallowing be retained, the removal 
 of intense depression may be cautiously attempted by small 
 doses, twenty or thirty drops, of aromatic spirit of ammonia. 
 A purgative enema should be administered ; and if insensi- 
 bility continue for some hours, the catheter should be used. 
 When reaction takes place, cold cloths or evaporating lotions 
 should be applied to the shaven scalp, with perfect rest, 
 quiet, an unstimulating diet, and an occasional laxative. If 
 serum be effused or lymph exuded during reaction in a case 
 of concussion of the brain, these morbid products, confined 
 within the bony case, give rise to symptoms of COMPRESSION. 
 If a blow on the head lacerate some of the blood-vessels 
 
CONGESTION OF THE BRAIN, APOPLEXY. 233 
 
 within the skull, the resulting hemorrhage occasions a grad- 
 ually increasing pressure on some part of the brain ; or if 
 the blow fracture the skull and drive a portion of the bone 
 inward, the brain suffers immediately from the pressure of 
 the intruding fragment. The symptoms and treatment of 
 compression are those of apoplexy, for the latter is caused 
 by the pressure of a hemorrhage or effusion which depends 
 on disease instead of on external violence. 
 
 402. In CONGESTION OF THE BRAIN the arteries bring an 
 excess of red blood and the capillaries become engorged. 
 The symptoms are headache, fever, great restlessness, and 
 delirium ; and not until effusion has taken place and exercises 
 a compression on the brain does the delirium subside into 
 the insensibility and profound stupor of the apoplectic state. 
 The gradual progress of the case indicates, in this instance, 
 the conditions to which the insensibility must be attributed. 
 403. APOPLEXY. Insensibility, as a direct result of 
 active congestion, is gradual in its development; but as an 
 indirect result it often occurs suddenly, particularly in 
 elderly persons, in whom the walls of the cerebral arteries 
 have undergone weakening and dilatation. The strain on 
 these weak points during a congestion of even a trivial char- 
 acter may be such as to occasion their rupture and a sud- 
 den extravasation of blood into the substance of the brain. 
 Pressure is exercised on the brain by this extravasated blood, 
 and is manifested by the same symptoms as the pressure 
 from an indriven portion of a fractured skull or the com- 
 pression arising from blood extravasated as a result of vio- 
 lence. The patient is unconscious, his face flushed, pupils 
 insensible to light and perhaps of different sizes, pulse slow, 
 hard, and full, breathing slow and somewhat irregular, the 
 inspiration snoring and the expiration puffing; generally 
 the features are drawn to one side, indicating the existence 
 
234 SUNSTROKE. 
 
 of paralysis [291]. The treatment consists in loosening 
 the clothing about the neck and chest, and applying cold to 
 the head, which, with the shoulders, should be kept elevated 
 by pillows; hot water with mustard to the feet and legs, 
 and the placing of a drop or two of croton oil on the tongue, 
 with a purgative enema if the bowels are not opened in the 
 course of an hour. Cloths or other absorbing material 
 should be adjusted under the patient with a rubber sheet to 
 protect the mattress ; and if the insensibility has lasted for 
 some time, a catheter should be introduced to evacuate the 
 bladder. 
 
 404. SUNSTROKE is the result of heat, over-exertion, and 
 an insufficient supply of water. If the water needful in 
 the system be not replenished from time to time as it is 
 dissipated in vapor from the lungs and skin, evaporation 
 will cease ; the skin, instead of being bedewed with mois- 
 ture, will become dry ; and the blood, altered by its loss of 
 water and its excess of heat, will tend to stagnate in certain 
 organs, as the lungs and brain. At first the patient may 
 have merely a sense of oppression in the chest, or of head- 
 ache, with increasing confusion of thought ; but his limbs 
 will speedily begin to tremble, and ultimately sink un- 
 der him as he falls insensible. His pulse is quick, com- 
 pressible, and small, sometimes intermitting; his breathing 
 short, shallow, and interrupted by deep-drawn sighs; his 
 lips are livid ; he clutches spasmodically at his chest, as if 
 to remove something that oppresses ; and he may be seized 
 every two or three minutes with violent convulsions which 
 stretch him out stiff and rigid for a few seconds, and then 
 gradually relax, with hesitating twitches which forebode a 
 recurrence. A man in this condition will die very shortly ; 
 or he will recover consciousness in a short time, if properly 
 treated, becoming perfectly well in a few hours or days ; or 
 
SUNSTROKE. 235 
 
 some accident may occur to the brain during its congested 
 condition, particularly if he be elderly and the subject of 
 degeneration of the walls of the cerebral arteries, and in 
 consequence of that accident he may remain unconscious for 
 many days, and have paralysis or other indications of injury 
 to the nervous system. 
 
 405. Manifestly, the sooner a sunstruck patient is treated 
 and recovered from his unconscious and convulsed condition 
 the less will be the risk of injury to the brain. He should 
 be immediately carried to the nearest shade, where his outer 
 clothing should be removed. If he still retain the power of 
 swallowing he may take as much water not iced water 
 as he will drink ; but if he is so insensible that no effort is 
 made at swallowing when a few drops of water are placed 
 in his mouth, his surface should be assiduously mopped 
 with dripping wet cloths, the moisture of which, while cool- 
 ing by its evaporation, will be absorbed by the vessels of 
 the skin, and will tend to relieve the abnormal condition of 
 his circulation, so that in a short time the power of swal- 
 lowing may be recovered. If, however, the patient fall 
 into a comatose state, he must then be treated as a case of 
 apoplexy [403]. 
 
 406. Iced water should not be given to a person suffering 
 from heatstroke. The cooling produced by it is merely 
 local. It cools the fauces and the stomach, and is in small 
 quantities grateful to the palate ; but its influence in lessen- 
 ing the temperature of the body generally is no greater than 
 that of the same quantity of water at the ordinary summer 
 temperature. Ingested water operates during its exhalation 
 from the lungs and skin, but to get there it must first be 
 absorbed into the circulation by the minute vessels of the 
 stomach. Cold contracts these vessels and interferes with 
 absorption. A person in ordinary health who desires to 
 
236 EPILEPTIC STUPOR. 
 
 experience the feeling of local cooling may take a glass of 
 iced water, as he can afford to wait for its absorption until 
 the subsidence of the temporary chill ; but one who is dying 
 for want of water should by no means have the absorbing 
 powers of his stomach rendered inactive by the tempera- 
 ture of the water supplied to him. 
 
 407. EPILEPTIC STUPOR. An attack of epilepsy consists 
 of loss of consciousness and convulsions. It varies in 
 severity from a momentary lapse of mind, with barely 
 appreciable spasms, or twitchings of the features, to a vio- 
 lent paroxysm lasting two or three minutes. When severe 
 the patient becomes suddenly pale, falls forward on his 
 face, sometimes with a loud, quick scream, and is immedi- 
 ately seized with a rigid spasm which lasts for ten or twenty 
 seconds, and is followed by rapid contractions and relaxa- 
 tions of the muscles, which contort the features and jerk 
 the body and limbs with much violence. These last for a 
 minute or two, during which the face becomes congested, 
 the pupils dilated, and the lips covered with foam, which 
 may be tinged with blood if the tongue has been injured by 
 the spasmodic action of the lower jaw; there may be also 
 involuntary discharges from the bowels and bladder. A 
 long-drawn sigh ends the fit, and the patient sinks into a 
 stupor which may last for several hours and be mistaken for 
 apoplexy on account of its heavy breathing and puffing ex- 
 pirations. The history of the case is, however, distinctive : 
 The patient is perhaps recognized as an epileptic subject, 
 or his present condition of stupor may be known to have 
 been preceded by convulsions ; the presence of foam on his 
 lips is suggestive of the epileptic struggle, and the absence 
 of paralysis tends to confirm this diagnosis by excluding 
 apoplexy as a cause. 
 
 408. In treating an epileptic a handkerchief or a gag of 
 
CONVULSIONS ALCOHOLIC STUPOR. 237 
 
 wood should be placed in the mouth of the patient to pro- 
 tect his tongue ; the neck and chest should be freed from 
 all constrictions ; and no more restraint should be used than 
 is required to guard against accidents. After the fit he 
 should be placed in bed to recover from its exhausting 
 effects. 
 
 409. CONVULSIONS, with temporary loss of consciousness, 
 occurring in young children who are not known to have dis- 
 ease of the brain, are usually due to the irritation of teeth- 
 ing or to some disorder of the digestive organs, as the 
 presence of indigestible matters or worms. The patient 
 should be placed across the lap of a nurse, and while ice- 
 cold water is applied to the head, the feet and legs should 
 be immersed in a pail of hot water. Meanwhile the gums 
 should be examined ; and if a rising tooth is found to be the 
 occasion of much redness and swelling, a free cut should be 
 made over it, lengthwise of the gum, to relieve the pressure. 
 If there is no tumefaction of the gum, an enema of soap- 
 suds should be administered, or an emetic of ipecacuanha, 
 if there be a history of some indigestible substances taken 
 into the stomach. 
 
 410. ALCOHOLIC STUPOR is distinguished from apoplexy 
 mainly by the condition of the pulse and pupils the former 
 is rapid, small, and soft, the latter dilated ; moreover, there 
 is no contraction of the facial muscles or other indication 
 of paralysis ; and cold water freely applied to the head has 
 usually some influence in arousing the patient from his 
 lethargy. In an unknown case the odor of alcoholic stimu- 
 lants in the breath should not be permitted to have weight 
 as evidence, because apoplexy or brain injury is by no 
 means inconsistent with the presence of alcohol in the 
 system. In every case of doubtful causation, the patient 
 should be taken into hospital and treated as if suffering 
 
238 DELIRIUM TREMENS INSENSIBILITY FROM COLD. 
 
 from congestion of the brain until his actual condition is 
 unmistakably revealed. Even when his stupor is known to 
 have been occasioned by his own vicious habits, he should 
 be treated as sick until the recovery of his intelligence. To 
 confine a man in this comatose condition in a guard-cell 
 merely exposes him to danger; it is no punishment, for 
 punishment can be inflicted only when the individual is sen- 
 sible of its application. 
 
 411. The treatment consists of cold to the head and an 
 emetic of mustard, if the patient have not already vomited 
 freely. If the pulse become weak and the skin cold and 
 clammy, hot coffee should be administered, or small doses 
 of aromatic spirit of ammonia in water, with frictions and 
 warmth to the general surface. 
 
 412. DELIRIUM TREMENS. Prolonged alcoholic excess 
 leads to a condition of nervous prostration characterized by 
 muscular tremors and delirium. The patient is constantly 
 anticipating some fancied evil or annoyance, which keeps 
 him in a state of nervous inquietude, talking anxiously 
 and with more or less incoherence. He is usually easily 
 controlled and diverted from his intentions, but he must be 
 watched closely for fear of accidents. Milk and beef 
 essence should be given as food, with bromid of potassium 
 or chloral, or morphine by hypodermic injection, to quiet 
 the nervous system and induce sleep. For OPIUM NARCOT- 
 ISM, see par. 523. 
 
 413. INSENSIBILITY FROM COLD. Exposure to extreme 
 cold acts like opium in exercising a benumbing influence on 
 the sensations, leading from drowsiness to a stupor so pro- 
 found that the system fails to recognize the necessity for 
 breathing. If the body is stiff, the tissues should be relaxed 
 by friction with cold water, after which artificial respk 
 
HEAT EXHAUSTION. 239 
 
 offers the only prospect of resuscitation. Even when the 
 insensibility has merely embarrassed but not arrested the 
 respiratory movements, the return of warmth to the body 
 must be gradually effected, lest the patient die in the 
 delirium of excessive reaction. Only such stimulants as 
 hot coffee, beef tea, and aromatic spirit of ammonia are 
 admissible. 
 
 414. Cases of insensibility associated with cerebral con- 
 gestion, and arising from causes which interfere with the 
 respiratory function, such as strangling, choking, smother- 
 ing, drowning, etc., are referred to under the heading of 
 Artificial Respiration, page 241. 
 
 415. HEAT EXHAUSTION. Insensibility from exhaustion 
 is a common occurrence on forced marches, particularly 
 among raw troops. Ordinarily the order of march provides 
 for a rest at the end of every hour to refresh the men, to 
 permit those who have fallen behind to recover their posi- 
 tion in the ranks, to readjust accoutrements, and to replen- 
 ish water supplies when occasion offers; but on a forced 
 march, those who have fallen behind have no opportunity 
 afforded them of rejoining their company. They struggle 
 on through the heat and dust until they become utterly 
 exhausted and drop unconsciously by the roadside, face 
 pale, lips bloodless, pulse rapid and feeble, respiration 
 sighing, and the muscular system affected with the tremors 
 of prostration. Recovery in these cases is speedy when 
 the conditions are favorable. The removal of the patient's 
 belts and burdens, rest in the recumbent position in the 
 shade, cold water to the head and face, upward frictions to 
 the limbs, and stimulants and water as required, generally 
 suffice to re-establish his powers. Frequently, however, 
 these cases of heat exhaustion are complicated with conges- 
 
240 HEAT EXHAUSTION. 
 
 live tendencies, manifested by dryness of skin, pulmonary 
 oppression, headache, and convulsive seizures [404]. In 
 such instances alcohol is contra-indicated; water alone, or 
 with a few drops of aromatic spirit of ammonia, is the 
 proper remedy. 
 
CHAPTER VIII. 
 
 ARTIFICIAL RESPIRATION. 
 
 416. A person at the point of death from asphyxia [227] 
 may be recovered by keeping up movements of the chest 
 that will alternately compress and expand the lungs ; but 
 no method of doing this is efficient unless the tongue of the 
 patient be prevented from blocking up the air passage. Dur- 
 ing insensibility it tends to fall backward in the throat and 
 close the upper end of the larynx. It must be seized, 
 pulled forward, and held in that position by an elastic 
 
 Silvester's method: Inspiration. 
 
 band, string, or tape passed around its base and under the 
 chin, by a pencil placed across its base and lodged in posi- 
 tion behind the back teeth, or by the fingers of an assistant 
 16 
 
242 ARTIFICIAL RESPIRATION. 
 
 enveloped in a dry handkerchief to prevent them from 
 slipping. 
 
 417. In SILVESTER'S METHOD the patient is placed on his 
 back, with a pillow or roll of clothing under his shoulders 
 to elevate them and carry the chin away from the breast- 
 bone. The operator kneels at his head, and, taking hold of 
 an elbow in each hand, makes the inspiratory movement by 
 drawing the arms outward away from the chest, and then, 
 continuing the motion, forcibly upward over the head of 
 
 Silvester's method : Expiration. 
 
 the patient. This drags the lower ribs upward and out- 
 ward, expands the chest, and causes the entrance of air. 
 The expiratory movement is made by passing the arms 
 down again along the side and front of the chest, and making 
 pressure on them when in that position, to force the ribs 
 downward and drive the air out of the lungs. This com- 
 pletes the respiratory movement, which should be repeated 
 at the rate of fifteen times per minute, until natural respi- 
 ration returns or the case is abandoned. 
 
 418. In MARSHALL HALL'S METHOD the patient is placed 
 
ARTIFICIAL RESPIRATION. 
 
 243 
 
 on the floor or ground with the face downward, his fore- 
 head resting on one arm, and a roll of clothing supporting 
 his chest. While in this position the weight of the body 
 compresses the ribs and expels the air from the chest an 
 artificial expiration which is deepened by making pressure 
 on the lower ribs. Then the operator, with one hand on 
 
 Marshall Hairs method: Expiration. 
 
 B 
 
 Marshall Hairs method: Inspiration. 
 
244 ARTIFICIAL RESPIRATION. 
 
 the patient's free arm near the shoulder, and the other 
 placed under or in front of the corresponding hip-bone, rolls 
 the body from face downward to its side and a little beyond. 
 An assistant aids in this movement by handling the head 
 and underlying arm. When the body has been thus rolled 
 somewhat more than half round, the chest becomes relieved 
 from superincumbent weight, and a certain volume of air 
 enters. After resting a second or two in this attitude of 
 inspiration, the patient is returned to the prone position, and 
 pressure made along the ribs to imitate the expiratory act. 
 
 419. Other plans have been advocated, such as that of 
 compressing the abdominal walls as if the object were to 
 drive the contents of the abdomen upward into the chest. 
 This forces the diaphragm upward and empties the lungs, 
 after which the sudden withdrawal of the pressure per- 
 mits of inspiration. Whichever method is used, it is 
 well, during its progress, to attempt to stimulate the res- 
 piratory powers by holding ammonia to the nostrils and 
 slapping the chest alternately with cloths wrung out of cold 
 and hot water. As soon as natural breathing has been 
 restored, efforts should be made to promote the circulation 
 by rubbing the limbs in the direction of the trunk; to 
 restore the warmth of the body by the use of warm clothing, 
 blankets, hot flannel, bottles, or bricks, and to stimulate the 
 vital actions by small doses of aromatic spirit of ammonia. 
 
 420. The conditions which call for artificial respiration 
 are those in which the lungs are sound but deprived of air, 
 either mechanically or by the substitution for air of some 
 gas or vapor which is not directly poisonous, or when .res- 
 piratory action has ceased on account of some narcotic influ- 
 ence exercised on the brain. These include : 
 
 (a) Strangulation by cord, ligature, or other compression 
 on the neck or windpipe. 
 
ARTIFICIAL RESPIRATION. 245 
 
 (I) Smothering from the mechanical closure of the nos- 
 trils and mouth by any substance, or even by interference 
 with the movements of the chest, as when one has been 
 imbedded to the neck in a sand-slide. In these cases the 
 mechanical cause must at once be removed, together with 
 articles of clothing which might interfere with the move- 
 ments of the chest. If the mechanical cause has occasioned 
 other injury than strangulation or smothering, artificial 
 respiration may be of no value, as when in hanging the 
 cervical vertebrae have been dislocated or fractured; but if 
 there be no evidence of this, and particularly should there 
 be a spasmodic quivering of the muscles or the faintest 
 indication of pulsation of the heart, efforts should be made 
 without loss of time to arterialize the venous blood by imi- 
 tating the movements of respiration. 
 
 (c) Choking from the pressure of something in the gullet. 
 When a man becomes suddenly suffocated while eating, the 
 fingers should be immediately passed over the base of the 
 tongue, and as far down as can be reached, to bring away 
 any foreign substance that may be there [432] ; after which 
 artificial respiration is in order, if necessary. 
 
 (d) Drowning by immersion in water : No time should 
 be lost in removing the body from the water j and except 
 in inclement weather, resuscitation should be attempted on 
 the spot. The upper or body clothing should be removed, 
 and, as the air tubes are frequently choked with indrawn 
 water, the patient should first be placed face downward on 
 the ground, and his body raised by the hands of the oper- 
 ator clasped underneath the abdomen to cause the intruded 
 water to escape, partly by drainage and partly by the 
 upward pressure on the lungs occasioned by the constriction 
 of the abdomen. The mouth and nostrils are then cleaned 
 and artificial respiration is instituted. Meanwhile the lower 
 
246 ARTIFICIAL RESPIRATION". 
 
 garments should be removed, and the surface dried and pro- 
 tected with blankets or shawls. 
 
 (e) Asphyxia from coal-gas, charcoal fumes, or the exhala- 
 tions of vats, pits, or mines. Care must be taken in recover- 
 ing the body that the rescuer, if overcome by the harmful 
 atmosphere, may be promptly withdrawn. The noxious 
 gas in such cases consists mainly of carbonic acid, carbon 
 dioxid, sometimes associated with carbonic oxid, carbon 
 monoxid. The former suffocates by preventing aeration of 
 the blood, while the latter has a directly poisonous influ- 
 ence ; but as coal-gas contains less than ten per cent, of the 
 poisonous oxid, there is a prospect of favorable results if 
 treatment by artificial respiration and cold affusion be 
 promptly instituted. 
 
 (/) Insensibility from ether or chloroform [276], carbonic 
 oxid, from opium [523], or from exposure to extreme cold 
 [413]. The escape of water-gas gives rise to most of the 
 deaths from carbonic oxid ; the gas contains thirty or forty 
 per cent, of this insidious poison. When opium is the cause 
 of danger, artificial respiration aims to prolong life until 
 the poisonous influence has been eliminated or counteracted 
 by other means. 
 
 421. SIGNS OF DEATH. There is no positive sign of 
 death except the occurrence of decomposition in the tissues 
 of the body. This is the statement of a scientific fact ; but 
 at the same time there is practically no difficulty in deter- 
 mining the presence of death long before putrefaction sets 
 in. The evidence of death consists of the concurrent exist- 
 ence of several conditions: 1. The continued cessation of 
 breathing, as determined by a polished surface held over 
 the lips and nostrils; 2. The continued absence of any 
 movement of the heart when closely watched for by the 
 ear and touch; 3. Relaxion of the muscles, passing into 
 
ARTIFICIAL RESPIRATION. 247 
 
 rigidity at the end of three or four hours; 4. The glazing 
 of the eyes ; 5. The progressive cooling of the body from 
 its normal living temperature to that of the surrounding 
 atmosphere. Many single tests of the presence of death 
 have been suggested. Perhaps the best of these is the tying 
 of a string around the end of a finger or lobe of the ear : no 
 change takes place on the dead body ; but if there be any 
 vital movement in the vessels the point beyond the ligature 
 becomes more or less congested. In tho wrist test a splint 
 is placed in front to protect the radial and ulnar arteries; 
 a cord is then tied tightly around the splint and wrist to 
 block the veins on the back of the hand. These veins grad- 
 ually become filled with blood if the heart's action and cir- 
 culation have not wholly ceased. The hypodermic injection 
 [502] of a few drops of a strong solution of ammonia has 
 also been recommended. If the body be not dead the 
 ammonia will produce on the skin, over the point where it 
 was injected, a bright red patch, on the surface of which 
 raised red spots will appear ; but in absolute death a brown 
 dark blotch will be developed. 
 
CHAPTER IX. 
 
 FOREIGN BODIES IN THE EYE, EAR, ETC. 
 
 422. Foreign bodies lodging in the eye cause much red- 
 ness and distress. If they are not visible on careful inspec- 
 tion of the globe, they should be looked for behind the 
 upper eyelid. To do this a probe is laid along the lid from 
 the root of the nose outward, and pressed lightly against 
 the upper part of the ball; at the same time the lid is 
 
 Everting the upper eyelid. The conjunctival vessels are congested. 
 
 pulled away from the globe by traction on the eyelashes, 
 and the patient is told to look downward, when the lid will 
 be tilted over the probe behind it, fully exposing its con- 
 junctival surface. The intruding substance should be 
 brushed away with a camePs-hair pencil or pledget of lint; 
 if it be partly embedded in the mucous membrane it should 
 be lifted out with the flat surface of a blunt-edged lancet. 
 A drop of olive or castor oil instilled into the eye will 
 relieve the irritation. 
 
 423. Eye-drops, such as solutions of nitrate of silver, 
 atropin, etc., are not dropped into the eye, but instilled or 
 insinuated. The patient turns his face upward, and the 
 
BODIES IK THE EYE, EAfc, ETC. 249 
 
 operator, having depressed and partly everted the lower lid 
 with the fingers of one hand, brings a drop hanging on the 
 end of a glass rod, tube, or dropper into gentle contact 
 with the mucous membrane, from which it flushes over the 
 surface of the eyeball. 
 
 424. When a particle of extraneous matter is embedded 
 in the conjunctiva the blood-vessels become enlarged, form- 
 ing a close-set network such as is represented in the illus- 
 tration just submitted. The enlarged vessels give rise to a 
 feeling as if sandy particles were lodged on the surface of 
 the membrane. Usually the removal of the irritant cause, 
 the seclusion of the patient in a shaded room, a dose of 
 aperient medicine, and the use of cold lotions will speedily 
 allay the congestive action ; but if the redness and other 
 symptoms persist after these measures have been tried for 
 a day or two, a drop of a solution of nitrate of silver, one 
 or two grains to the fluidounce of water, instilled morning 
 and evening, will generally be efficient. 
 
 425. Sometimes, however, the eyelids become swollen 
 and puffy, closing over the eyeball, yet allowing the tume- 
 fied, red, and inflamed mucous membrane to protrude be- 
 tween them and giving issue to a free discharge of puru- 
 lent matter. As this matter is infectious, the greatest care 
 must be used to prevent the spread of. purulent ophthalmia 
 by infected fingers, towels, etc. The disease is apparently 
 due sometimes to atmospheric changes, in which case both 
 eyes of the patient will suffer simultaneously; at other 
 times it results from the infection of gonorrheal discharges, 
 and in these cases one eye is usually first affected, and is 
 seriously endangered before the other receives the conta- 
 gion. Best, quiet, low diet, and aperient medicines are 
 required as constitutional remedial agents, whilst the local 
 measures consist of repeated syringing and warm fomenta- 
 
250 FOREIGN BODIES IN THE EYE, EAE, ETC. 
 
 tions to clear away accumulated matter, scarification of the 
 tumefied membrane if it project much through the fissures 
 between the lids, and the introduction of a solution of 
 nitrate of silver to stimulate the enlarged vessels to contract. 
 Neglect in a case of this kind may lead to total loss of vision 
 by sloughing of the cornea, as that part of the eye is de- 
 pendent on the conjunctiva for its supply of nutriment. 
 
 426. When men have been exposed for a considerable 
 time to a garish light, as that reflected from stretches of 
 sand or snow, the retina or sensitive membrane of the eye 
 may become temporarily strained and unable to take cog- 
 nizance of ordinary impressions. This condition, which 
 has received the name of snow-blindness, usually requires 
 no other treatment than rest in the shade for a few days to 
 enable the nervous matter to recover its normal functions. 
 Sometimes, however, the local reaction which takes place 
 becomes developed into a general inflammation of the eye, 
 requiring special surgical attention. 
 
 427. foreign bodies in the nose. Young children some- 
 times push beans, buttons, or other small objects into the 
 ttose, and are unable afterward to withdraw them. They 
 may sometimes be removed by a vigorous effort to blow 
 through the blocked-up nostril or by sneezing artificially 
 induced ; failing this, they must be withdrawn by a fine for- 
 ceps or blunt hook, afterward washing out the cavity with 
 warm water in which a little common salt has been dissolved. 
 
 428. Sometimes, in southern climates, uncleanly children 
 or intemperate adults become affected with maggots in the 
 nasal cavities. These cause much local irritation, loss of 
 sleep, fever, and ultimately delirium. They may be cleared 
 out by making the patient inhale half a drachm of chloro- 
 form and immediately thereafter syringing out the cavities 
 with a warm solution of common salt, repeating the opera- 
 
FOREIGN BODIES IN THE EYE, EAR, ETC. 251 
 
 tion at intervals of a few hours, until all the maggots have 
 been removed. 
 
 429. Foreign bodies in the ear. Insects cause great dis- 
 tress, and should be immediately dislodged by tilling the 
 canal with warm oil or gently syringing with warm water. 
 The latter procedure generally suffices to remove small 
 bodies, such as beads, seeds, etc. ; if it fail, the case should 
 be left for fully qualified surgical skill. Plugs of cotton- 
 wool may be withdrawn by forceps after dissolving their 
 waxy adhesions by instilling a few drops of olive oil. Wax 
 should not be picked out, but softened by instillations of oil 
 at night and syringing with warm water next morning. 
 
 430. The ear should never be syringed with cold water ; 
 the water used should always be distinctly warm to the 
 fingers. The patient, or an assistant, holds the edge of a 
 
 Syringing the ear. 
 
 cup or receiver closely to the side of the neck below the 
 lobule. The operator takes hold of the upper and back 
 part of the ear with the fingers of one hand, pulling it 
 upward, backward and slightly outward to straighten the 
 canal, while he lays the nozzle of the syringe just within 
 its entrance and pushes the piston gently and slowly home. 
 Two or three two-ounce syringefuls generally suffice to 
 
FOREIGN BODIES IK THE EYE, EAR, ETC. 
 
 cleanse the canal. After syringing, the water should be 
 permitted to drain from the ear, which should be dried with 
 the twisted corner of a towel or fragment of lint. 
 
 431. Foreign bodies in the trachea. When buttons, beads, 
 seeds, small coins, etc., enter the larynx or trachea of chil- 
 dren, efforts at removal should be restricted to coughing 
 while the patient is held with the head and body inclined 
 downward. 
 
 432. The foreign bodies which stick ^in the pharynx are 
 usually fish-bones. If the bone can be seen, or felt by the 
 tip of the finger, when the tongue is depressed, it should be 
 removed by the fingers or forceps. If it be too low down 
 for this procedure, large mouthfuls of half -chewed bread 
 should be swallowed to carry it along. It must be remem- 
 bered that the tearing of the mucous membrane will for 
 some time afterward give rise to the impression in the 
 mind of the patient that the bone has not been dislodged. 
 Large bodies, such as fragments of meat causing choking, 
 must be immediately removed with the fingers. 
 
 433. Foreign bodies in the stomach. When a child has 
 swallowed any of the small bodies mentioned, the alarm of 
 friends should be quieted and the patient fed for a day or 
 two on oat-meal, puddings, etc., after which a laxative dose 
 of castor-oil should be given, with instructions to look for 
 the foreign body in the intestinal discharges. 
 
CHAPTER X. 
 
 FRACTURES. 
 
 434. A fracture, surgically, is a break in the tissue of a 
 bone. It is simple when the bone is broken at one point; 
 comminuted when broken into more than two fragments; 
 impacted when one fragment is wedged into the other ; com- 
 pound or open when a wound penetrates from the surface to 
 the plane of the fracture ; and complicated when it is asso- 
 ciated with other serious injuries, as contusion, laceration, 
 etc. A fracture may be comminuted and the soft parts 
 contused and lacerated, yet if the skin be unbroken, extrav- 
 asated blood and effused serum are absorbed and satisfactory 
 repair goes on ; but in a compound fracture which becomes 
 infected by its exposure to the air, violent inflammation, 
 burrowing suppurations, and sloughing cause much suffer- 
 ing and danger. 
 
 435. The symptoms of fracture are pain, swelling, loss 
 of power, deformity, unnatural mobility, and crepitation. 
 There is nothing characteristic in the first three, as they 
 may be present in bruises and dislocations; but angular 
 deformity in the case of a long bone manifests the nature 
 of the injury as definitely as the mobility in a part that 
 ought to be solid, or the crepitus or grating when the broken 
 fragments are moved on each other. All fractures of the 
 long bones are more or less oblique ; and the shortening and 
 difficulty of retaining the fragments in their proper relations 
 to each other are proportioned to the obliquity ; the lower 
 fragment, as being the more movable, is the one displaced. 
 
254 FRACTURES. 
 
 436. A fracture should be treated as soon as possible after 
 the accident, because when swelling and muscular contrac- 
 tion have occurred it is more difficult to bring the broken 
 ends into accurate contact (coaptatwri). When a bone lies 
 so near the surface that the fingers can recognize it, it is 
 easy to ascertain whether coaptation has been effected; but 
 when the bone is well covered with muscles, the recognition 
 of a proper setting is more difficult, and must depend upon 
 the removal of all observable deformity. 
 
 437. Splints are used to keep the broken ends in contact 
 until union is effected. They are of wood, pasteboard, per- 
 forated felt, gutta-percha, strong 
 leather, sheet-tin, or zinc, or any 
 other material which possesses the 
 proper strength, and can be cut 
 to suit the necessities of the case. 
 The angles formed by the meeting 
 of the sides and ends should, in 
 all splints, be rounded off; the 
 
 Reversing roller on forearm. edgeg Q ^^ ^-^^ smoothed> 
 
 and of wooden ones bevelled. Pasteboard, leather, and 
 gutta-percha must be softened in hot water before they 
 can be moulded to the part for which they are in- 
 tended. Gutta-percha requires practice for its successful 
 application, inasmuch as a slight excess of heat transforms 
 it into a sticky, unmanageable mass. It should be folded in 
 muslin which extends beyond its ends, and immersed in 
 hot water while held by the free ends of its muslin wrapper 
 until the needful plasticity is attained. In the absence of 
 anything better, a handful of selected straw may be cut to 
 the proper length and quilted between the folds of soft cloth. 
 
 438. All splints, of whatever material, must be padded 
 before being put to use over the fractured bones. Several 
 
FRACTURES. 255 
 
 layers of sheet wadding are cut to give the needful thick- 
 ness of pad on the face of the splint. These are retained 
 in position by being folded with the splint in muslin as a 
 packet is folded in paper, the free ends being brought back 
 and stitched together behind, leaving the front of the pad 
 smooth and unwrinkled. Oakum, patent lint, and cotton 
 batting are also used for this purpose, but they do not make 
 so smooth a pad as the sheet cotton. When the bones have 
 been brought into their proper place the splints are applied 
 and retained in position by a bandage, or preferably by 
 strap-and-buckle fastenings, because they leave the limb 
 partly in sight, and can be relaxed or tightened with facil- 
 ity. The loop bandage answers in the absence of straps ; a 
 length of about three feet is cut from a roller, and doubled 
 lengthwise on itself; this is passed around the splinted 
 limb and the free ends are drawn tightly through the bight ; 
 these ends are then separated from each other and tied 
 firmly at their meeting on the opposite side of the limb. 
 
 439. In applying a roller for the retention of splints or 
 any other purpose, each turn is made to overlap that which 
 preceded it; and when the increasing thickness of the limb 
 prevents the roller from lying flat and at the same time 
 preserving the overlap, the difficulty is overcome by what 
 is called reversing. The upper border of the turn is folded 
 obliquely over the forefinger of the left hand, while the 
 roller in the right hand is made to describe a half turn on 
 its long axis, after which the circular movement is contin- 
 ued until the point is reached where the next reverse has to 
 be made. If a roller which encases or encircles a limb is 
 likely to become wetted, it should be applied lightly, else 
 the contraction which follows the wetting will make it 
 harmfully tight. 
 
 440. Sometimes the bandage itself is made to act the part 
 
256 
 
 FRACTURES. 
 
 of a splint by saturating it with some substance, such as 
 starch, soluble glass, or plaster of Paris, which will endue 
 it with a solidity and resistance sufficient for the purpose. 
 Whichever of these materials is employed, the limb is first 
 lightly encased in an ordinary roller, and its hollows and 
 inequalities filled with cotton batting, after which the so- 
 called immovable dressing is applied. A colored tape should 
 be placed longitudinally beneath this dressing to act as a 
 guide for the knife, scissors, or cutting pliers used in its 
 
 Reversing roller on leg. 
 
 Many-tailed bandage over 
 starched splints. 
 
 subsequent removal. The unyielding character of these 
 dressings renders them applicable only in fractures in which 
 there is no danger of the development of inflammatory 
 swelling. 
 
 441. Starch is prepared as for laundry use. The ban- 
 dages to be used are unrolled, soaked in the starch solu- 
 tion, re-rolled, and applied as an ordinary roller. Strips 
 of saturated bandage may be laid on longitudinally to 
 strengthen the casing, after which another circular or spiral 
 starched roller is used, or a many-tailed bandage may be 
 
FRACTURES. 257 
 
 employed. This latter consists of strips cut long enough 
 to go once and a half round the limb. These are arranged 
 on a towel or pillow, the upper one being laid down first, 
 and each successive strip overlying that which preceded it 
 by half its width. The strips are then brought beneath the 
 limb, around which they are applied as shown in the cut. 
 The starch bandage takes from twenty -four to thirty -six 
 hours to set. Should it become loose by the subsidence of 
 any swelling existing at the time of its application, it must 
 be cut along the line of colored tape, its edges trimmed, and 
 the casing again closed and sustained in position by an 
 ordinary roller. 
 
 442. A saturated solution of the silicate of soda may be 
 used in the same manner as the starch solution. It sets 
 slowly, but makes a light and firm support. 
 
 443. Plaster of Paris is of use as a support in fracture by 
 virtue of its setting readily when mixed with an equal vol- 
 ume of water. Usually when thus mixed it consolidates 
 in three minutes; common salt hastens, mucilage or glue 
 retards, the consolidation; white of egg beaten up with the 
 plaster gives it greater tenacity. To form a splint of this 
 material, several thicknesses of washed muslin are folded to 
 the required shape ; these are immersed in and saturated 
 with the liquid plaster, refolded to the proper shape, 
 smoothed, and applied to the part, which is held in position 
 until the plaster sets. When a limb is to be encased the 
 dry plaster is first rubbed into the bandages which are to 
 be used, and the limb is wrapped in cotton wadding, which 
 is kept in place by an ordinary bandage ; after this the pre- 
 pared rollers are soaked in water and applied in circular 
 turns without reverses; some of them may be cut into 
 lengths and laid on longitudinally to give greater strength 
 to the casing. 
 
 17 
 
258 SPECIAL FRACTURES. 
 
 444. Union between the broken ends of a bone does not 
 usually begin to take place until about ten days after the 
 injury, so that any malposition detected during this period 
 is susceptible of rectification. Three to six weeks are 
 required for a firm cementation of the ends, the time de- 
 pending on the size of the injured bone and the accuracy 
 of the coaptation ; small bones, as those of the fingers, 
 unite more readily than larger ones. 
 
 SPECIAL FRACTURES. 
 
 445. FRACTURE OF THE SKULL may occur without notable 
 symptoms other than those of the concussion [401] which 
 might be present irrespective of the fracture ; and they may 
 get well without at any time giving symptomatic evidence 
 of their existence. Sometimes a fissure or depression may 
 be felt through the scalp, and, when the base is the seat of 
 injury, there is occasionally a watery discharge from the 
 ears, a continued bleeding from them, or the appearance 
 of blood extravasated beneath the conjunctiva. As soon as 
 the patient rallies from the concussion, his head should be 
 shaved and cold applied, purgatives administered, and rest 
 and quiet enjoined. Should symptoms of compression be 
 present from the moment of the injury, there is probably 
 some displacement of bone; should compression be devel- 
 oped with increasing intensity some time after the injury, it 
 probably results from hemorrhage within the cranium. 
 
 446. When the fracture is compound, its edges may be 
 discovered by exploration with the finger; and if any part 
 of the bone is found to be driven inward, a cautious at- 
 tempt is made by the surgeon to remove the fragment or 
 raise it to its proper level. Slight symptoms of compres- 
 sion may sometimes be removed by relieving the brain of 
 
FRACTURES OF THE SPINE. 259 
 
 this pressure ; but in these fractures the compression, when 
 severe, is usually caused by an associated hemorrhage, and 
 is unaffected by the restoration of the bone. 
 
 447. When the brain is laid open, foreign matter should 
 be gently removed and the wound cleaned with an antisep- 
 tic solution, after which a compress should be laid over it 
 and retained by a bandage to prevent protrusion of the 
 brain substance. 
 
 448. The arch is the most common site of FKACTURE OF 
 THE LOWER JAW. Crepitus and irregularity in the line of 
 the teeth readily indicate the nature of the injury. A 
 pasteboard splint is moulded to the front and under surface 
 of the jaw, and bound in position by a four-tailed bandage 
 [395]. The splint below and the teeth of the upper jaw 
 above preserve the proper relations between the fragments. 
 
 449. The SPINE is fractured by falls from a great height 
 or the fall of a heavy weight on the body when bent. The 
 injury is usually attended with profound shock. Its symp- 
 toms depend on the situation of the fracture and the pres- 
 sure on, or damage to, the spinal cord. Local violence may 
 break off one or more of the spinous processes that pro- 
 ject behind, without much injury to the contents of the 
 spinal canal; but when the bodies of the vertebrae are 
 involved in the fracture, there is usually paralysis of those 
 parts of the body which receive their nerves from the cord 
 below the seat of injury. Any necessary movement of the 
 patient should be made with the utmost care, to avoid 
 increasing the injury to the cord of its membranes. To 
 turn him over on his face for a thorough investigation of 
 the fracture would invite such a displacement of the lower 
 portion as might cut the cord in two. 
 
 450. In these fractures there is severe pain, with swelling 
 and other signs of contusion, irregularity of the spinous 
 
260 FKACTUKE OF THE KIBS. 
 
 processes, and possibly crepitus on movement. When the 
 cord is injured in the loins, the lower extremities are par- 
 alyzed, the urine retained, and the faeces passed involun- 
 tarily; when in the dorsal region, the symptoms include, in 
 addition, a tympanitic swelling of the abdomen, due to 
 paralysis of the muscular coat of the intestine; and when in 
 the neck, the upper extremities become paralyzed. Frac- 
 tures of the spine have generally an unfavorable ending, 
 reached sooner or later according as the site of the injury 
 is in the upper or lower part of the column. Above the 
 third cervical vertebra death may be immediate, from in- 
 jury to the phrenic nerves, which preside over the respi- 
 ratory movements of the diaphragm ; in the lower part of 
 the cervical region, the patient lives only a few days; in 
 the dorsal region, he may linger for two or three weeks, 
 and in the lumbar region for one or two months, greatly 
 distressed toward the end by increasing bed-sores. The 
 patient should be put to bed in the position which gives 
 him least discomfort, and the catheter must be used regu- 
 larly to prevent distention of the bladder. 
 
 451. The RIBS are frequently fractured by blows, falls, 
 or the counter-pressure of opposing forces, as when a wheel 
 passes over the chest. The middle ribs are most liable to 
 injury, as the upper have a better protection from the over- 
 lying soft parts, and the lower have a greater elasticity. 
 Fracture is detected by pressing the finger along the skin 
 over the line of the rib supposed to be injured, or by plac- 
 ing the hand on the part while the patient makes an effort 
 at coughing. It is treated by confining the chest in a 
 bandage either several turns of a broad roller, or a closely 
 fitting jacket fastened by straps and buckles or eyelets and 
 laces to keep the parts at rest and throw the burden of 
 the respiratory movements on the abdominal muscles. 
 
FRACTURE OF THE HUMERUS. 261 
 
 452. When the COLLAR-BONE is fractured near its mid- 
 dle, the inner fragment remains in its place, but the outer 
 is dragged downward, forward, and inward by the weight 
 of the extremity. A wedge-shaped pad is fitted, base up- 
 ward, into the armpit; the arm is brought slightly inward 
 across the chest, and the elbow and humerus are pressed 
 upward so as to force the point of the shoulder upward 
 and backward. A long roller is then applied to retain the 
 limb in this position. A few turns are passed around the 
 chest to fix the end, after which the arm is included with 
 the chest in each turn ; the roller is then carried below the 
 elbow and over the opposite shoulder, and the operation 
 finished by some circular turns to fix the whole. The vari- 
 ous turns should be stitched here and there to prevent dis- 
 placement. 
 
 453. When this bone is fractured near its outer extremity, 
 there is little tendency to displacement, and all that is 
 needful is to keep the arm bound to the side and to support 
 the forearm in a sling. 
 
 454. The flatness of the SHOULDER-BLADE preserves it 
 from fracture, but occasionally the acromion process is 
 broken off. The patient complains of a great sense of 
 weight, and the roundness of the shoulder is lost; but the 
 deformity disappears when the arm is pushed perpendicu- 
 larly upward so as to raise the broken fragment. In treat- 
 ing this injury, a cushion is placed between the elbow and 
 the side to relax the deltoid, and the arm is kept at rest in 
 this position by being bandaged to the side and having the 
 elbow and forearm supported in a short sling. 
 
 455. A transverse fracture of the HUMERUS above the con- 
 dyles looks like a dislocation backward of the radius and 
 ulna at the elbow [481], because there is an unnatural 
 prominence behind the joint, with a depression above it, 
 
262 FRACTURE OF THE HUMERUS. 
 
 and the front of the forearm is shortened ; but it differs 
 from a dislocation in that if the arm be fixed and traction 
 made on the forearm, the unnatural appearance will be 
 removed and the grating of the fractured ends may be per- 
 ceived. Treatment: Eeduce by traction, and preserve in 
 position by a roller bandage applied around the lower part 
 of the arm and the upper part of the forearm ; use two 
 padded splints one straight, in front of the humerus, the 
 other bent at a right angle, with one part behind the 
 humerus and the other below the forearm. Fasten by 
 buckle or loop bandages, and support the elbow and forearm 
 in a sling. 
 
 456. Sometimes from the nature of the violence the outer 
 or inner condyle is broken off, causing a prominence which 
 may simulate dislocation. Crepitation may be felt when 
 the inner condyle is fractured by grasping the prominence 
 and at the same time moving the forearm backward and 
 forward; when the outer condyle is fractured, crepitation 
 is best elicited by alternately pronating and supinating the 
 hand [157]. In treating these fractures, keep the forearm 
 at a right angle with the arm, the back of the hand turned 
 upward and the fingers bent if the inner condyle is involved, 
 and the palm upward and the fingers straight if the outer 
 condyle is the subject; then apply a roller around the lower 
 part of the arm and upper part of the forearm, and over 
 this a padded rectangular splint of pasteboard or other suit- 
 able material, placing one part behind the humerus and the 
 other below the forearm, and securing all with a roller. 
 The injured limb should be supported in a sling. 
 
 457. When swelling comes on quickly in fractures near 
 the elbow, it is well to support and rest the limb, and to 
 apply evaporating lotions to subdue inflammation before 
 splinting the injured bone. 
 
FRACTURE OF THE RADIUS. 263 
 
 458. When the shaft of the bone is broken, there is no 
 difficulty in recognizing the injury. The inability of the 
 patient to raise his arm, its mobility when handled, crepi- 
 tation, and angular deformity sufficiently announce its na- 
 ture. When the fracture is in the lower part a splint 
 should be applied in front and another behind ; but if the 
 fracture is about the middle, the splints should be placed on 
 the inner and outer sides. When the fracture is in the 
 upper part, the upper fragment may be dragged outward 
 and the lower fragment inward, or vice versa, according as 
 certain muscles are broken off with the one or left attached 
 to the other [154]. In either case traction should be made 
 on the lower fragment until all shortening of the limb is 
 removed, when three splints should be applied, one along 
 the front, a second behind, and the third on the outer 
 aspect of the arm. A wedge-shaped pad is then placed 
 along the inner aspect, with its thick end in the armpit 
 if the upper fragment be displaced inward, so that when 
 the arm is afterward bandaged to the side the pressure of 
 this pad may keep it in its place; but if the lower frag- 
 ment be displaced inward, the thick end of the pad should 
 be below and its apex in the armpit. In bandaging the 
 arm to the side the roller should be applied firmly over the 
 fragment which has the outward tendency and lightly over 
 that which tends inward. 
 
 459. The weight of the arm in all these fractures of the 
 humerus should be supported by a sling; but care should 
 be taken that it does not press the elbow upward, lest it 
 give rise to shortening of the 'bone in cases in which the 
 line of fracture is oblique. 
 
 460. Fractures of the RADIUS are characterized by loss 
 of the power of voluntarily effecting the movements of pro- 
 nation and supination ; the hand is supported by the patient 
 
264 FRACTURE OF THE TlL^A. 
 
 in the prone position. When the fracture is in the middle 
 or lower third, it may be felt by the finger; if it be in the 
 upper third, where the bone lies deeper in the muscles, it 
 may be detected by grasping the upper part of the forearm 
 in one hand, pressing the thumb firmly on the head of the 
 radius, on the outer aspect of the posterior prominence of 
 the elbow, and alternately supinating and pronating the 
 injured limb with the other hand. The fracture is revealed 
 by the grating of the fractured ends on each other and by 
 
 Fracture at wrist. 
 
 the failure of the head of the bone to participate in the 
 rolling motion given to the lower fragment. When the 
 fracture is near the wrist Colles's fracture its site be- 
 comes swollen by effusion into the sheaths of the tendons, 
 which gives the injury the appearance of a dislocation, the 
 more so that this same swelling interferes with the motion 
 of the fingers; but crepitus readily distinguishes between 
 the fracture and the dislocation. 
 
 461. Fracture of the ULNA may usually be discovered by 
 drawing the finger along the edge of the bone on the poste- 
 rior and inner aspect of the forearm. There is a depression 
 at the seat of the fracture on account of the lower fragment 
 settling toward the radius. 
 
 462. Fracture of both bones is readily recognized by the 
 unnatural mobility, the angular deformity, and the grating 
 of the fragments. 
 
 463. In splinting these fractures, the forearm should be 
 bent at a right angle to the arm to equally relax the mus- 
 
FRACTURE OF THE PELVIS. 265 
 
 cles on the anterior and posterior aspects, and the hand 
 should be kept midway between pronation and supination, 
 i.e., with the thumb upward and the little finger down- 
 ward, because, if union were to take place with the hand 
 prone, the power of supination would be restricted, and if 
 with the hand supine, pronation would be impaired. If 
 both bones are broken, the hand should be kept in line with 
 the forearm; if the radius alone is fractured, the hand 
 should be slightly depressed; and if the ulna alone is in- 
 jured, the hand should be raised. Two splints are re- 
 quired, one for the back and one for the front of the fore- 
 arm, the former reaching only to the wrist, the latter to the 
 roots of the fingers. These splints should be broader than 
 the breadth of the forearm, that the bandages may not com- 
 press the bones laterally ; and they should have a thicker 
 padding along the centre of their length than on the margins, 
 that they may make pressure on the space between the shafts 
 of the two bones and keep the fragments parallel. They are 
 fastened by the buckle, loop, or common roller bandage, after 
 which the forearm is supported in a sling. 
 
 464. The METACARPAL BONES extend from the wrist to 
 the roots of the fingers. Their fractures are treated on a 
 pasteboard or other splint applied to the palmar aspect and 
 extending along the forearm to the ends of the fingers. It 
 should be well padded, particularly in the hollow of the 
 palm. 
 
 465. Small splints on FRACTURED FINGERS may be fas- 
 tened by strips of rubber plaster. 
 
 466. The PELVIS [164] is fractured only by great vio- 
 lence, as in falls from a height to rocky ground or the fal 
 of a horse on its rider. It is often difficult to detect the 
 fracture, the existence of which must be assumed from the 
 nature of the causative violence, the inability of the patient 
 
266 FRACTURE OF THE THIGH-BONE. 
 
 to support himself, a feeling of laceration at the fractured 
 part when any exertion is made, and the absence of any 
 other obvious explanation of these symptoms. The legs of 
 the patient should be bound together to prevent motion, and 
 the utmost care used in transporting him to bed lest dis- 
 placement be augmented or the pelvic viscera injured by 
 splinters. The catheter should be introduced and retained 
 for some days, to lessen the danger of extravasation of 
 urine in case of possible injury to the bladder, as the escape 
 of urine into the peritoneal cavity would be followed by 
 fatal peritonitis, and into the cellular tissue of the pelvis 
 by diffuse inflammation, sloughing, and abscesses. The pa- 
 tient should be placed in bed in the position in which he 
 is most comfortable, usually on his back, with his knees 
 flexed and supported by pillows under them. 
 
 467. Fractures of the THIGH-BONE close to the hip-joint 
 occur mostly in aged people, from slight shocks, as in mak- 
 ing a misstep. When they occur in younger people they 
 
 Fractured thigh treated by straight splint. 
 
 are usually the result of great violence, and are often com- 
 plicated with other injuries requiring the most intelligent 
 surgical treatment. In these fractures there is, as in most 
 of the dislocations of the hip-joint, a shortening of the limb, 
 and inability on the part of the patient to move it; but it 
 may be readily lengthened by traction, rotated, or otherwise 
 moved by the surgeon. When the patient lies on his back 
 
FRACTURE OF THE THIGH-BONE. 267 
 
 the foot is usually everted, that is, rolled outward on the 
 heel so as to carry the toes away from the central line of 
 the body. Crepitus may be felt by placing one hand over 
 the great trochanter [165] and giving a rotatory motion to 
 the limb with the other. The patient is placed on a hard 
 mattress, and a roller is applied from the toes to above the 
 knee to support the tissues and prevent swelling from the 
 bandage to be subsequently applied higher up. The ordi- 
 nary wire mattress is too yielding for use in such cases, but 
 when supported beneath by wooden slats it answers the 
 purpose excellently. The splint employed should be long 
 enough to extend from the lower ribs to three or four inches 
 beyond the foot, and it should be provided with two holes 
 near its upper and two notches at its lower end. The limb 
 having been extended, by traction, to its proper length, the 
 splint, well padded, particularly at the ankle, is applied on 
 the outer side. A roller, fixed by several turns around the 
 ankle, is looped around the foot and through the notches at 
 the end of the splint to keep the foot in position ; this 
 bandage is then carried upward beyond the knee. Exten- 
 sion and counter-extension are effected by the application 
 of what is called the perineal band. A large smoothly folded 
 and well-padded handkerchief is applied to the crotch of 
 the injured side, and the ends carried, one in front, the 
 other behind, the hip to the holes in the splint, through 
 which they are passed and tied firmly together. By this 
 means the splint, and with it the part of the limb below 
 the fracture, is kept down in its proper place. A small 
 wooden splint is applied to the inside of the thigh; and 
 afterward a broad bandage is passed around the pelvis and 
 brought down the thigh to aid in keeping the apparatus in 
 position. 
 
 468. Fractures of the SHAFT OF THE FEMUR generally 
 
268 FRACTURE OF THE THIGH-BONE. 
 
 override each other from half an inch to two inches, owing 
 to the contraction of the powerful muscles connected with 
 the bone. American surgeons usually treat this injury in 
 the straight position by short thigh-splints and extension by 
 weights. A roller is applied from the toes to the ankle; a 
 strip of plaster two and a half inches wide is then made to 
 adhere firmly to each side of the limb from the fracture to 
 the ankle, but each strip is cut so long that the lower ends 
 
 Fractured thigh in coaptation splints ; extension by weights. 
 
 may overlap, forming a loop about four inches beyond the 
 sole of the foot; the roller is then carried upward to the 
 level of the fracture. A flat wooden foot-piece, three inches 
 wide and four or five long, is firmly attached within the 
 loop of adhesive plaster, and to it is made fast a cord which 
 passes over a pulley to sustain the extending weights. The 
 weight of the body of the patient affords the counter-extend- 
 ing force, which may be increased by raising the foot of the 
 bed on blocks, or by means of a perineal band extending 
 upward and made fast to the head of the bedstead. Four 
 padded splints are applied to the thigh, and kept in posi- 
 tion by loop or buckle bandages; and support is further 
 given to the limb by sand-bags, particularly on the outer 
 aspect, to prevent eversion of the foot. 
 
 469. Some surgeons treat fractures of the thigh-bone, 
 particularly of its upper part, in a slightly flexed position, 
 the body being somewhat raised in bed, the thigh and leg 
 supported on a double inclined plane, and the foot, to pre- 
 
FRACTURE OF THE LEG. 269 
 
 vent its eversion, made fast to a suitable foot-piece [471]. 
 Small splints are applied by buckle bandages to the anterior 
 and lateral aspects of the thigh. Smith's anterior splint 
 acts the part of a double inclined plane for suspending the 
 
 Smith's anterior splint. 
 
 limb in the flexed position. It consists of a framework of 
 stout wire, which is applied to the anterior aspect of the 
 limb; short strips of strong muslin or bandage are attached 
 to the wires, and pass beneath the limb, to form a cradle 
 for its support. The splint is then bound on firmly by 
 
 Smith's anterior splint applied. 
 
 roller bandages, and the whole suspended as shown in the 
 accompanying illustration. The thigh attachment for sus- 
 pension should be near the seat of the fracture ; the leg 
 attachment about half way between the knee and the ankle. 
 470. In FRACTURES OF THE LEG, not including gunshot 
 fractures, both bones are usually broken, and in their lower 
 third, their weakest point. Any break in the anterior bor- 
 der of the tibia can readily be detected by the fingers j but 
 
270 FRACTURE OF THE LEG. 
 
 when the fracture is near the ankle-joint the strong muscles 
 of the calf may draw the lower fragments and heel back- 
 ward, or, if the fracture be oblique, the foot may be dis- 
 placed outwardly or inwardly. In these cases the absence 
 of dislocation is known by the removal of the deformity 
 under the influence of slight traction. When the fibula 
 alone is broken, as is sometimes the case from a twist of 
 the foot, crepitus may be felt by firmly grasping the parts 
 and moving the broken ends on each other. 
 
 471. When, in fracture of either or both bones, there is 
 little deformity, the plaster of Paris, or starch bandage 
 strengthened by a pasteboard splint, may be immediately 
 applied. When the fracture is in the upper third of the 
 leg, the upper fragments are prone to be tilted forward, 
 particularly when the muscles of the anterior aspect of the 
 thigh are put on the stretch by bending the knee. The 
 straight is, therefore, the best attitude for the treatment of 
 such fractures. A roller is applied to the limb, which is 
 then placed on a straight wooden splint, somewhat hollowed 
 on its upper surface, and extending from the middle of the 
 thigh to the heel ; after which a pasteboard or gutta-percha 
 splint is moulded to each of the lateral aspects. When the 
 
 Double inclined plane for fractures of lower extremity. 
 
 fracture is below the upper third, the flexed position of the 
 limb is considered to give better results. The double 
 inclined plane for this purpose ends below in a foot-piece, 
 
FRACTURE OF THE LEG. 271 
 
 and has a screw beneath the knee-joint by which the angle 
 of elevation may be altered to suit the necessities of the 
 case or to permit of jussive motion to the joint when the 
 confinement of the limb has continued for a long time. 
 The fracture-box is often used for the treatment of these 
 fractures, and is particularly useful in gunshot injuries, 
 and those which are associated with wounds of the soft 
 parts. It consists of a bottom which extends from the 
 knee to the sole, two sides which are hinged so that they 
 
 Fracture box for the leg. 
 
 may be approximated over the contained limb, and a foot- 
 piece fixed at an appropriate angle. A soft pillow is laid 
 in the box, or oakum, bran, etc., may be used- for this pur- 
 pose; the injured limb is then deposited in it, and the 
 necessary pressure exerted by tying stout tapes or strips of 
 bandage around its yielding sides. If bran is used, a soft 
 muslin cloth should be laid in the box in the first instance, 
 that its ends may be folded securely around the limb and 
 fastened to prevent the leakage of its contents. 
 
CHAPTEK XI. 
 
 DISLOCATIONS. 
 
 472. A dislocation is a displacement of the bones form- 
 ing a joint; the ligaments are stretched or ruptured, and 
 the articulating surfaces of the bones more or less separated 
 from each other. The bone dislodged is usually that on 
 the lower or distal side of the joint; the other remains in 
 its place. 
 
 473. Dislocation is characterized by pain, swelling, loss 
 of power over the part, and deformity from the unnatural 
 position of the dislodged bone. Deformity in fracture may 
 be removed by pulling the parts gently into their proper 
 place, but it. returns when the traction ceases ; dislocation 
 offers a fixed resistance to efforts of this kind ; but once the 
 deformity is removed by the application of a greater force, 
 it does not return. Moreover, deformity in fracture is asso- 
 ciated with a mobility in parts which should be rigid, while 
 in dislocation there is rigidity of parts which are naturally 
 mobile. Ordinarily, therefore, there is little difficulty in 
 determining whether an injury is a fracture or dislocation, 
 particularly if the examination is made before inflammatory 
 swelling is developed. Counter- extension, extension, and 
 manipulation are required to reduce a dislocation. Counter- 
 extension is the force applied to the upper bone to fix it in 
 its place, so that the extensional force applied to the lower 
 bone may be wholly utilized in drawing it away from its 
 unnatural position. Manipulation tilts the lower bone into 
 
DISLOCATION OF THE LOWER JAW. 273 
 
 its place by direct pressure or by some suitable movement of 
 the limb, when the extending and counter-extending forces 
 have freed the bones from their unnatural position. The 
 extending force should be steady, and gradually increased 
 until its object is accomplished. The use of pulleys for 
 multiplying power is seldom required in the recent injuries 
 which constitute surgical emergencies; and chloroform is 
 rarely needful, as the primary shock sufficiently relaxes the 
 muscles. 
 
 474. When a dislocation is complicated by fracture close 
 to the head of the dislocated bone it is always difficult, and 
 sometimes impossible, to effect its reduction. 
 
 475. After a dislocation has been reduced, the joint 
 should be supported by a sling, bandage, or splint for a 
 week or more until the risk of recurrence has been obviated 
 by the recovery of the lacerated or stretched ligaments. 
 
 476. The LOWER JAW is dislocated by opening the mouth 
 too widely, as in yawning, etc., or by a downward blow on 
 the chin while the mouth is half open ; both sides are usu- 
 ally displaced, sometimes only one. The head of the bone 
 slips from its natural position, immediately in front of the 
 ear, over and in front of the eminence which forms the 
 anterior margin of its articular cavity. The mouth is locked 
 in the half-open position ; speech and deglutition are effected 
 with difficulty, and there is a dribbling of saliva from over- 
 secretion by the stimulus of pressure on tne salivary glands. 
 To reduce : Two pieces of soft wood, each about as thick 
 as the thumb, are placed, one on each side, between the 
 upper and lower posterior molars, and are held in this 
 position by an assistant standing behind the patient. The 
 operator then places his fingers under the arch of the bone 
 and raises it, gradually increasing the power, by which 
 means the head of the bone is tilted downward and back- 
 
 18 
 
274 DISLOCATION OF THE LOWER JAW. 
 
 ward over the articular eminence, when the muscles of 
 mastication immediately return it to its cavity with a snap. 
 In the absence of an assistant, the operator may insert his 
 thumbs into the patient's mouth, and press the posterior 
 lower molars downward, while with his fingers he raises 
 
 A DISLOCATED Lower JAW : The condyloid process a of the lower jaw has 
 slipped over the articular eminence b from its natural position in the articular 
 cavity c which lies in front of the canal of the ear. The alveolar arch d is thus 
 projected forward and the mouth is open because the coronoid process, e, strikes 
 against the lower edge of the malar bone / ; g is the angle of the jaw and h its 
 
 the chin ; but in this case the thumbs should be guarded by 
 strong leather gloves. A chin bandage [395] should be 
 worn for a few days to support the joint. 
 
 477. The most common displacement of the inner end of 
 the CLAVICLE is that in which it is thrown forward from" its 
 articulation with the sternum or breast-bone by violence 
 applied to the front of the shoulder. The most common 
 displacement at the outer end of the bone is the removal 
 from it, in a downward direction, of the acromion process 
 of the scapula by direct violence, as by falls or blows on 
 the shoulder. The nature of the injury, in either case, is 
 easily distinguished by the unnatural projection of the end 
 of the collar-bone as it lies beneath the skin. Both luxa- 
 tions are reduced by placing the knee, as a fixed point, 
 
DISLOCATION OF THE SHOULDER-JOINT. 
 
 275 
 
 between the patient's shoulder-blades and drawing the 
 shoulders steadily backward while an assistant in front of 
 the patient makes pressure to direct the end of the bone 
 into its place. After reduction the retentive apparatus 
 used for fracture of the clavicle [452], with a pad over the 
 displaced end of the bone, should be used to preserve the 
 parts at rest. 
 
 478. Dislocations of the SHOULDER-JOINT are more com- 
 mon than those of all the other joints of the body taken 
 together ; and what is called the down- 
 ward displacement of the head of the 
 humerus into the armpit is by far the 
 most frequent of the shoulder luxa- 
 tions ; in fact the others are extremely 
 rare as compared with it. The in- 
 jury is easily recognized: The round- 
 ness of the shoulder is lost ; its apex 
 is formed by the projecting acromion, 
 beneath which may be felt a depression 
 caused by the absence of the head of 
 the bone from the glenoid cavity of 
 the scapula; the patient supports his 
 forearm, as in fracture, with the hand 
 of the uninjured side; but the arm is rigid, generally 
 in line with the long axis of the body, but with the elbow 
 projecting somewhat from the side. The long axis of the 
 bone is seen to extend from the elbow to the armpit, in 
 which situation its round head may be felt, particularly if 
 at the same time an effort be made to raise the elbow. [In 
 the accompanying illustration the shaft of the humerus is 
 too perpendicular ; it should have had a decided outward 
 slope.] Raising or lowering the elbow is difficult and causes 
 great pain, but a slight forward and backward movement 
 
 Dislocation downward 
 of the humerus at the 
 shoulder, the head of the 
 bone lying below the 
 glenoid cavity of the 
 scapula. 
 
276 
 
 DISLOCATION OF THE SHOULDER- JOINT. 
 
 may sometimes be effected without much inconvenience. 
 This projection of the elbow may indeed be looked upon as 
 a reliable sign of dislocation if it persist when the hand of 
 the patient is laid upon his uninjured shoulder. The fingers 
 tingle and become numb from pressure by the displaced 
 bone on the large nerves traversing the axillary space, and 
 the limb may soon become swollen from interference with 
 the circulation. 
 
 479. When recent, this dislocation is easily reduced. An 
 assistant holds the body of the patient fixed; another 
 makes traction on the elbow in the line of the bone, at first 
 downward and outward, and 
 
 afterward more directly out- 
 ward by gradually raising the 
 elbow, to draw the humerus out 
 of its abnormal position, while 
 the fingers of the operator in 
 the armpit press outward and 
 upward to help the head over 
 the edge of the glenoid cavity ; 
 and as soon as this is accom- 
 plished the muscles restore the 
 bone with a snap to its natural 
 position. 
 
 480. Various modes have 
 been suggested of accomplish- 
 ing reduction when assistance 
 
 is limited to one person, as, for instance: The patient 
 is seated on a low chair on which the operator places 
 his foot so as to insert his knee into the axilla; with 
 one hand he fixes the shoulder, and with the other grasp- 
 ing the elbow he draws the humerus downward, at the 
 same time endeavoring, by pressing it inward, with his 
 
 Reducing a downward disloca- 
 tion of the humerus at the shoul- 
 der-joint. 
 
DISLOCATION OF THE ELBOW-JOINT. 277 
 
 knee as a fulcrum, to tilt its head over the edge of the 
 articular cavity. Again : The patient lies on his back on 
 the ground while the operator, seated by his injured side 
 and facing him, makes traction on the hand and forearm, 
 and with his unbooted foot in the axilla directs the head of 
 the bone to its cavity. Or : The armpit of the patient is 
 hooked over the top bar of a wooden fence and the operator 
 makes traction on the displaced bone, the inertia of the 
 
 Dislocation backward of the radius and ulna at the elbow. 
 
 .patient on the other side of the fence affording the counter- 
 extending or resisting force, while the breadth of the top 
 rail,- under these conditions, lifts the head of the bone over 
 the edge of the cavity. In muscular subjects it may be 
 needful to clove-hitch [483] a skein of yam or some other 
 strong soft material to the arm, by which to make the 
 necessary traction. After reduction the arm must be sup- 
 ported in a sling for several days. 
 
 481. The most frequent of the dislocations at the ELBOW- 
 JOINT is that in which both bones of the forearm are carried 
 backward and project beyond the lower end of the humerus. 
 The deformity is similar to that in fracture of the lower end 
 of the arm-bone, but it cannot be removed, as in that case, 
 by gentle traction ; the forearm and arm are fixed in their 
 abnormal relation to each other, and cannot be unlocked 
 without the intelligent application of suitable force. One 
 assistant fixes the humerus, another makes traction on the 
 
DISLOCATION OF THE HAND. 
 
 forearm in the direction of its length, and the operator, 
 placing the fingers of one hand in front of the forearm close 
 to the elbow, and those of the other on the projection behind 
 the joint, endeavors to pull the bones away from their posi- 
 tion against the lower end of the humerus. Or: The 
 patient being seated on a chair, the operator rests his foot 
 on it and places his knee in the bend of the injured elbow, 
 pressing against the front of the radius and ulna to dislodge 
 them j one hand fixes the humerus while the other makes 
 traction on the forearm, and, after the knee-pressure has 
 been kept up for some time, bends the forearm around the 
 knee to bring the articulating surfaces into contact. The 
 joint and forearm must afterward be supported in a sling. 
 
 482. Dislocation of the HAND from the lower end of the 
 bones of the forearm is an extremely rare injury, at one 
 time supposed to be more common because fracture of the 
 lower end of the radius [460] was frequently mistaken 
 for it. 
 
 483. The thumb has three joints one opposite the upper 
 part of the ball, one on a level with the web, and a third 
 
 Formation of the clove-hitch. 
 
 in the free portion. All are liable to luxation, but the mid- 
 dle joint most frequently meets with this injury, the lower 
 bone being usually thrown backward on the upper. To 
 apply a suitable extending force it is sometimes needful to 
 use a skein of thread or a strong tape made fast to the 
 thumb by a clove-hitch, with a few turns of a wetted roller 
 
DISLOCATION OF THE HIP-JOINT. 279 
 
 applied beneath to protect the skin. The clove-hitch is 
 made by forming two loops as in the cut, and then placing 
 that on the right over or in front of the other, so as to form 
 a double loop ; when traction is made on its ends this loop 
 around the thumb does not slip. 
 
 484. The joints of the fingers, when dislocated, are 
 reduced in the same manner as those of the thumb. 
 
 485. DISLOCATIONS OF THE HIP-JOINT are accidents which 
 require the best surgical intelligence for their treatment. 
 In presenting them briefly in this place, it is not suggested 
 that members of the hospital corps should be prepared to 
 undertake their management, but merely that they should 
 have that amount of knowledge of the conditions involved 
 which will enable them to give intelligent assistance to the 
 operator in his efforts at reduction. This knowledge, under 
 the pressure of an emergency which coincides with the 
 absence of better surgical skill, may be of much benefit to 
 the patient. 
 
 486. The head of the femur may be thrown out of its 
 cavity in any direction, but systematic writers on surgery 
 divide dislocations at the hip-joint into five classes : 1, 
 Upward on the dor sum or outer aspect of the ilium; 
 2, upward and backward into a notch between the ilium 
 and ischium; 3, upward and forward toward the pubes; 
 4, downward and forward below the pubes ; and 5, anom- 
 alous dislocations which do not properly belong to any of 
 the four classes stated. Sixty per cent of the dislocations 
 of the hip- joint belong to the first class ; twenty -five to the 
 second; the remaining fifteen to the other classes. 
 
 487. When the head of the bone is thrown upward on 
 the dorsum of the ilium, the hip bulges from the unnatural 
 position of the bone, the limb is shortened, the knee rolled 
 'inward and advanced across the lower third of the opposite 
 
280 
 
 DISLOCATION OF THE HIP-JOIKT. 
 
 thigh, and the foot inverted, with the great toe resting on 
 the top of the arch of the opposite foot. The patient can- 
 not move the limb, nor can the surgeon straighten it or 
 withdraw it from the other. The head of the bone is 
 directed backward and the trochanter forward. The injury 
 
 Dislocation upward on 
 the ilium. 
 
 Dislocation upward and 
 backward. 
 
 is distinguished from fracture of the neck of the femur by 
 n version, immobility, and the absence of crepitus. 
 
 488. When the head of the bone rests on the ischiatic 
 notch there is less shortening and the knee is less advanced ; 
 the lirnb is rotated inward and the great toe rests on the 
 root of the toe of the opposite foot. The head of the bone 
 is directed backward and the trochanter forward. 
 
 489. When the head is thrown upward and forward 
 toward the pubes there is also shortening; but the knee 
 and foot are rotated outward and drawn away from the 
 opposite limb; the roundness of the hip is lost, and the 
 
DISLOCATION OF THE HIP-JOINT. 
 
 281 
 
 head of the bone, which is directed forward, forms an 
 easily discovered tumor in the groin on the outer side of the 
 femoral artery. 
 
 490. The downward dislocation is also characterized by 
 the limb being carried away from that of the opposite side; 
 
 Dislocation upward and forward. 
 
 Dislocation downward. 
 
 but in this instance there is lengthening; and although the 
 foot is advanced, there is neither inversion nor eversion. 
 The head of the bone is directed inward and the trochanter 
 outward. 
 
 491. In dislocation upward the operator places his foot 
 in the perineum as a counter-extending force ; he passes the 
 loop of a skein of worsted, which is attached by a clove- 
 hitch to the lower part of the thigh of the patient, over his 
 neck, so that by stretching himself backward he may bring 
 a considerable extending force to bear on the dislocated 
 bone ; and when these forces have been continued for some 
 time he endeavors with both hands to rotate the knee out- 
 
282 DISLOCATION OF THE HIP-JOINT. 
 
 ward so as to tilt the head of the bone into its cavity. But 
 generally in these dislocations chloroform has to be admin- 
 istered and steady traction by pulleys used for the purposes 
 of extension. For instance, in the upward dislocation the 
 patient lies on his back ; a sheet is folded to form a perineal 
 band, the ends of which are made fast to some immovable 
 object so situated that its resistance shall be exercised in 
 line with the long axis of the femur; a skein of worsted is 
 
 Reduction of upward dislocation. 
 
 then clove-hitched above the knee, or a suitable leathern 
 band buckled on this part, and hooked on to the system of 
 pulleys, which are so arranged that the extending force may 
 also be in line with the long axis of the femur. When these 
 forces have brought the head of the bone down to its proper 
 level, the operator rotates the knee slightly outward to 
 complete the reduction; or if difficulty be experienced in 
 effecting this, he passes a towel beneath the thigh close to 
 the hip-joint, and tying its ends together, places the bight 
 over his neck and endeavors by raising his body to lift the 
 head of the bone into its cavity while using his hands on 
 the pelvis as a counter-force. 
 
 492. In the upward and backward dislocation the patient 
 lies on his side and the extending and counter-extending 
 forces are directed in a line across the middle of the sound 
 thigh. 
 
 493. When the head of the bone is thrown toward the 
 
DISLOCATION OF THE HIP-JOINT. 283 
 
 pubes, the patient is placed on his sound side; counter- 
 extension by the perineal band is upward and forward in 
 front of the line of the body, and extension downward and 
 backward behind the line of the body ; a towel is used to 
 lift the bone into its place. 
 
 494. In the downward dislocation the patient lies on his 
 back ; the pelvis is fixed by a sheet which is made fast to 
 
 Reduction of upward and backward dislocation. 
 
 some immovable object on the sound side; another sheet is 
 passed into the perineum and its ends are carried up between 
 the body and the counter-extending girth, after which they 
 
 Reduction of upward and forward dislocation. 
 
 are attached to the pulleys ; extension is made in an upward 
 and outward direction as regards the position of the patient; 
 and when these forces have been sustained for some time, 
 
284 DISLOCATION OF THE KNEE-JOINT. 
 
 the operator from the sound side passes his hand beneath 
 the patient's sound ankle, and, grasping the ankle of the 
 injured limb, draws it toward him, thereby throwing the 
 head of the bone outward into its place. 
 
 495. In all these dislocations a long straight splint [467] 
 
 Reduction of the downward dislocation. 
 
 must be applied on the outer side, after reduction, and 
 retained for two or three weeks to support the joint and 
 prevent motion. 
 
 496. The PATELLA or KNEE-CAP is sometimes driven out- 
 ward, less frequently inward, from its position in front 
 of the knee-joint. Eeduction is effected by bringing the 
 limb forward on the body to relax the muscles on the ante- 
 rior aspect of the thigh, and then pressing the bone inward 
 or outward, as may be required, to restore it to its place. 
 
 497. Dislocations at the KNEE-JOINT are dangerous from 
 the violence needful to cause them and from their inflam- 
 matory consequences. The nature of the injury is easily 
 distinguished. Reduction is accomplished by extension 
 from the ankle and counter-extension from the thigh to 
 separate the bones, with pressure by the fingers of the oper- 
 ator outward, inward, forward, or backward, as may be re- 
 quired to bring the head of the tibia into its proper place. 
 
 498. The most frequent of the dislocations of the ANKLE- 
 
DISLOCATION OF THE ANKLE-JOINT. 285 
 
 JOINT is that iii which the foot is twisted outward, so that 
 its inner edge rests on the ground. The lower end of the 
 tibia forms a projection on the inner aspect of the joint, 
 and there is a depression on the outer aspect about two 
 inches above the joint where the thinner bone, the fibula, 
 generally gives way. This accident has often been called 
 "Pott's fracture," after the surgeon who first described the 
 true condition of the parts involved. It is treated by exten- 
 sion to the foot, counter-extension to the leg or thigh, and 
 manipulation to return the bones to their natural relation- 
 ship. The leg is then placed on an inclined plane with 
 a foot-piece, or otherwise supported until the fractured 
 fibula becomes united and the ruptured ligaments healed. 
 
 499. Other dislocations at the ankle and of the bones of 
 the FOOT are rare or so complicated by the violence which 
 caused them that the displacement of the bones is only one, 
 and often a secondary one, of the conditions that require 
 surgical treatment. 
 
CHAPTER XII. 
 
 THE MANAGEMENT OF CASES OF POISONING. 
 
 500. The strong acids and alkalies can hardly be called 
 poisons. When taken accidentally, they seldom reach the 
 stomach, as their presence in the mouth discovers the acci- 
 dent and leads to the immediate rejection of the mouthful. 
 When taken intentionally, however, the stomach is involved. 
 There is intense thirst with burning and agonizing pain, 
 nausea, and vomiting of matters mixed with darkened blood 
 and portions of mucous membrane. After much suffering 
 the patient becomes exhausted, his pulse rapid and weak, 
 skin cold and clammy, leading to death by collapse. 
 Sometimes the shock of the injury [304] is so great that 
 death may occur with little suffering. In other cases, par- 
 ticularly when ammonia has been used, death may occur 
 from suffocation caused by tumefaction of the larynx. The 
 corrosive agent should be immediately neutralized. Mag- 
 nesia answers best for the strong acids, as it is bland in 
 itself and disengages no gas to distend the injured stomach; 
 but in its absence chalk, whiting, washing or baking soda 
 may be used, or even soap and water, as the fatty acid of 
 the soap does not interfere with the antidotal power of its 
 alkali. When potash, soda, or ammonia is the corrosive 
 agent, vinegar, lemon juice, aromatic sulphuric acid, etc., 
 suitably diluted, must be administered. Subsequently, the 
 whites of two or three eggs should be given in water, or in 
 their absence, milk, olive oil, or mucilaginous drinks, as 
 
MANAGEMENT OF CASES OF POISONING 287 
 
 gruel, acacia water, or linseed tea. The intense suffering 
 should be alleviated by subcutaneous injections of morphine, 
 and the patient sustained during threatening collapse by 
 injections of brandy, warmth, and friction. 
 
 501. Poisons, from the point of view of those who are 
 called upon to rescue the patient, may be divided into three 
 classes. 
 
 I. Local irritants which produce an irritation or inflam- 
 mation of the alimentary canal. 
 
 II. Those which combine with the local irritation a cer- 
 tain action on some other part of the system. 
 
 III. Those which exert their influence on the nervous 
 system with little or no local action on the alimentary canal. 
 
 502. In every case of poisoning the first object of treat- 
 ment is to rid the stomach of the deleterious agent, and 
 meanwhile, if possible, to prevent its absorption. If free 
 vomiting is occasioned by the poisonous agent itself the use 
 of warm water may suffice to secure its removal ; otherwise 
 evacuation is best accomplished by the stomach-tube or 
 stomach-pump, because the use of these instruments is not 
 attended with the exhaustion that is prone to follow repeated 
 vomiting. To wash out the stomach by siphon action we 
 require the flexible stomach-tube of the stomach-pump case, 
 about a metre of rubber tubing to fit on to the stomach-tube, 
 and a large funnel, holding about two litres, to fit into the 
 other end. The stomach-tube is warmed, oiled, and intro- 
 duced while the patient is supported in the sitting posture. 
 Its tip, in beginning its descent, should be in contact with 
 the back part of. the pharynx. When introduced it is con- 
 nected with the rubber tubing and funnel, the latter filled 
 with warm water and held below the level of the patient's 
 stomach. When all is ready the funnel is raised that its 
 contents may flow gently into the stomach, and when the 
 
288 MANAGEMENT OF CASES OF POISONING. 
 
 latter is distended it may be emptied by lowering the funnel 
 toward the floor. The stomach should be flushed out sev- 
 eral times. Should any solid matters block the stomach 
 apertures of the tube they may be cleared out by raising 
 the funnel. The stomach-pump consists of a barrel and 
 piston, the nozzle of the former fitted on its end with a 
 flexible stomach-tube and on its side with another tube for 
 conveying the pumped liquids into a receiving basin ; but 
 the valves of the pump are so constructed that the action of 
 the instrument may be easily reversed, thus enabling the 
 operator to pump liquids into as well as out of the stomach. 
 Water should be alternately pumped in and removed until 
 it comes away clear. When the stomach tube or pump are 
 not at hand, mustard or sulphate of zinc should be preferred 
 as emetics, because they act promptly and with little strain- 
 ing or depression. The dose is one or two teaspoonfuls of 
 the former, or two grams of the latter, in a tumblerful of 
 warm water, vomiting being afterward solicited by tickling 
 the fauces and drinking large quantities of tepid water. 
 Ipecacuanha, in two-gram doses, may also be used. Sul- 
 phate of copper, from its irritant properties, is likely in 
 many cases to increase the poisonous effect if it be not 
 efficient as an emetic ; and tartar emetic induces too much 
 prostration to be used in cases which so often tend to death 
 by the supervention of collapse. Hydrochlorate of apomor- 
 phine, .006, may be given by hypodermic injection when the 
 patient is unable to swallow. In using the hypodermic 
 syringe the exact quantity of the solution to be injected is 
 drawn into the barrel, the needle is adjusted, and the pis- 
 ton pressed lightly until the appearance of the contained 
 liquid at the point of the instrument shows that all air has 
 been expelled. The skin is then pinched up between the 
 forefinger and thumb, and the needle is pushed into the 
 
MANAGEMENT OF CASES OF POISONING. 289 
 
 subcutaneous cellular tissue. The injection should be made 
 slowly and gently, and after the withdrawal of the instru- 
 ment the finger should be kept on the puncture for a few 
 seconds. The arm or forearm is usually selected as the 
 most convenient site, avoiding the vicinity of the subcu- 
 taneous veins. 
 
 503. The prevention of absorption is effected by the 
 administration of a chemical antidote which will combine 
 with the poison in the stomach to the formation of a sub- 
 stance which is insoluble or inert. This may often be 
 attempted pending the evacuation of the stomach. Tannic 
 acid, for instance, unites with the poisonous alkaloids, and 
 also with tartar emetic, forming insoluble compounds. It 
 is well, therefore, in treating poisoning by vegetable sub- 
 stances, to make the patient drink 250 c.c. of water contain- 
 ing a gram of tannin, or freely of an infusion of green tea, 
 particularly if there is any delay in procuring the stomach- 
 tube or emetic. The tannin is given in the expectation of 
 holding the deleterious agent prisoner until it can be 
 removed ; but the necessity for its removal is not obviated, 
 for the tannin compound is soluble and poisonous under 
 certain conditions that might be present in the alimentary 
 canal. So in the case of poisoning by salts or oxids of 
 the metals, arsenic and antimony excepted, it is well to 
 have the patient swallow the whites of two or three eggs 
 diffused in water, for albumen forms insoluble compounds 
 with most of these poisonous substances. If eggs are not 
 at hand, milk or flour and water may be used as less 
 efficient substitutes, as the casein of the one and the gluten 
 of the other have a chemical action somewhat similar to 
 that of albumen. But as these compounds are also liable 
 to be dissolved under certain conditions, those produced 
 with corrosive sublimate and sulphate of copper being, for 
 19 
 
290 MANAGEMENT OF CASES OF POISONING. 
 
 instance, soluble in an excess of albumen, ifc is proper to 
 get them out of the stomach as speedily as possible. 
 
 504. When the poisonous substance is known, the chem- 
 ical antidote is sometimes indicated with precision. Thus, 
 when nitrate of silver has been swallowed, a solution of 
 common salt destroys its causticity by precipitating the sil- 
 ver as an insoluble chlorid ; when oxalic acid has been used, 
 chalk or whiting neutralizes its irritant qualities by convert- 
 ing it into an insoluble oxalate; carbolic acid and sugar of 
 lead are rendered inert by the use of a soluble sulphate 
 such as Epsom or Glauber's salt; phosphorus is converted 
 into a harmless phosphid by sulphate of copper, and arsenic 
 is deprived of its poisonous properties by the hydrated oxid 
 of iron. In all the cases mentioned except the last, the 
 antidote is administered when available, irrespective of the 
 antecedent or subsequent use of emetics ; but in the excep- 
 tional case of arsenic, the stomach should be evacuated in 
 the first instance, and the antidote be permitted to remain 
 for the neutralization of any residuum of the poison. 
 
 505. Having prevented further injury from the ingest- 
 ed poison by neutralizing and evacuating its unabsorbed 
 remains, the attention of the attendant should be de- 
 voted to relieving suffering and obviating the tendency to 
 death. 
 
 506. The relief of suffering is called for mainly by the 
 irritant class. The burning pain in the stomach and bowels 
 indicates the inflamed or eroded condition of the mucous 
 membrane, and calls for the use of cooling, bland, and pro- 
 tective liquids, as olive oil, mucilage of acacia, linseed tea, 
 barley water, and gruels, with small quantities of ice or 
 ice water to allay thirst. Mustard to the pit of the stom- 
 ach or large emollient poultices over the abdomen afford 
 relief, but opium is the chief reliance in aggravated cases, 
 
MANAGEMENT OF CASES OF POISONING. 291 
 
 given by the mouth, by enema, or hypodermically. As 
 death in these cases is the result of increasing prostra- 
 tion and collapse, the tendency must be counteracted by 
 the use of beef essence, free stimulation, warmth, and fric- 
 tions. 
 
 507. The irritant effects of the few poisonous substances 
 in the second class are controlled as stated in the last para- 
 graph; but oil should not be used as a protective in the case 
 of phosphorus or cantharides, as it dissolves the poisonous 
 principle in both instances, and would probably aggravate 
 the symptoms. The strangury of cantharides is controlled 
 by twenty or thirty drops of liquor potassse taken hourly 
 in water. Collapse is treated as in the purely irritant class ; 
 but in aconite poisoning digitalis may be tried to counteract 
 its directly depressant action on the heart ; and if the dan- 
 ger from carbolic acid be rather from failure of the respira- 
 tion than from collapse, atropine, enemata of coffee, water 
 douches, and artificial respiration should be employed. 
 
 508. Of the poisons of the third class, opium, belladonna, 
 and hyoscyamus produce a stupor in which the respiratory 
 wants of the system are unheeded, and the patient dies 
 because he does not respire. Chloral kills in the same way, 
 but there is in addition a paralyzing action on the heart 
 and muscular system that renders strychnine, .003 subcu- 
 taneously, of value as a remedy. Prussic acid, hemlock, 
 and tobacco also paralyze the muscular system, and require 
 stimulants, atropine, .001, digitalis, 1 c.c. of the tincture, 
 or strychnine hypodermically to counteract their influence, 
 and artificial respiration to prolong the hope of recovery. 
 Hellebore depresses the heart's action, an effect which is 
 counteracted by digitalis ; while the excitement of the heart 
 occasioned by digitalis is quieted by aconite. Strychnine 
 calls for bromid of potassium and chloral, and inhalations 
 
292 MANAGEMENT OF CASES OF POISONING. 
 
 of chloroform or nitrite of amyl to control the muscular 
 spasms and lessen the danger of exhaustion from their con- 
 tinuance, or of death from their intensity. 
 
 I. IRRITANTS. 
 
 509. ARSENIC causes burning pain in the stomach, with 
 great thirst, nausea, vomiting of brownish matter and blood- 
 stained mucus, tenderness of the abdomen and purging with 
 much griping, straining, and suppression of urine; great 
 prostration with much anxiety, fainting, palpitations, and 
 cramps, ending in collapse with cold and clammy skin, 
 sighing respiration, and imperceptible pulse. The stomach- 
 tube or emetics ; after which a tablespoonful of recently pre- 
 pared ferric hydrate, given every five or ten minutes, until 
 the patient is relieved. The hydrate is prepared by pre- 
 cipitating a solution of tersulphate of iron by liquor of 
 ammonia, and straining and washing the precipitate to free 
 it from excess of ammonia. An antidote, ferri oxydum 
 liydratum cum, magnesia, the preparation of which involves 
 no loss of time in washing, has been provided by the Phar- 
 macopeia. The tersulphate solution is treated with an 
 excess of magnesia, instead of ammonia, and the precipitate 
 is immediately administered by the tablespoonful, for neither 
 the magnesia nor its sulpahte which is formed during the 
 precipitation interferes with the action of the hydrated 
 oxid. Suffering is then relieved and inflammation allayed 
 by mucilaginous drinks, cataplasms, and morphine, and 
 threatening collapse averted by stimulants and the warmth 
 of hot-water bottles, flannels, and friction. 
 
 510. CORROSIVE SUBLIMATE is similar in its action to 
 arsenic, causing gastric and intestinal inflammation and col- 
 lapse. Egg-albumen, milk or flour and water ; the stomach- 
 
MANAGEMENT OF CASES OF POISONING. 293 
 
 tube or emetics ; subsequent treatment as in arsenical poi- 
 soning. 
 
 511. SUGAR OP LEAD induces the usual gastric symptoms, 
 but the vomited matters contain white chlorid of lead; 
 there is great abdominal tenderness with cramps and in- 
 creasing prostration, but the astringency of the lead salt 
 prevents the purging that generally characterizes irritant 
 poisoning. Sulphate of soda, sulphate of magnesia, or aro- 
 matic Bulpkuric acid in water; the stomach-tube or emetics ; 
 subsequent treatment as in arsenical cases. 
 
 512. NITRATE OF SILVER produces local symptoms with 
 much constitutional disturbance. Common salt in solution ; 
 the stomach-tube or emetics, and subsequent treatment as in 
 arsenic. 
 
 513. ZINC SALTS. The sulphate, taken sometimes by 
 mistake for Epsom salt, is its own antidote by emetic action ; 
 subsequent collapse requires treatment as in arsenic. 
 
 514. COPPER SALTS. The primary effects are those of lo- 
 cal irritants ; the sulphate may .be its own antidote. White 
 of egg, milk, or flour and water; the stomach-tube or emetics 
 if required ; subsequent treatment as in arsenical poisoning. 
 
 515. TARTAR EMETIC. Collapse is hastened by a direct 
 depressant action on the circulation. This poison acts as 
 its own antidote in evacuating the stomach. Tannin in 
 solution, or infusion of green tea, with morphine to allay 
 excessive vomiting and relieve suffering, and stimulants as 
 required. 
 
 516. OXALIC ACID. Chalk or whiting diffused in water; 
 the stomach-tube or emetics, and subsequently measures to 
 relieve suffering and avert, or recover from, collapse. 
 
 517. CROTON OIL, COLOCYNTH, and other DRASTIC CA- 
 THARTICS tend to death by exhausting the patient. The 
 stomach-tube or emetics ; opium and stimulants. 
 
294 MANAGEMENT OF CASES OF POISONING. 
 
 518. COLOHICUM causes violent local irritation with in- 
 tense prostration. Tannin or green tea ; the stomach-tube or 
 emetics ; morphine and stimulants. 
 
 II. IRRITANTS WITH A SPECIFIC ACTION. 
 
 519. CANTHARIDES produce the gastro- enteric symptoms 
 of irritant poisoning ; and also an irritant action on the kid- 
 neys, manifested by strangury and bloody urine; death is 
 preceded by delirium and convulsions. The stomach-tube 
 or emetics ; mucilaginous, but not oily, preparations ; 
 morphine and stimulants. 
 
 520. ACONITE causes a burning feeling in the throat and 
 stomach, with nausea, vomiting, purging, and intestinal 
 pains; numbness and tingling of the muscles, merging into 
 paralysis; great depression of the circulation and prostra- 
 tion, ending in general collapse, sometimes with convulsions 
 and stupor. The stomach-tube or emetics ; stimulants by 
 the rectum, or subcutaneously if rejected by the stomach; 
 warmth and frictions ; tincture of digitalis, 1 c.c., hypoder- 
 mically, and repeated, if need be, to strengthen the heart's 
 action. 
 
 521. PHOSPHORUS manifests its irritant properties by 
 heat and swelling of the tongue and throat ; pain and dis- 
 tention of the abdomen, with mucous or bilious vomiting 
 and purging, sometimes bloody; anxiety, restlessness, 
 cramps, and convulsions, ending in stupor or general col- 
 lapse. /Sulphate of copper, .2 in a tumbler of water every 
 five minutes until vomiting is induced; if free vomiting 
 have already occurred, the copper should be given once, 
 with opium to promote its retention; sulphate of magnesia 
 to carry off the poison by its cathartic action ; mucilaginous, 
 but not oily, drinks ; cataplasms, opiates, and stimulants as 
 required. 
 
MANAGEMENT OF CASES OF POISONING. 295 
 
 522. CARBOLIC ACID occasions a burning feeling, whiten- 
 ing the mucous membrane of the throat and stomach, and 
 speedily rendering it insensitive by coagulating its albu- 
 minoid principle; intense depression, cold and clammy 
 skin, feeble pulse, insensibility quickly deepening into stu- 
 por, with death from failure of the respiration or of the 
 heart. Sulphate of soda or sulphate of magnesia, white of 
 egg, milk or flour and water ; stomach-tube or apomorphine 
 subcutaneously, as emetics when introduced into the stomach 
 have little influence on its disorganized mucous membrane. 
 Stimulants by enema, or ammonia or brandy by hypodermic 
 injection, with warmth and frictions if syncope threaten ; 
 atropine and artificial respiration if the breathing fail. 
 
 III. POISONS ACTING ON THE NERVOUS SYSTEM. 
 
 523. OPIUM NARCOTISM. When a poisonous dose of 
 opium has been taken, the patient speedily passes from 
 drowsiness into a deepening stupor, in which his nervous 
 centres ultimately fail to recognize the necessity for respir- 
 ing, and he passes into death by ceasing to breathe. At 
 first the face is flushed and the breathing stertorous, the 
 pulse full and slow, and the stupor profound ; but this con- 
 dition differs in several points from apoplexy. There is no 
 paralysis other than the temporary relaxation and loss of 
 power involved in the loss of consciousness; the pulse, 
 although full, is soft and easily compressed, the pupils are 
 contracted, and the patient may be aroused to some degree 
 of confused consciousness by shaking, slapping, douching 
 with cold water, and speaking to him in loud, sharp tones. 
 After a time the pulse becomes weaker, small, scarcely per- 
 ceptible; the respiration diminishes in frequency by long 
 intervening pauses, and inspiration is slow and often inter- 
 rupted ; the face becomes pale, the skin clammy and cool, 
 
296 MANAGEMENT OF CASES OF POISONING. 
 
 the extremities cold. In the early stages the patient should 
 be douched with cold water, to rouse him from his stupor ;, 
 the stomach-tube should be used or an emetic of mustard or 
 sulphate of zinc administered, after which strong coffee is 
 swallowed from time to time, or administered by enema, to 
 counteract the narcotic tendency. Every effort must be 
 made to keep the patient awake and conscious of the neces- 
 sity of breathing. If the stomach-tube is not at hand and 
 an emetic cannot be taken by the mouth, a hypodermic 
 injection [502] of .006 apomorphine may be used. The 
 respirations should be closely watched, and if they are 
 found to be steadily decreasing, and to have fallen below 
 ten per minute, sulphate of atropine .001 should be given 
 by subcutaneous injection, and repeated once or twice at 
 intervals of ten minutes if no favorable result be observed 
 in the mean time; but if the respiration becomes more fre- 
 quent, or even more regular, and particularly if the con- 
 tracted pupils undergo a slight relaxation, the patient may 
 be permitted to rest without further effort on his behalf, 
 unless called for by a subsequent impairment of the regu- 
 larity or frequency of the breathing. Permanganate of 
 potassium, .4, is recommended by some as a valuable anti- 
 dote ; the water used in washing out the stomach might 
 have this quantity of the permanganate dissolved in it. 
 Artificial respiration may be used as a last resource. 
 
 524. CHLORAL. The chloral sleep deepens into stupor, 
 during which respiration fails and the pulse becomes weak 
 and small. Treatment as in opium poisoning, with sul-i 
 phate of strychnine, .003, by hypodermic injection, if death 
 from heart failure seems impending. 
 
 525. BELLADONNA AND HYOSCYAMUS. Dryness and con- 
 striction of the throat, burning in the stomach, dimness of 
 vision, with dilated pupils, hurried breathing, headache, 
 
MANAGEMENT OF CASES OF POISONING. 297 
 
 and delirium ending in stupor, with feeble pulse, cold 
 extremities, and diminished respiration ; sometimes a scarlet 
 rash on the skin. Tannin ; the stomach-tube or emetics ; 
 coffee ; mustard and friction to the extremities. 
 
 526. PBUSSIC ACID, CYANIDE OF POTASSIUM. Death 
 occurs quickly from paralysis of the respiration and heart. 
 Cold douche and ammonia to the nostrils ; artificial respira- 
 tion and frictions ; enemata of brandy. When OIL OF BIT- 
 TER ALMONDS is the poisonous agent, there will probably be 
 time for the use of emetics, with subsequent treatment by 
 stimulants. 
 
 527. HEMLOCK. Extreme muscular prostration and death 
 from paralysis of the respiration; no delirium or coma. 
 Tannin or green tea ; the stomach-tube or emetics; stimu- 
 lants ; frictions ; atropine and artificial respiration. 
 
 528. TOBACCO induces dizziness, confusion of ideas, faint- 
 ness, nausea and vomiting, intense muscular prostration, and 
 fatal collapse with or without stupor. Tannin ; stomach- 
 tube ; stimulants, warmth, frictions, and strychnine by sub- 
 cutaneous injection. 
 
 529. HELLEBORE. Intense prostration, imperceptible 
 pulse, cold, clammy skin, nausea and attempts at vomiting, 
 fainting, and fatal collapse. Tannin or green tea ; stomach- 
 tube or emetics ; morphine and stimulants by the mouth or 
 rectum; ammonia, frictions, and digitalis. 
 
 530. DIGITALIS. Nausea, vomiting, and great prostra- 
 tion, with cold sweats and feeble, almost imperceptible 
 pulse, stupor or delirium, and death from spasm of the 
 heart. Tannin or green tea / the stomach-tube or emetics ; 
 stimulants and one or two minims of tincture of aconite by 
 hypodermic injection. 
 
 531. STRYCHNINE. Violent spasms of the muscular sys- 
 tem, lasting from one to five minutes, with intervals of 
 
298 MANAGEMENT OF CASES OF POISONING. 
 
 relaxation, prolonged sometimes for half an hour. During 
 a convulsion the features are contorted, the body bent rigidly 
 backward, and the breathing stopped or much impeded; 
 brain not affected. The patient dies of asphyxia during a 
 convulsion, or exhausted by the frequency and violence of 
 the fits. Tannin ; stomach-tube or emetics ; bromid of po- 
 tassium, 7 gm., and chloral, .7, to control the paroxysms, 
 with chloroform or nitrite of amyl inhalations when the con- 
 vulsions are specially severe ; artificial respiration as a last 
 resource. 
 
 532. POISONING BY ARTICLES OF FOOD. Meat, sausage, 
 cheese, shell-fish, certain species of mushrooms, fruits, etc., 
 sometimes occasion nausea, vomiting, violent cramps, pain, 
 diarrhea, and great depression of the vital powers. The 
 stomach-tube or emetics and cathartics to remove the noxious 
 material, with stimulants to relieve the subsequent depres- 
 sion. 
 
 533. POISONING BY KHUS TOXICODENDBON. A cutaneous 
 inflammation somewhat resembling erysipelas [372] is 
 often occasioned by contact with or even by exposure to 
 emanations from the leaves of the poison oak, poison ivy, 
 and other species of Khus. The poison oak is a small 
 shrubby plant with a leaf which consists of three leaflets : 
 two lateral, each about four inches long and two-thirds as 
 broad, springing directly from the leaf-stalk, ovate and 
 pointed at the apex, and one terminal, stalked, ovate, with 
 a wedge-shaped base and pointed apex all notched or 
 lobed on the margins and downy on the under surface. 
 The poison ivy climbs on trees and rocks to a considerable 
 height ; its leaflets are usually smooth above and below and 
 entire on the margins. The head and face become affected, 
 and sometimes the hands and upper extremities, or the hips, 
 scrotum, and adjoining parts of the thighs. The affected 
 
MANAGEMENT OF CASES OF POISONING. 299 
 
 surface is of a lurid-red color, covered, in aggravated cases, 
 with vesicles, the contents of which become incrusted on 
 drying, or ooze as a thin liquid from superficial fissures. 
 Pain, heat, irritation, and swelling are associated with the 
 redness; but although these often occasion considerable 
 suffering and loss of sleep, there is seldom much constitu- 
 tional disturbance. Generally the inflammation subsides in 
 about a week without leaving subcutaneous suppurations. 
 [t is treated with aperient medicines and cooling lotions. 
 
CHAPTER XIII. 
 
 DISINFECTANTS AND THE MANAGEMENT OF INFECTIOUS 
 DISEASES. 
 
 534. DISINFECTANTS are to be used only for a specific 
 purpose ; in the absence of any infectious disease they are 
 not required, and their expenditure for purposes of general 
 post sanitation is not authorized. Sulphate of iron and 
 other cheap deodorants and antiseptics may be used when 
 necessary, but the necessity for their use is regarded as a 
 reproach upon the sanitary police of a post. 
 
 535. Boiling in water may be relied upon to purify arti- 
 cles of body -clothing and bed-linen which have been exposed 
 to the infection of disease. All infected articles must of 
 course be kept separate from the general wash. 
 
 536. Solution of corrosive sublimate, one drachm to the 
 gallon of water, chlorinated lime, one ounce to the gallon, 
 solution of chlorinated soda diluted with nine volumes of 
 water, carbolic acid in a two-per-cent. solution, andtrikresol, 
 also in a two-per-cent. solution, are efficient disinfectants in 
 certain cases. They may be used for washing the floors, 
 woodwork, walls, etc., of rooms; they may be used also 
 for the hands, and, with the exception of the sublimate solu- 
 tion, for general personal use and for disinfecting soiledi 
 linen before transferring it to the laundry. Stronger solu- 
 tions should be employed for the treatment of excreta or for 
 saturating the sheets in which a dead body is to be enveloped 
 pending the arrangements for burial. A suitable strength 
 
DISINFECTANTS. 301 
 
 is obtained by dissolving two drachms of corrosive sublimate 
 or four ounces of chlorinated lime in a gallon of water, or 
 by making a five-per-cent. solution of carbolic acid. Any 
 of these should be added, in volume equal to that of the 
 material to be disinfected, to each dejection in cases of 
 typhoid fever, cholera, yellow fever, and epidemic dysen- 
 tery, to the matters vomited in cholera, yellow fever, scarlet 
 fever, and diphtheria, and to the expectorations in the two 
 last-named diseases and typhoid pneumonia. The disin- 
 fectant should be permitted to act on the excreta for an 
 hour, after which the contents of the vessel may be disposed 
 of, preferably by burial. Quicklime prepared as milk of 
 lime, 1 part to 8 or 10 of water, may be used for disinfect- 
 ing excreta. As contact with metals decomposes the subli- 
 mate solution, it should be used only in wooden, earthen- 
 ware, or other suitable vessels. Formalin has lately been 
 used as a disinfectant, in solution and also in the form of 
 gas, but it has not been placed on the Army Supply-Table. 
 
 537. Privy-vaults or cesspools that have become infected 
 by the addition of discharges direct from the patient must 
 be treated liberally with milk of lime, chlorinated lime, or 
 strong solutions of sublimate or carbolic acid. 
 
 538. A dry or oven heat of 230 Fahr., continued for two 
 hours, is useful in dealing with infected garments which 
 would be injured by immersion in boiling water or disin- 
 fecting solutions. 
 
 539. Free exposure to flowing steam for an hour or more 
 is an efficient disinfectant for clothing, and the only one 
 that can be satisfactorily applied to mattresses. Clothing 
 should be unfolded and mattresses uncovered and freely 
 opened up to penetration by the steam. 
 
 540. Fumigation with sulphur has been extensively used 
 by municipal health officers in the disinfection of rooms, 
 
302 MANAGEMENT OF INFECTIOUS DISEASES. 
 
 particularly after small-pox, and by quarantine officers in 
 purifying yellow-fever ships. This fumigation is directed 
 to the destruction of infection in the crevices of the floors, 
 walls, etc., all of which should be carefully cleared of dust 
 before their exposure to the fumes. The dust thus col- 
 lected should be burned. Many articles may be conve- 
 niently disinfected without injury to their texture or color 
 during the fumigation of the room in which the patient was 
 treated. Each article should be unfolded and freely exposed 
 to the sulphurous acid. The fumigation should last for 
 twenty-four hours, during which three pounds of sulphur 
 should be consumed for every thousand feet of cubic space. 
 Articles of metal should be removed or covered with grease 
 to protect them from the fumes. Due precaution must be 
 taken against danger from fire, as by placing the sulphur 
 in iron vessels bedded in sand ; and the room must be made 
 as air-tight as practicable by closing all the chinks. 
 
 541. Destruction by fire should be resorted to only when 
 disinfection by other means would cost more than the value 
 of the articles, as in the case of soiled dressings, clothes, and 
 bedding that are so worn out as not to be worth the trou- 
 ble of disinfecting, mattresses and pillows that would re- 
 quire the penetration of superheated steam to give reliable 
 results, and tents when the contagious disease that called 
 for their use is at an end. 
 
 542. When a contagious disease appears in a command, 
 it is important that it should be recognized at the earliest 
 possible moment. 
 
 543. ITCH or SCABIES usually makes its appearance on the 
 hands, in or about the clefts of the fingers, and from this 
 it spreads over the body and limbs, affecting chiefly the 
 flexures of the joints and other parts where the skin is thin ; 
 the head and face are seldom involved. It consists of dis- 
 
ARMY ITCH. 303 
 
 tinct reddish points with a minute bead of liquid at the 
 apex ; but as the intolerable itching leads to scratching and 
 subsequent inflammation, its vesicular character is often 
 obscured. It is caused by a minute insect, the acarus sca- 
 biei, which burrows in the skin near the vesicles. When 
 the insect is killed the inflammation subsides immediately. 
 Sulphur ointment at night, with a thorough scrubbing in 
 the bath-tub in the morning, repeated on two or three 
 successive days, effects a cure. Clothing, bed-linen, and 
 blankets should be boiled to destroy their contagion. 
 
 544. A disease called ARMY or CAMP ITCH must be dis- 
 tinguished from the parasitic scabies or itch of civil life. 
 It is developed in hot weather during an active campaign 
 when neither time nor facilities for personal cleanliness are 
 available. The over-stimulation of the skin during the 
 perspiration of hurried marches, combined with the rough 
 contact of coarse-fibred underclothing, gives rise in some 
 sensitive constitutions to an eruption of minute papules 
 which itch intolerably, particularly during the night, when 
 the attention of the individual becomes fixed on his cuta- 
 neous sensations. This condition is known as prickly heat. 
 In aggravated cases the papules are torn during the efforts 
 of the patient to find relief by scratching, and the surface 
 presents many dried points of dark blood. Dust and dirt 
 accumulate on the irritated skin and intensify the irritation. 
 The pediculus corporis or body louse may appear under con- 
 ditions of filth and overcrowding, and the irritation of its 
 presence augments the mental and bodily disquietude of the 
 affected individual. When any or all of these irritative 
 causes produce in some parts papules with darkened sum- 
 mits, and in others scabs and crusts of dried, purulent matter 
 with a thin, acrid liquid oozing from their cracks and fis- 
 sures, the disease is called camp itch. It affects the chest, 
 
304 SMALL-POX. 
 
 abdomen, and outer aspect of the limbs, while scabies is 
 generally found in the clefts of the fingers, the flexures of 
 the joints, the inner aspect of the limbs, and other similarly 
 protected parts. Rest in hospital with baths, the removal 
 of all sources of irritation, and lead lotion or some anti- 
 septic ointment, will usually control the disease. 
 
 545. Three species of pediculi occasionally find favorable 
 conditions for their development on the uncared-for human 
 surface. One of them, that mentioned in the preceding 
 paragraph, will sometimes in a prolonged campaign appear 
 in a squad or company, spreading from man to man by the 
 contact of blankets or baggage. Its body is whitish, elon- 
 gated, and somewhat flattened. It makes its abode and de- 
 posits its ova or nits along the seams or folds of the inner 
 garments. The other species are rarely seen in military 
 commands. They are the pedieulus capitis, which infests 
 the scalp, and the pedieulus pubis, which may spread from 
 its nominal locality over the whole of the surface except the 
 scalp. The one is smaller in size than the pedieulus cor- 
 poris, but is otherwise of similar appearance ; the other is 
 square-shaped, flattened, and provided with crab-like claws. 
 Both deposit their nits about the roots and stems of the 
 hair. Personal cleanliness with the application of red pre- 
 cipitate or mercurial ointment, and the boiling or burning 
 of infected clothes, will speedily free the individual from 
 such undesirable companionship. 
 
 546. SMALL-POX. When an individual becomes affected 
 with headache and fever two weeks after he has been ex- 
 posed to the contagion of small-pox, his case should be 
 regarded as suspicious, particularly if there be much pain 
 in the loins and obstinate vomiting. On the third day of 
 the fever small reddish points appear on the forehead and 
 nose. Next day similar points are found on the neck, 
 
VACCINATION. 305 
 
 chest, and arms, while those on the forehead have become 
 darker in color and larger, feeling like small shot under the 
 skin ; meanwhile, as the eruption comes out the fever abates. 
 These developments authorize the immediate isolation of 
 the patient under the care of special nurses, who should be 
 protected by fresh vaccine lymph, even though they bear 
 the scars of small-pox itself. The command should then 
 be inspected with the view of protecting by revaccination 
 those who have not recently undergone the operation. By 
 isolation is meant the transfer of the patient to a separate 
 ward, room, or tent, where he will have communication 
 with none save those in attendance, and where the inter- 
 course of the latter with the outside shall be so regulated as 
 to prevent the transmission of infection. 
 
 547. Vaccination is effected by punctures, scratches, or 
 abrasions. When lymph is taken from the vesicles of a 
 healthy vaccinated child on the eighth day of its vaccina- 
 tion the operation is said to be arm-to-ann vaccination. 
 This is the best way of dealing with children under ordi- 
 nary circumstances. But when large numbers of persons 
 have to be vaccinated without delay on account of probable 
 exposure to contagion, fresh lymph must be obtained in 
 quantity, dried on quills or ivory points in the form of 
 crusts, or made up into cones. Vaccine lymph derived from 
 a vesicle on the arm of a vaccinated person is said to be 
 humanized ; when obtained, as it generally is, by artificial 
 cultivation on the calf, it is called bovine lymph. In oper- 
 ating by puncture, which is suitable only for persons with 
 thick skins, a somewhat blunt lancet is run horizontally 
 under the cuticle or scarf skin for about 2 mm. Three such 
 punctures are made close to each other, and three others at 
 a distance of 3 cm. from the first set. A little of the lymph 
 is then inserted into each puncture. If ivory points are 
 20 
 
306 VACCINATION. 
 
 used, the lymph must be moistened with water before inser- 
 tion ; fragments of crusts or cones must be rubbed up with 
 a drop or two of water to the consistence of cream. Instead 
 of punctures, two sets of light scratches may be made, each 
 covering a space about 5 mm. in diameter and 3 cm. apart, 
 into which the lymph is rubbed with the flat of the lancet, 
 ivory point, or quill. In the case of tender skins which 
 bleed readily, it is better to scrape the surface at the two 
 points until the cuticle is removed, and then rub in the 
 lymph as into the scratches. The outer aspect of the left 
 arm is usually selected as the site for vaccination. In 
 exposing this site it is advisable as a rule to drop the 
 clothes from the shoulder rather than to roll up the sleeves, 
 for the latter if tight will by their pressure engorge the 
 arm, promote the oozing of blood, and prevent absorp- 
 tion. 
 
 548. On the third day after the insertion of the lymph in 
 a primary or first vaccination, a slight reddisti tumefaction 
 is observable, which next day is tipped with a little clear 
 lymph. This vesicle increases in size until the eighth day, 
 when it becomes umbilicated or depressed in the centre and 
 surrounded by an areola of cutaneous inflammation. The 
 lymph is now mature and fit for use in other cases. By the 
 tenth day the inflammation extends an inch or more in all 
 directions from the vesicle, which loses its pearly color and 
 becomes turbid and purulent. At this time there is usually 
 a slight feverishness, and the glands in the armpit may be 
 swollen. In a day or two the pustule breaks and dries up 
 into a brownish crust, the inflamed areola meanwhile disap- 
 pearing. The crust falls off about the twenty-first day, leav- 
 ing a characteristic, slightly depressed cicatrix. 
 
 549. When one who shows scars of a successful vaccina- 
 tion is subjected to revaccination, the progress of the vesicle 
 
CHICKEN-POX. 307 
 
 as above described is often modified by the influence of the 
 primary vaccination. The vesicle and its areola may be 
 smaller and the crust fall off at an earlier date. Vaccina- 
 tion protects from small-pox; but as its influence fades in 
 time, it does not continue to protect completely, although it 
 renders the disease, which is then usually called varioloid, 
 less protracted and less dangerous to the individual than it 
 otherwise would have been. So vaccination protects from 
 revaccination ; but as its influence fades, it does not protect 
 completely, the resulting vesicles being modified as small- 
 pox would have been modified had the individual been 
 infected with the matter of the small-pox pustule instead 
 of with that of the vaccine vesicle. These modified results 
 of revaccination must therefore be recorded as successful 
 operations because they exhaust the existing susceptibility 
 to small-pox. 
 
 550. The convalescent from small-pox should be kept in 
 isolation until the skin is free from crusts. Infected cloth- 
 ing or bedding should be destroyed by fire or disinfected by 
 boiling, steam, or sulphur fumes. Tents, when not required 
 for further use as pest hospitals, should be burned. In- 
 fected rooms are disinfected by fumigating with sulphur or 
 by cleaning away all dust, washing with solution of cor- 
 rosive sublimate or chlorid of lime, and freely ventilating. 
 
 551. CHICKEN-POX. It is sometimes of importance to 
 distinguish between chicken-pox and small-pox or so-called 
 varioloid. The onset of both is by fever ; but in small-pox 
 the fever is severe and lasts for three days before the 
 papules appear, while in chicken-pox it is mild and precedes 
 the eruption of vesicles by twenty-four hours only. The 
 vesicles of small-pox are urnbilicated and take nine days to 
 mature ; those of chicken-pox are usually rounded and begin 
 to dry up by the end of the third day. Small-pox lasts 
 
308 ROSEOLA. 
 
 three or four weeks ; chicken-pox runs its course in eight 
 or nine days. 
 
 552. The chicken-pox patient should be isolated from 
 other children until the skin is free from crusts or scabs. 
 The clothes and bed-linen should be disinfected by boiling ; 
 the room by thorough cleaning, swabbing with solution of 
 corrosive sublimate, and free ventilation. 
 
 553. SCARLET FEVER manifests itself from three to five 
 days after exposure to the contagion. Marked feverish- 
 ness, redness of the throat, and perhaps pain or difficulty 
 in swallowing are its first symptoms. At the end of 
 twenty-four hours an eruption of small scarlet dots appears 
 on the neck and chest, and afterward on other parts of the 
 surface, coalescing first into large, irregularly shaped 
 patches, and by the end of the second day into a generally 
 diffused efflorescence. The eruption lasts from four to six 
 days, during which the fever continues and the throat 
 affection becomes aggravated, the fauces swollen, and the 
 tonsils covered with soft, yellowish sloughs. 
 
 554. A scarlet-fever patient should be carefully isolated, 
 no matter how mild the disease may be in that particular 
 case ; for although mild cases are sometimes called scarlaMna, 
 their contagion is as dangerous to others as that of the most 
 aggravated case of the disease. Isolation should be kept 
 up until the desquamation of the skin has been completed. 
 Bed-linen and body-clothing should be boiled, and the room 
 and all articles that would be injured by boiling fumigated 
 with sulphur, the walls and floors being subsequently treat- 
 ed with corrosive sublimate or chlorid of lime in solution. 
 
 555. ROSEOLA. It is sometimes impossible to distinguish 
 cases of this unimportant rash from mild cases of scarlet 
 ever. The appearance of the eruption is similar in both, 
 and in both there may be no other symptom on which to 
 
TYPHOID FEVER. 309 
 
 base a diagnosis. In uncertain cases it is best to isolate as 
 if scarlet fever were under treatment [557]. 
 
 556. MEASLES. About eight days after exposure to the 
 contagion, the patient becomes affected with feverishness, 
 cold in the head, and sometimes also in the chest. When 
 these have continued for three or four days, the eruption 
 appears on the face, and in the course of four days more it 
 has spread over the neck, chest, abdomen, and limbs ; but 
 by the time the later crops are appearing the earlier are 
 already fading. The eruption consists of small dots, which 
 coalesce into irregular-shaped patches of a dull red color, 
 associated with slight tumefaction, particularly on the face. 
 The patient should be isolated until the fine scales of 
 desquamation have been completely shed. Clothing and 
 bedding should be disinfected by boiling, and rooms by 
 thorough cleaning, washing with sublimate or fumigating 
 with sulphur. 
 
 557. ROTHELN or GERMAN MEASLES bears the same 
 relation to measles that roseola bears to scarlet fever, or 
 chicken-pox to small-pox. When these mild diseases oc- 
 cur epidemically, there is no difficulty in showing their 
 differences from the dangerous eruptive fevers which they 
 resemble ; but when the first cases occur, the doubt as to 
 their character often calls for careful isolation and treat- 
 ment until their true nature has been revealed by further 
 observation. 
 
 558. TYPHOID FEVER [79, 80]. The infection of this 
 fever resides in the stools of the fever patient. Laun- 
 dresses frequently contract the disease from contact with 
 soiled linen. The discharges of a typhoid patient should 
 be received into vessels containing corrosive sublimate or 
 chlorid of lime ; soiled bed-linen and clothing should be 
 steeped in a solution of chlorinated lime or soda before 
 
310 CHOLERA AND YELLOW FEVER. 
 
 being removed from the ward; the floor and furniture, 
 when tainted in any way, should be immediately washed 
 with one of the solutions mentioned, and the person of the 
 patient sponged when necessary with a dilution of chlori- 
 nated soda. The ward, as in all infectious diseases, should 
 be freely ventilated. As the disease is propagated chiefly 
 by the introduction of its infection with food or drink, care 
 should be exercised by attendants and others in purifying 
 the hands after contact with infected articles, particularly 
 before eating, and obviously no food or drink should be 
 used in the room or ward save by the typhoid patients. 
 When the disease prevails as an epidemic, its spread is 
 usually occasioned by an infected water supply. In this 
 case water must be obtained from other sources, and be 
 carefully guarded from infection ; but if a natural pure sup- 
 ply be not available, the water must be boiled, distilled, or 
 filtered efficiently before being used as a drink. 
 
 559. CHOLERA AND YELLOW FEVER [82]. All the meas- 
 ures suggested for limiting the spread of typhoid fever are 
 applicable in the management of cholera cases. In the 
 presence of an epidemic, the purity of food and drink 
 requires every care. With the exception of fruits that are 
 protected by an outer rind, no article of food should be eaten 
 that has not been subjected to heat in its preparation for 
 the table. Disinfectants should be freely used in the sinks, 
 as the dejections of choleraic diarrhea are as infectious as 
 the rice-water discharges of defined cholera. It is well, 
 also, to use similar disinfectant and protective measures 
 when dealing with yellow fever. 
 
 560. As in both these diseases the locality appears to 
 become infected, security can sometimes be attained only 
 by promptly withdrawing from the dangerous region. If 
 troops fall back before the advance of the disease, or pass 
 
CHOLERA AND YELLOW FEVER. 311 
 
 to one side of the line of its advance, they will escape 
 seizure, provided judicious quarantine restrictions are im- 
 posed on intercourse with infected localities. When, how- 
 ever, such a retreat is incompatible with strategic require- 
 ments, a line of sentinels should be posted around the camp 
 to cut off all unauthorized communication. No person 
 should be admitted within the lines without undergoing 
 quarantine examination; no baggage or supplies without 
 being disinfected or passed by the quarantine officer. Wa- 
 ter-supply, if it comes from without, or if a suspicion of 
 contamination from without can be harbored against it, 
 must be boiled before being used, even for police purposes ; 
 while any pure supply should be placed under guard for use 
 as drinking water. Should it be impossible to procure 
 such supply by other means, it ought to be boiled, distilled, 
 or filtered through germ-proof filters. Police regulations 
 should be scrupulously carried out. The troops should be 
 protected from all antihygienic influences. There should 
 be no unnecessary exposure to sun, rain, or night air, and 
 no drills or fatigue duties other than to furnish occupation 
 and needful exercise. When the military conditions per- 
 mit, the camp should be viewed as engaged in an active 
 campaign against an insidious and implacable enemy, and 
 the attention of every officer devoted to superintending the 
 conduct of his men with special reference to this view. 
 
CHAPTER XIV. 
 
 PHARMACY. 
 
 561. All the members of the hospital corps are instructed 
 in the elements of pharmacy. Those who show a bent 'for 
 this kind of work are afterward assigned to duty in the 
 dispensary. The course of instruction teaches the care of 
 the dispensary, the names and uses of the utensils and 
 apparatus, and the methods of cleaning them ; the care of 
 the scales, and the use of the metric system of weights and 
 measures. The student is then required to familiarize 
 himself with the various articles on the shelves of the dis- 
 pensary and the pharmaceutical processes connected with 
 them, as solution, evaporation, precipitation, filtration, 
 fusion, sublimation, distillation, etc. ; the making of pills, 
 mixtures, tinctures, ointments, etc. ; and the use of the 
 thermometer, hydrometer, urinometer, etc. Poisons and 
 their antidotes [p. 286], and disinfectants, with their uses 
 in limiting the spread of infectious diseases [p. 300], also 
 form part of this course. 
 
CHAPTER XV. 
 
 ELEMENTS OF COOKERY. 
 
 562. Lectures are given to hospital corps companies of 
 instruction on the articles of the ration, their money value 
 in connection with the accumulation of a hospital fund, the 
 principles involved in cooking them and in arranging for 
 variety in bills of fare ; but a knowledge of practical work 
 in the preparation of food can be obtained only by experi- 
 ence in the kitchen. The " Manual for Army Cooks," pub- 
 lished under the direction of the Commissary General of 
 Subsistence, 1 gives full instructions on the subject. 
 
 563. All substances used as food are of an organic, and 
 hence putrescible, nature. If bacterial germs are kept 
 away the substance will not putrefy, but will dry up like 
 the preserved meat strips in use in Mexico and other hot 
 countries. The germs of putrefaction are so constantly 
 present in the atmosphere that it is difficult to preserve 
 food for any time when heat and moisture also are present; 
 but when there are unclean spots in a kitchen or store-room 
 the speedy putrefaction of exposed articles becomes a cer- 
 tainty. Cleanliness is therefore the first requisite in a 
 cook ; no excuse should hold good against a want of clean- 
 liness. 
 
 564. The application of heat in the process of cooking 
 promotes the breaking up of the organic tissues and facili- 
 tates their digestion. Moreover, as heat destroys all germs, 
 
 1 Washington. Government Printing-office, 1896. 
 
314 JLLIMEHTATIOtf. 
 
 the thorough cooking of food is preventive of intestinal 
 worms, trichiniasis, etc., and lessens the danger of seizure 
 in times of epidemic disease. The albuminoids, when 
 introduced into the stomach in their raw state, undergo 
 coagulation with subsequent solution of the coagulum in the 
 gastric juices. Heat applied in cooking coagulates the 
 albuminoids and prepares them for immediate solution. At 
 the same time it disintegrates or gelatinizes the fibres and 
 permits the dissolving process to penetrate more readily 
 into their substance. Starch, which forms so large a pro- 
 portion of all vegetable food, is indigestible in its raw 
 state, but under the influence of heat its granules are 
 broken up and its solubility increased by its transforma- 
 tion into dextrin and glucose. 
 
 565. Heat is applied in cooking by various methods, as 
 boiling, stewing, frying, broiling, roasting, and baking. 
 
 566. The water used in boiling is merely the medium by 
 which the heat is communicated. None of the juices of the 
 meat or other article should be permitted to waste into it. 
 To this end the water should be slightly salted and boiling 
 vigorously when the meat to be boiled is dropped into it. 
 After five minutes of active boiling the process is conducted 
 at a slow boiling or simmering temperature for a period 
 varying with the weight of the meat, usually estimated at 
 about fifteen minutes per pound. Salt meats, however, 
 should be put on the fire with cold water. Over-boiled 
 meat, like a hard-boiled egg, is tough from the density of 
 its coagulation. Fish is boiled in like manner until the 
 meat is found to separate readily from the back-bone, after 
 which it should be removed from the water and drained, 
 else it will become water-logged and insipid. Potatoes and 
 other root vegetables should be cut into pieces of equal size, 
 that the heat may penetrate to the centre of each at the 
 
ALIMENTATION. 315 
 
 same time. If potatoes are peeled before boiling, the water 
 should be strongly salted to prevent the antiscorbutic salts 
 from being dissolved out. When a fork passes easily to 
 the centre, the water should be poured off and the vessel 
 replaced on the fire to get rid of superfluous moisture by 
 steaming. Beans, peas, rice, and other hard grains require 
 soaking in water before boiling. Milk, particularly if 
 thickened by the swelling starch cells of any of the meals 
 or flours, should be stirred constantly to prevent the scorch- 
 ing of the bottom layer; preferably, such preparations 
 should be made in a vessel having a water jacket. 
 
 567. In stewing meat, the small quantity of water used 
 is intended to be a part of the food. The meat is chopped 
 up to facilitate its disintegration, and the boiling is con- 
 ducted slowly and with care, to avoid scorching. 
 
 568. In making soup or leef stock, it is intended that the 
 whole of the soluble organic substances shall be transferred 
 to the water. Gelatin, dissolved from bones by seven or 
 eight hours' continued boiling, forms the basis of the soup; 
 but this is usually strengthened by the addition of meat 
 which, from its toughness, cannot be disposed of otherwise 
 to advantage. Gelatin is held by some physicians to be of 
 no value as a nutriment, but this seems inconsistent with 
 the results of every -day experience. Simmering, rather 
 than active boiling, is required in making soup ; froth and 
 grease should be skimmed off as they gather on the surface. 
 The stock should be kept for use in tin or- earthenware ves- 
 sels ; iron vessels give it an unpleasant taste. The soup is 
 completed by adding vegetables, cut into small dice, to 
 flavor and give substance. 
 
 569. In making beef tea, lean meat is chopped up finely 
 and simmered with water, a pint to a pound. Beef essence 
 consists of the juices collected by digesting the chopped 
 
316 ALIMENTATION. 
 
 meat in a water bath. The meat is usually placed in a 
 wide-mouthed bottle, which is securely corked, and cooked 
 in a kettle of boiling water. 
 
 570. Hot fat or lard is used as the means of communicat- 
 ing heat in the process of frying. The melted fat should be 
 hot enough to give out occasional puffs or jets of smoke be- 
 fore it is ready for the immersion of the articles to be fried. 
 The transmitted heat cooks the interior, and none of the fat 
 penetrates unless the temperature be too low. Meats should 
 be rolled in dry crumbs, cracker dust, flour, or corn-meal. 
 Food is also said to be fried when it is cooked in a pan 
 with merely enough of fat to prevent it from becoming 
 scorched and sticking to the hot metal. A fork should not 
 be used in turning meats, as the holes made by it permit 
 escape of the juices. 
 
 571. Broiling is generally conducted over a clear, smoke- 
 less fire by means of a supporting gridiron ; but if it be done 
 before instead of over the fire, the juices of the meat may be 
 collected in a dish and used for dressing. 
 
 572. Roasting is properly conducted in front of a clear, 
 hot fire, the roast swinging round by a mechanical contriv- 
 ance to present every part in sequence to the radiated heat. 
 A polished concave reflector on the off side concentrates the 
 rays on the meat, and a dish placed underneath collects the 
 liquid drips, which should be spooned up from time to time 
 and flushed over the roast. 
 
 573. Baked meats are now generally called roasts. The 
 oven is at a proper heat when the arm, bared to the elbow, 
 can be thrust in and held for about fifteen seconds without 
 discomfort. The meat, properly skewered and placed in a 
 roomy pan, requires frequent attention while in the oven. 
 If it be not basted or flushed with the melted fat from the 
 pan at short intervals, the juices from the interior will be 
 
ALIMENTATION. 317 
 
 evaporated, and the roast will become dry and insipid. 
 Meats are baked about fifteen minutes to the pound. 
 
 574. If flour be mixed with a little water into a stiff, 
 plastic mass, and then kneaded and teased with the fingers, 
 dipping it into water from time to time to wash away the 
 starch that exudes from it, there will be found to remain a 
 tough, elastic, grayish substance which has been called 
 gluten. The presence of at least ten per cent, of this sub- 
 stance in flour is essential to the making of good bread. 
 Besides its gluten and starch, flour contains a small 
 quantity of glucose, which, when mixed with yeast, becomes 
 transformed into alcohol and carbon dioxid. In bread- 
 making the flour is converted into a stiff dough by knead- 
 ing with water and yeast ; after which it is set aside over 
 night at about 75 Fahr. to ferment. If the temperature 
 be too low, fermentation will not take place ; if too high 
 or too long continued the dough will become sour from the 
 transformation of a part of the alcohol into vinegar. Dur- 
 ing the fermentation the dough rises by the development 
 of carbon dioxid in minute bubbles throughout its substance, 
 each bubble held in position by a cell-wall of the sur- 
 rounding gluten and starch. The mass is then kneaded over 
 again to perfect the mixture and break up any large cavi- 
 ties which may have formed, and is cut off into loaves of 
 the size desired. These are permitted to stand for half an 
 hour for the continuance of fermentation in the forms, after 
 which they are placed in the oven. The heat expands the 
 minute bubbles of gas which permeate the dough, and the 
 loaf swells correspondingly ; but this ceases as the moisture 
 becomes dissipated and the surface hard and brown. Dur- 
 ing the process the starch-cells swell and burst, and much 
 of their material becomes converted into glucose. Bread- 
 making transforms a stiff, solid mass of gluten and indi- 
 
318 ALIMENTATION. 
 
 gestible starch into a substance so porous that the liquids 
 of the alimentary apparatus can easily penetrate it. It 
 must not be forgotten, however, that all the advantages of 
 good bread are lost if it be eaten while still warm from the 
 oven. It is then in an unfinished state ; there is so much 
 moisture and plasticity in it that chewing, instead of break- 
 ing it up into minute particles, consolidates it again into a 
 heavy, glutinous mass. By the time it is thoroughly cold 
 this undesirable plasticity is lost. One hundred pounds of 
 flour yield about 133 pounds of bread. 
 
 575. Dough may be made porous also by mixing with it 
 certain substances which will permeate its mass with bub- 
 bles of carbon dioxid. Carbonate of ammonia is sometimes 
 used for this purpose. The heat of the oven liberates and 
 expands the gas, and at the same time dissipates the volatile 
 ammonia. But most of the baking-powders, as these sub- 
 stances are called, consist of cream of tartar and bicarbon- 
 ate of soda mixed with a proportion of corn-starch to keep 
 them from acting on each other until they are wanted. 
 These add to the bread a certain quantity of Eochelle salt 
 tar tr ate of soda and potash as the result of their com- 
 bination. Acid phosphate of lime and bicarbonate of soda, 
 with starch as a preservative, are sometimes used, the re- 
 sidual salts in this instance being phosphates of lime and 
 soda. Alum and bicarbonate are also used; part of the 
 sulphuric acid of the alum liberates the carbon dioxid, and 
 alumina remains as an insoluble and probably inert powder 
 along with the sulphates of potash and soda. Leavened or 
 fermented bread is more readily digested than that raised 
 with these powders, as during fermentation starch becomes 
 changed to a considerable extent into dextrin and glucose. 
 
I1STDEX TO PAEAGEAPHS. 
 
 A. 
 
 Abdomen, compression of, as a 
 mode of artificial respira- 
 tion, 419 
 
 contusions of, 837 
 wounds of, 399 
 Abscess, 340 
 Absorbent cotton in burns, 330 
 
 system, 220 
 
 Absorption from the stomach, 211 
 from the small intestine, 218 
 from the large intestine, 219 
 by the skin, 237 
 of putrefactive products of 
 
 wounds, 372 
 
 of catgut ligatures, 388, 389 
 induced by counter - irrita- 
 tion, 313 
 
 Acarus scabiei, 543 
 Accessory foods, 198 
 Accidents, etc. , management of, 
 
 264 
 etc., which call for artificial 
 
 respiration, 420 
 Accommodation of the eye, 252 
 Acid phosphate of lime in bak- 
 ing, 575 
 Acids, corrosive effects of, on 
 
 the skin, 332 
 poisoning by, 500 
 Aconite as a poison, 520, 507 
 
 Aconite as a remedy in poison- 
 ing, 530 
 
 Acromion process, fracture of, 
 
 454, 152 
 Acting Hospital Stewards, duties 
 
 of, 9 
 
 Actual cautery, in dog bites, 376 
 Administration building of gen- 
 eral hospitals, 114 
 Administrative system of the 
 
 human body, 244 
 Aeration of the blood in the 
 
 lungs, 225 
 ^Ether, inhalation of, 276, 277, 
 
 279 
 Affusion, cold, in asphyxia from 
 
 noxious gases, 420 
 Agriculture, a cause of malari- 
 ous exhalations, 71 
 Air, carbon dioxid in, 226 
 
 effects of deprivation of, 22T 
 exposure to, for the arrest of 
 
 bleeding, 386 
 furnace-heated, 113 
 respired ; effects of breath- 
 
 ing it, 228 
 respired, upward tendency 
 
 of, 231 
 
 sanitary analysis of, 229 
 volume of, required to ven- 
 tilate, 230 
 
320 
 
 INDEX TO PARAGRAPHS. 
 
 Air cells of lungs, 222 
 
 movement, during ordinary 
 
 breathing, 225 
 Air space in log huts for winter 
 
 use, 93, 96 
 
 in hospital wards, 113 
 Airing of bedding on transports, 
 
 108 
 
 of interior of huts, 94, 99 
 ward or barrack -rooms, ne- 
 cessity for, 85 
 Albumen of the blood, 170 
 as a food, 198 
 test for, in urine, 297 
 Albuminoids decomposed into 
 
 urea, 240 
 digestion of, in the small 
 
 intestine, 217 
 
 of food, solution of, in stom- 
 ach, 211, 212 
 in fresh meat, 199 
 in pork, 199 
 
 influence of cooking on, 564 
 Albuminuria in yellow fevers, 
 
 109 
 Alcohol in serpent bites, 377 
 
 insensibility from, 410 
 Alimentation, 198 
 Alkalies, poisoning by, 500 
 Alum in baking, 575 
 as a styptic, 383 
 Ambulances, cases that require 
 
 transportation in, 27 
 Ambulance boxes for emergency 
 supplies during service, 30 
 companies, 27 
 
 Ambulance officers, duties and 
 responsibilities of, 27, 31, 
 61 
 
 Ambulance stations during bat- 
 tle, 39, 42 
 
 train on the march, 31, 32 
 American National Red Cross, 56 
 Ammonia as a counter-irritant, 
 
 313, 317, 329 
 to the nostrils to promote 
 
 respiration, 419 
 poisoning by, 500 
 in serpent bites, 377, 379 
 Amoeboid movements, 172 
 Amputation, triangular bandage 
 
 on stump after, 370 
 Amputations, assistance required 
 
 during, 273 
 
 Anaesthesia, local, 280, 281 
 Anaesthetics, 276 
 Anastomosis, 187 
 
 venous, 193, 195 
 Animal heat, 243 
 Ankle, sprains of, 338 
 
 dislocation of, 498, 167 
 Anterior tibial artery controlled 
 
 by pressure, 367, 182 
 Antidotes, chemical, in poison- 
 ing, 503 
 
 Antimony as a poison, 515, 503 
 Aorta, 178, 181 
 
 Apomorphin as an emetic in poi- 
 soning, 523, 502, 522 
 Apoplexy, 403 
 Arachnoid membrane, 247 
 Areolar tissue, 143 
 Arm, fracture of, 455-459, 154 
 to arm vaccination, 547 
 sling for, 370 
 Army itch, 544 
 
 Arnica in contusions and sprains, 
 337, 338 
 
INDEX TO PARAGRAPHS. 
 
 321 
 
 Arrow wounds, 373 
 Arsenic as a poison, 509, 503, 504 
 Arsenical soap in toothache, 346 
 Arterial blood, 176, 188, 197 
 coats, retraction of, when 
 
 cut, 385 
 
 hemorrhage, 385 
 Arteries which can be com- 
 pressed, 367 
 enlargement and contraction 
 
 of, 185 
 
 Artery forceps, 273, 389 
 Articles of Geneva Convention, 
 
 54, 55 
 Artificial respiration, 416 
 
 respiration, conditions 
 
 which call for, 420 
 respiration in chloroform in- 
 sensibility, 278 
 respiration in cases of poi- 
 soning, 507, 508, 522, 523, 
 526, 527, 531 
 Asphyxia, 227, 416 
 
 from coal - gas, charcoal 
 
 fumes, etc., 420 
 Astigmatism, 257 
 Astragalus, 168 
 
 Astringents for capillary hemor- 
 rhage, 383 
 A-tent, 89 
 Atropin as a poison, 525 
 
 as a remedy in poisoning, 
 
 507, 508, 522, 523, 527 
 Attending surgeons at field divi- 
 sion hospitals, 30 
 Auditory canal, 259 
 Auricles of heart, 176 
 Autumnal fevers, causation of, 
 64-71 
 
 21 
 
 Axilla, 180 
 Axillary artery, 180 
 
 artery controlled by pres- 
 sure, 367 
 
 vein, 190 
 
 B. 
 
 Back-bone, 146 
 
 Bacteria of nitrification, 116 
 
 of putrefaction in food, 563 
 
 of putrefaction in wounds, 
 
 359, 362, 363 
 Baked meats, 573 
 Baking of bread, 574 
 
 powders, 575 
 
 Bandage, triangular, 370, 395 
 Bandages, roller, 439 
 
 starch, etc., 441 
 
 tailed, 441 
 Base hospitals, 110 
 Basilic vein, 194 
 Baths, 270 
 
 Bath-tub connections with soil- 
 pipe, 124 
 
 Battle, the field hospital during, 
 35-52 
 
 injuries and loss in, 27 
 Bayonet wounds, 355 
 Bed, preparation of, for patient, 
 
 268 
 Bedding of the field hospital, 
 
 30, 43 
 
 Bed-sores, 293 
 Bedsteads in temporary camps, 
 
 91 
 Beef essence, 569 
 
 stock, 568 
 
 tea, 569 
 Bees, stings of, 379 
 
322 
 
 INDEX TO PARAGRAPHS. 
 
 Belladonna as a poison, 525, 
 
 508 
 
 Bell-traps, 133 
 Bicarbonate of soda in baking, 
 
 575 
 
 Biceps muscle, 156, 180, 194 
 Bicuspids, 206 
 Bile, 216 
 
 Bite of rabid dogs, 376 
 Bladder, urinary, 239, 161 
 hemorrhage from, 295 
 Blank forms for reports, etc., 
 
 14-17 
 Blankets, airing of, 99 
 
 in the field hospital, 30 
 Bleeding from wounds, 367, 385 
 Blisters, 318 
 
 on burned or scalded sur- 
 faces, 330 
 on the feet, 353 
 introduction of medicine by 
 
 means of, 237 
 Blood, the, 169-172 
 
 alteration of, in sunstroke, 
 
 404 
 apoplectic extravasation of, 
 
 403 
 expectorated, in chest 
 
 wounds, 397 
 
 flow of, accelerated by mus- 
 cular action, 195 
 in the pleural cavity, 397 
 quantity transmitted to an 
 
 organ, 185, 215 
 in urine, 295 
 vomiting of, in poisoning, 
 
 509, 521 
 
 Blood-colored urine in malarial 
 fevers, 295 
 
 Blood -corpuscles, renovation of, 
 
 215 
 
 Bloodless operations, 275 
 Blood-letting, vein selected for, 
 . 194 
 
 Boiling as a cooking process, 566 
 influence of, on hard waters, 
 
 119 
 
 as a mode of purifying wa- 
 ter, 106 
 
 in water as a disinfecting 
 measure, 272, 535, 543, 
 550, 552, 554, 556 
 Boils, 341 
 
 blind, 342 
 Bone, 142 
 
 capillaries of, 188 
 forceps, 273 
 
 Books of record kept at hospi- 
 tals, 18, 134 
 Bovine lymph, 547 
 Bowels, condition of, related to' 
 
 varicose veins, 196 
 Brachial artery, 180 
 
 artery controlled by pres- 
 sure, 367 
 plexus, 248 
 Brain, the, 244-247 
 
 compression of, 401 
 concussion of, 401 
 congestion of, 402 
 influence of venous blood 
 
 on, 227 
 
 exposure of, in wou^jds, 447 
 Brassard of hospital corps, 54 
 Bread-baking, 574 
 Breast-bone, 151 
 Brigade hospitals, during war, 
 24, 25 
 
INDEX TO PARAGRAPHS. 
 
 323 
 
 Bright 's disease, 296 
 
 Broiling as a cooking process, 
 571 
 
 Bromid of potassium in poison- 
 ing, 508, 531 
 
 Bronchial breathing, 225 
 tubes, 222 
 
 Bruises. 337 
 
 Bubo, treatment by pressure, 327 
 
 Buffy coat of blood, 170 
 
 Bugs in the ear, 429 
 
 Bunions, 352 
 
 Burns, 329-331 
 
 C. 
 
 Calcaneum or heel-bone, 168 
 Camp of field hospital, estab- 
 lishment of, 33, 34 
 importance of site of, 62 
 change of site needful, 80, 
 
 102, 109 
 Camp-site, selection of, 72, 73, 
 
 109 
 
 Camp-grounds, old, objectiona- 
 ble, 73 
 
 Camp guard of field hospital, 34 
 Camp diseases, 75-86 
 Camps, cleanliness of, 101 
 
 sanitary care of, 107 
 Canine teeth, 205, 206 
 Cantharides as a counter-irritant, 
 
 318 
 
 as a poison, 519, 507 
 Capelline bandage, 394 
 Capillaries, 188 
 Capillary hemorrhage, 188, 382, 
 
 383 
 
 Carbolic acid in infectious dis- 
 eases, 536, 537 
 
 Carbolic acid as a poison, 522, 
 
 504, 507 
 
 acid in burns, 329 
 acid in toothache, 346 
 Carbolized catgut, 388 
 Carbonate of ammonia in bread- 
 making, 575 
 of soda in burns, 329 
 Carbon dioxid exhaled from the 
 
 lungs, 197, 229 
 insensibility from, 420 
 a measure of the vitiation of 
 
 respired air, 229 
 in bread-making, 574, 575 
 in air before and after breath- 
 ing, 226, 229 
 Carbonic oxid, insensibility 
 
 from, 420 
 Carbuncles, 343 
 Carcasses, disposal of, 103 
 Cardiac region, 177 
 Caries, 346 
 Carotid arteries, 180 
 
 artery controlled by pres- 
 sure, 367 
 Carpus, 158- 
 Carron oil in burns, 329 
 Cartilages of the air tubes, 222 
 of the joints, 153 
 of the ribs, 151 
 Casein as a food, 198 
 
 of milk, 200 
 Cases to be reported, 15 
 Castor oil in injuries of the eye, 
 
 332 
 Catgut ligatures, absorption of, 
 
 388 
 
 Cathartics, drastic, as poisons, 
 517 
 
324 
 
 INDEX TO PARAGRAPHS. 
 
 Catheter, in brain injuries, 401, 
 
 403 
 in fracture of the pelvis, 
 
 466 
 
 in fractures of the spine, 450 
 Catlin, 273 
 Cauterization of poisoned 
 
 wounds, 375-377 
 Cellular tissue, 143 
 Centigrade temperature scale, 
 
 287 
 
 Centipedes, stings of, 378 
 Cephalic vein, 194 
 Cerebral nerves, 244 
 Cerebrospinal meningitis in 
 
 overcrowded quarters, 85 
 Cervical nerves, 248 
 
 vertebrae, 146 
 Cess-pools, disinfection, of, 537 
 
 of general hospitals, 121 
 Chafing in the groins, 354 
 Chair for dental operations, 347 
 Chalk in cases of poisoning, 
 
 500, 504, 516 
 Chaplain of hospitals, duties of, 
 
 137 
 
 Charcoal in frost-bite, 335 
 Cheese, poisoning by, 532 
 Chemical analysis of drinking- 
 water, 118 
 Chest, triangular bandage for, 
 
 370 
 
 wounds of, 397 
 wounds, effects of, on respi- 
 ration, 227 
 Chicken-pox, 551 
 Chief Surgeon, duties of, 35, 39, 
 
 42, 46 
 Chilblains, 336 
 
 Chill, increased heat of body 
 
 during, 322 
 
 Chloral as a poison, 524, 508 
 as a remedy in poisoning, 
 
 508, 531 
 
 Chlorids in the urine, 241 
 Chlorinated solutions as disinfec- 
 tants, 536, 537, 550, 554, 558 
 Chloroform by inhalation, 276, 
 
 278 
 in cases of poisoning, 508, 
 
 531 
 
 in dislocations, 473, 491 
 Choking, artificial respiration 
 
 for, 420 
 
 by fragments of meat, 432 
 Cholera, 82, 559 
 Chronic inflammation, 327 
 Chyle, 218 
 
 Chyme, 211, 214, 218 
 Cicatrix of burns, 330 
 Cicatrization of wounds, 360 
 Cineritious matter of the brain, 
 
 246 
 
 Circulation of the blood, 174 
 systemic, 175-196 
 pulmonary, 197 
 portal, 192 
 collateral, 187 
 Cisterns, 116 
 Clavicle, 152 
 
 dislocation of, 477 
 fracture of, 452, 453 
 Cleanliness in the kitchen, 563 
 in the treatment of wounds, 
 
 open sores, etc., 282 
 personal, in winter quarters, 
 
 100 
 of troops on transports, 108 
 
INDEX TO PARAGRAPHS. 
 
 325 
 
 Clerical work, 14, 18, 58, 59, 134 
 Climatic influences, a cause of 
 
 camp diseases, 75 
 Clothing Account Book, 14, 18 
 fragments of, in wounds, 
 
 356 
 inadequate, a cause of camp 
 
 diseases, 75, 76 
 Clotting of blood, 170, 172 
 Clove -hitch, 483, 480, 491 
 Coagulability of fibrin, 170 
 
 of lymph, 220 
 Coagulated blood, arrest of 
 
 hemorrhage by, 385 
 Coagulation of blood, 170, 172 
 
 of chyle, 218 
 
 Coaptation of fractures, 436 
 Cocaine as an anaesthetic, 281 
 Coccyx, 147 
 Coffee as a remedy in poisoning, 
 
 507, 523, 525 
 
 Colchicum as a poison, 518 
 Cold in the treatment of inflam- 
 mation, 309 
 baths, 270 
 climates, food required for, 
 
 200 
 
 Colic from lead in drinking- 
 water, 120 
 Collapse, 304 
 
 from loss of blood, 368 
 in wounds of chest, 397 
 in cases of poisoning, 500, 
 506, 509, 510, 513, 515, 
 516-518, 520, 522, 528-532 
 Collar-bone, 152 
 
 dislocation of, 477 
 fracture of, 452, 453 
 Collateral circulation, 187 
 
 Colles's fracture, 460 
 Colocynth as a poison, 517 
 Color-blindness, 258 
 Colorless corpuscles of blood, 
 
 172 
 
 Comminuted fractures, 434 
 Common iliac arteries, 181 
 
 tent, 89 
 
 Complicated fractures, 434 
 Complications of wounds of 
 
 chest, 397 
 
 Compound fractures, 434 
 Compresses, 358 
 
 graduated, 384 
 Compression of brain, 401, 445, 
 
 446 
 
 Concave glasses to aid sight, 255 
 Concentration of troops, effects 
 of, on hospital department, 22 
 Concussion of brain, 401, 445 
 Condemnation of medical prop- 
 erty, 17 
 
 Condiments, 198 
 Condyles of the femur, 165 
 of the humerus, 155, 156 
 of the humerus, fracture of, 
 
 455, 456 
 
 Cone for inhalation of ether, 279 
 Congestion, 305, 185 
 chronic, 327 
 of the brain, 402 
 Congestive fevers, in over- 
 crowded quarters, 85 
 malarial fevers, causation of, 
 
 64-71 
 Conjunctivitis, 424, 425 
 
 caused by gonorrhoeal mat- 
 ter, 425, 282 
 Connective tissue, 143 
 
326 
 
 IN^DEX TO PARAGRAPHS. 
 
 Contagious character of diseases 
 iii overcrowded quarters, 
 85 
 
 diseases, 83-85, 543-560 
 diseases should be recog- 
 nized early, 542 
 Contractility of arteries, 185 
 
 of muscles, 143-145 
 Contraction of cicatrix in burns, 
 
 330 
 
 Contused wounds, 355-363 
 Contusions, 337 
 
 exudations in, 363 
 Convex glasses to aid sight, 254, 
 
 256 
 
 Convolutions of the brain, 245 
 Convulsions from disordered di- 
 gestion, 409 
 of epilepsy, 407 
 of sunstroke, 404 
 in teething children, 205, 
 
 409 
 
 Cooking, 562 
 Cooks of field hospitals, duties 
 
 of, 31, 34, 37 
 
 Copper, salts of, as poisons, 514 
 Corium, 233 
 Cornea, 251, 257 
 
 sloughing of, 425 
 Corns, 351 
 Corpuscles of the blood, 171, 172 
 
 of lymph, 220 
 Corrosive sublimate decomposed 
 
 by metals, 536 
 sublimate as a disinfectant, 
 536, 537, 550, 552, 554, 
 555, 558 
 
 sublimate as a poison, 593, 
 510 
 
 Corrosive acids, effects of, on the 
 
 skin, 332 
 action of strong acids and 
 
 alkalies, 500 
 Cotton, wadding or batting as a 
 
 padding for splints, 438 
 Cotton-wool in burns, 329, 330 
 Cotyloid cavity, 164 
 Council on the effects of deceased 
 
 soldiers, 14 
 
 Counter-extension, 467, 473 
 Counter-irritation in inflamma- 
 tion, 313, 320 
 in chronic inflammations, 
 
 328 
 
 Cowhorn forceps, 347 
 Cradles, 357 
 Cranium, bones of, 148 
 
 fractures of, 445 
 Cream of tartar in baking, 575 
 Crepitus in fractures, 435 
 Croton oil as a counter-irritant, 
 
 320 
 
 as a poison, 517 
 Croup, suffocative paroxysms of, 
 
 313 
 
 Crusta petrosa, 208 
 Crystalline lens, 251 
 Cupping-glasses, 312 
 Cuticle, 233, 234 
 
 development of, in vesicated 
 
 burns, 330 
 Cut throat, 396 
 
 Cyanid of potassium as a poison, 
 526 
 
 D. 
 
 Dead, disinfection of the bodies 
 of the, 536 
 
INDEX TO PARAGRAPHS. 
 
 32? 
 
 Dead house of General Hospi- 
 tals, 114 
 Deafness attending sore throat, 
 
 259 
 
 Death from chloroform inhala- 
 tion, 278 
 signs of, 421 
 
 in fractures of the spine, 450 
 Deaths and interments, Register 
 
 of, 18 
 sudden, in camp, due to 
 
 overcrowding, 85 
 en route to base hospitals, 
 
 how recorded, 47 
 Decay of vegetation, influence 
 of, on malarious exhalations, 
 69 
 Decomposition as a sign of 
 
 death, 421 
 Deficiency of food, effects of, 
 
 203 
 
 Deformities caused by the con- 
 traction of burns, 330 
 Deformity in fractures and dis- 
 locations, 435, 473 
 Deglutition, 204 
 Delirium attending hemorrhage, 
 
 368 
 
 tremens, 412 
 
 Deltoid muscle, 153, 154 
 Dental pulp, 208, 209 
 Dentine, 208 
 Derma, 233 
 Descriptive Lists and Books, 17, 
 
 18 
 
 Desquamation after inflamma- 
 tion, 305 
 in burns, 329 
 in frost-bite, 334 
 
 Destruction by fire as a disinfect- 
 ing agency, 541, 550 
 Detached troops, hospital provi- 
 sion for, 53 
 Dextrin, 564, 218 
 
 produced by action of saliva, 
 
 210 
 
 Diabetes, 296, 298 
 Diaphragm, 161, 223 
 Diarrhoea, association of, with 
 
 scurvy, 77 
 causation of, 76, 202 
 caused by hard waters, 119 
 in teething children, 205 
 Diet, deficient, effects of, 77, 203 
 errors of, a cause of boils, 
 
 341, 342 
 errors of, a cause of camp 
 
 diseases, 76 
 
 full, when required, 201 
 of invalids, 283 
 low, as a remedial measure, 
 
 326 
 
 of patients in hospital, 201 
 variety of, necessity for, 200 
 Digestion in the large intestine, 
 
 219 
 
 in the small intestine, 217 
 in the stomach, 211-213 
 Digitalis as a poison, 530, 508 
 as a remedy in cases of poi- 
 soning, 507, 508, 520, 529 
 Dining-room of General Hospi- 
 tals, 114 
 Discharge papers of enlisted 
 
 men, 14 
 Discipline of General Hospitals, 
 
 136 
 Disinfection, 272, 535 
 
328 
 
 INDEX TO PARAGRAPHS. 
 
 Disinfection by boiling water, 
 
 535, 550, 552, 554, 556 
 by carbolic acid, 536, 537 
 by chlorinated lime or soda, 
 
 536, 537, 549, 554, 558 
 by corrosive sublimate, 536, 
 
 537, 549, 552, 554, 558 
 by destruction by fire, 541, 
 
 550 
 
 by dry heat, 539 
 
 by sulphur vapor, 540, 550, 
 554, 556 
 
 by steam, 539, 550 
 
 in chicken-pox, 552 
 
 in cholera, 559 
 
 of excreta, 536 
 
 in glanders, 381 
 
 of hands, dressings, etc. , in 
 surgical work, 272 
 
 in itch, 543 
 
 in measles, 556 
 
 of privy-vaults or cesspools, 
 537 
 
 in scarlet fever, 554 
 
 in small-pox, 550 
 
 in typhoid fever, 558 
 
 in yellow fever, 559 
 Dislocations, 472-499 
 Dislocation, prevention of recur- 
 rence, 475-477, 480, 481, 495 
 
 complicated, 474 
 
 symptoms of, 473 
 
 treatment of, 473 
 Displacement of bone in frac- 
 tures, 435 
 
 danger of, in fractured pel- 
 vis, 466 
 
 danger of, in fractures of 
 the spine, 449, 450 
 
 Dissection wounds, 375 
 Distilled water in cholera or 
 
 yellow-fever epidemics, 560 
 Diuretics in inflammation, 321 
 Division hospital, capacity of, 
 
 30 
 
 hospital, personnel of, 30 
 hospital, on the march, 31 
 hospital in battle, 35-52 
 Dog bites, 376 
 
 Dorsal artery of the foot, con- 
 trolled by pressure, 367, 
 182 
 
 nerves, 248 
 vertebrae, 146 
 
 Double inclined plane for frac- 
 tures, 469, 471 
 Douche, cold, in poisoning, 523, 
 
 526 
 
 Douching for the arrest of bleed- 
 ing, 386 
 Drainage, 127 
 natural, 63 
 for sanitary purposes a cause 
 
 of malaria, 66, 71 
 surface, of camp, 94, 98 
 Drains of general hospitals, 121 
 for sewage and waste water, 
 
 122, 127-129 
 from wounds, 359 
 Draughts in ventilation, 230 
 Dressings, disinfection of, 272 
 Drill, manual, 19, 20 
 Drowning, resuscitation of the, 
 
 420 
 Drum-corps, duties of, during 
 
 battle, 38 
 
 Drum of the ear, 259 
 Dry cupping, 312 
 
ItfDEX TO PARAGRAPHS. 
 
 329 
 
 Dryness of camp site essential 
 
 to health, 63 
 
 Dugouts as winter quarters, 95 
 Dulness on percussion, 161 
 Dura mater, 247 
 Dust, influence of, in camps, 73 
 Dysentery, 81 
 
 E. 
 
 Ear, 259 
 
 foreign bodies in, 429 
 method of syringing, 430 
 Ears, bleeding from, in fractured 
 
 skull, 445 
 Earth-closets, 121 
 Ecraseur, 385 
 
 Education of members of Hospi- 
 tal Corps, 12 
 Effusion of serum, 173 
 Egg albumen in cases of poison- 
 ing, 500, 503, 510, 514, 522 
 Elbow-joint, dislocation of, 481 
 
 fractures near, 456, 457 
 Elevators, dental, 349 
 Emetics, in alcoholic coma, 410 
 in opium poisoning, 523 
 in poisoning, 502, 504, 509- 
 
 520, 525-527, 529-532 
 Emmetropia, 253 
 Emphysema, 396, 397 
 Enamel of teeth, 208, 209 
 Engorgement of blood-vessels, 
 
 relief of, 307-320 
 Epidemic disease, specially re- 
 ported, 15 
 
 disease prevented by cook- 
 ing, 564 
 
 of measles in newly raised 
 regiments, 84 
 
 Epidemic of typhoid fever in 
 
 newly raised regiments, 80 
 Epigastrium, 151, 161 
 Epilepsy, 407, 408 
 Epistaxis, 283 
 Epsom salt in poisoning, 504, 
 
 511, 521, 522 
 
 Equipment of hospital corps, 21 
 Eruption of chicken-pox, 551 
 of measles, 556 
 of roseola, 555 
 of scarlet fever, 553 
 of small-pox, 546 
 of the teeth, 205, 206 
 Erysipelas, 372, 113 
 Escharotics in poisoned wounds, 
 
 395 
 
 Esmarch's bandage, 275 
 Estimates for repairs, etc., to 
 
 post hospitals, 16 
 Ether, inhalation of, 276, 277, 
 
 279 
 
 Eustachian tube, 259 
 Eversion of the foot in disloca- 
 tion of the hip-joint, 489 
 of the foot in fractured fe- 
 mur, 467 
 Excreta, disinfection of, 536, 537, 
 
 109 
 
 Excretion, 221-242 
 Executive officer of a general 
 
 hospital, duties of, 134 
 officer of field division hos- 
 pital, 29 
 Exercise, food required for, 200, 
 
 201 
 
 influence of, on the flow of 
 blood through the veins, 
 195 
 
330 
 
 IHDEX TO PARAGRAPHS. 
 
 Exercise, passive, 328 
 Exhalations, cutaneous, quanti- 
 ty of, 236 
 
 from moist soils, 64, 71 
 Exhaustion from loss of blood on 
 
 marches, 415, 32 
 Experience, importance of prof- 
 iting by, 23 
 
 Expiration, mechanism of, 223 
 Extemporized general hospitals, 
 
 111 
 
 Extension in reducing disloca- 
 tions, 473 
 
 by weights in cases of frac- 
 tured thigh-bone, 468 
 Extensor muscles of the upper 
 
 extremity, 156, 159 
 tendon of the thigh, 166 
 Extensors of the toes, 167 
 External iliac arteries, 181 
 jugular vein, 193 
 saphenous vein, 194 
 Extraction of teeth, 347-349 
 Extravasation of blood, 173 
 Exudation, 173 
 
 absorption of, by massage, 
 
 328 
 Eye, 251-258 
 
 drops, mode of using, 423 
 foreign bodies in, 422 
 injury to, by acids, 332 
 teeth, 205, 206 
 
 Eyes, glazing of, as a sign of 
 death, 421 
 
 F. 
 
 Face, bones of, 149 
 Facial nerve, 249 
 
 Faeces, 219 
 
 involuntary passage of, 290, 
 
 407, 450 
 Fahrenheit's temperature scale, 
 
 '287 
 Fainting, 302 
 
 on forced marches, etc., 415 
 Faintness from loss of blood, 
 
 266, 368 
 Farcy, 380, 381 
 Fat, emulsification of, in the 
 
 small intestine, 216, 218 
 as a food, 198, 199 
 Fatty layer underlying the skin, 
 
 232 
 
 Fauces, 204 
 Felon, 344 
 Felt, perforated, as a material 
 
 for splints, 437 
 
 Female nurses in general hospi- 
 tals, 114 
 Femoral artery, 181, 182 
 
 artery, controlled by pres- 
 sure, 367 
 hernia, 163 
 vein, 191 
 Femur, 165 
 
 fractures of, 467-469 
 dislocation of head of, 487- 
 
 495 
 Fermentation in the soil a cause 
 
 of malaria, 65 
 Festering of wounds, 362 
 Fever, inflammatory, 322 
 Fibrin of the blood, 170 
 Fibrinous principles of food, 
 
 198 
 
 Fibrous tissue, 144 
 Fibula, fractures of, 470 
 
INDEX TO PARAGRAPHS. 
 
 331 
 
 Field dressing of gunshot 
 
 wounds, 369 
 hospitals, 22-24 
 hospital during battle, 35-52 
 hospital on the march, 31-34 
 hospital work, object of, 45 
 hospitals during winter 
 
 camps, etc., 57 
 Return of killed, wounded, 
 
 and missing, 59 
 Service, organization for, 
 
 22-30 
 
 tourniquet, 387 
 Final statements of enlisted 
 
 men, 14 
 
 Finger nails, growth of, 174 
 ligature on, as evidence of 
 
 death, 421 
 
 pressure for arrest of hemor- 
 rhage, 386 
 
 tips, sensitiveness of, 234 
 bones of, 158 
 dislocation of, 484 
 fracture of bones of, 465 
 Fire, precautions against, in hos- 
 pitals, 115, 140 
 First aid in accidents, 264 
 
 aid in gunshot wounds, 365 
 dressing - stations during 
 
 battle, 39, 41, 42 
 Fish, boiling of, 566 
 
 bones in gullet, 432 
 Flies, infections carried by, 109 
 Floating ribs, 151 
 Flour, use of, in burns, 329, 330 
 Flour and water in poisoning, 
 
 503, 510, 514, 522 
 wheat, composition of, 198, 
 199 
 
 Fluctuation, 340 
 Fly-blisters, 318 
 Fogs, connection of, with ma- 
 laria, 67 
 
 Foliage, green, influence of, on 
 
 malarious exhalations, 67, 69 
 
 Follicles of small intestine, 214 
 
 of stomach, 211 
 Food, effects of deficiency of, 
 
 203 
 
 effects of excess of, 202 
 improper, 76 
 of invalids, 283 
 propagation of typhoid fever 
 
 by, 558 
 
 digestibility of different ar- 
 ticles of, 212 
 Foot, dislocations of, 499 
 
 triangular bandage for, 370 
 Forced respiration, 223 
 Forearm, fractures of, 460, 463 
 Foreign bodies, intrusion of, into 
 
 the system, 422-433 
 matter in wounds, 356, 358, 
 
 369, 397, 399 
 Four-tailed bandage, 394, 395, 
 
 448 
 
 Fractures, 434-471 
 Fracture-box for fractures of the 
 
 leg, 471 
 Fractures, gunshot, of the leg, 
 
 471 
 
 progress of union in, 448 
 symptoms of, 435 
 Fresh-air inlet into main drain 
 
 of buildings, 129 
 Friction in chronic inflamma- 
 tions, 328 
 Frost-bites, 334 
 
332 
 
 INDEX TO PARAGRAPHS. 
 
 Fruits, spoiled, bad effects of, 
 
 532 
 
 Frying as a cooking process, 570 
 Fund, hospital, 14, 139, 201 
 Fumigation by burning sulphur, 
 
 540, 550, 554, 556 
 
 G. 
 
 Gall-bladder, 216 
 Ganglia, sympathetic, 244, 262 
 Gangrene, in frost-bite, 334, 335 
 less common in hand than 
 
 foot, 187 
 hospital, 113 
 Garters a cause of varicose 
 
 veins, 196 
 Gases, asphyxia from noxious, 
 
 420 
 
 Gastric juice, 211 
 Gelatin as a nutrient, 568 
 
 in bone, 142 
 
 General Hospitals, plans of, 111 
 Geneva Convention, Articles of, 
 
 54, 55 
 
 German measles, 557 
 Germs, destruction of, by cook- 
 ing, 564 
 
 Glanders, 380, 381 
 Glands, lymphatic, 220 
 of the mesentery, 218 
 sebaceous, 235 
 sudoriparous, 236 
 Glauber's salt as an antidote in 
 
 poisoning, 504, 511 
 Glenoid cavity, 152, 155 
 Glucose, 564, 574 
 
 produced by action of saliva, 
 
 etc., 210, 217, 218 
 Gluteal muscles, 165 
 
 Gluten as a food, 198 
 
 of wheat flour, 574, 199 
 Graduated compresses, 384 
 Granulation, 359 
 Granulations, indolent, 361 
 Gravel, 299 
 Gravitation, influence of, on the 
 
 circulation, 308 
 
 Gray matter of the brain, 246, 263 
 
 matter of the spinal cord, 248 
 
 Grease in kitchen and pantry 
 
 sink-traps, 124 
 Green blindness, 258 
 Gristle, 151 
 Gumboils, 345 
 Gums, lancing of, in teething 
 
 children, 205, 407 
 Gunshot wounds, 364-371 
 Gutta-percha filling for teeth, 
 
 346, 350 
 splints, 437 
 
 H. 
 
 Haemoglobin, 171 
 Haemorrhoids, 196 
 Haemothorax, 397 
 Hair follicles, 235 
 Hall's method of artificial respi- 
 ration, 418 
 
 Hamstring muscles, 166 
 Hand, pronation and supination 
 of, 157, 158 
 
 triangular bandage for, 370 
 Hands, disinfection of the, 272 
 Hard corns, 351 
 Hardness of waters, 119 
 Head, bandages for, 394, 395 
 
 wounds of, 393 
 Heart, 175-177 
 
INDEX TO PARAGRAPHS. 
 
 333 
 
 increased action during ex- 
 ercise, 195 
 cessation of movements, a 
 
 sign of death, 421 
 nerves of, 262 
 
 Heat as an aid to ventilation, 231 
 in the preparation of food, 
 
 564, 565 
 
 in the treatment of inflam- 
 mation, 310 
 animal, 243 
 
 dry, as a disinfectant, 538 
 febrile, 322 
 Heat-stroke, 404 
 
 and ventilation of pavilion 
 
 wards, 112 
 
 Hellebore as a poison, 529, 508 
 Hemiplegia, 291 
 Hemispheres of the brain, 245 
 Hemlock as a poison, 527, 508 
 Hemorrhage, 381-392 
 arterial, 385 
 capillary, 188, 382, 383 
 venous, 384 
 danger of recurrence during 
 
 reaction, 390, 303 
 from collateral circulation, 
 
 187, 388, 392 
 intermediate, 391 
 nature's modes of arresting, 
 
 385 
 
 Hemorrhoids, 196 
 Hernia, 162, 163 
 Hip, triangular bandage for, 370 
 Hip-bones, 164 
 Hip-joint, dislocations of, 485- 
 
 495 
 
 Hopper water-closet, 123 
 Horses, glandered, 380, 381 
 
 Hospital boats and cars, 110 
 
 Corps, enlistments for, 3 
 
 Corps, instruction of, 4, 12 
 
 Corps, organization for field 
 service, 27-30 
 
 Corps, reports of, 14 
 
 Corps, uniform, etc., of, 21 
 
 fever, 85 
 
 fund, statement of, 14 
 
 gangrene, 372, 113 
 
 provision for detached 
 troops, 53 
 
 savings, 201 
 
 Stewards, appointment and 
 duties of, 7-10 
 
 Stewards, duties of, at field 
 division hospitals, 29, 30 
 
 Stewards, number of, at di- 
 vision hospitals, 28 
 
 Stewards, number of, al- 
 lowed to posts, 8 
 
 Stewards, number of, with 
 ambulances in time of 
 war, 27 
 
 Stewards, qualifications of, 
 10 
 
 Stewards' quarters, esti- 
 mates for, 16 
 
 Stewards, re-examination of, 
 
 prior to re-enlistment, 7 
 Hospitals, Base, 110 
 
 Field, 25-52 
 
 General, 110-140 
 
 Post, 1-21 
 
 Regimental, inefficiency of, 
 
 24 
 Hot baths, 270 
 
 water as a counter-irritant, 
 320 
 
334 
 
 INDEX TO PARAGRAPHS. 
 
 Houses near field hospitals, 36, 
 
 44, 51 
 
 Humanized vaccine, 547 
 Humerus, 155 
 
 head of, dislocation down- 
 ward, 477-480 
 fracture of, 455-459, 154 
 Huts for troops during winter, 
 
 92-96 
 Hydrochloric acid, burns by, 
 
 332 
 Hyoscyamus as a poison, 525, 
 
 508 
 
 Hypermetropia, 256 
 Hypodermatic injection, 502 
 Hypodermic syringe, disinfec- 
 tion of, 272 
 
 Ice, use of, in irritant poisoning, 
 
 506 
 Iced water, objections to use of, 
 
 in heat-stroke, 406 
 Identification cards, 15 
 Ileo-csecal valve, 219 
 Ilium, 164 
 
 Immovable dressings for frac- 
 tures, 440-443 
 
 dressings for sprains, 338 
 Impacted fractures, 434 
 Incised wounds, 355-357 
 Incisors, 205, 206 
 Indolent sores, treatment of, 328 
 Infection, 543-560 
 Inferior vena cava, 191, 192 
 Inflammation, 301-326 
 
 chronic, 327, 328 
 
 local characteristics of, 305 
 
 treatment of, 306-321 
 
 Inflammations, special ; their 
 symptoms and treatment, 329- 
 354 
 
 Inflammatory fever, 322-326 
 Information slips, 18 
 Inguinal hernia, 163 
 Insects in the ear, 429 
 Insensible perspiration, 236 
 Insensibility, causes of, 400-415 
 by anaesthetics, 278 
 from alcohol, 410 
 from apoplexy, 403 
 from cold, 413 
 from concussion of the brain, 
 
 401 
 from congestion of the brain, 
 
 402 
 from compression of the 
 
 brain, 401 
 from epilepsy, 407 
 from fainting, 415 
 from interference with the 
 
 respiration, 414 
 from narcotic poisoning, 523 
 from sunstroke, 404 
 Inspection of troops on trans- 
 ports, 108 
 
 monthly sanitary, 16 
 of camps, 107 
 
 Inspiration, mechanism of, 223 
 Instillation of eye-drops, 423 
 Instruments, surgical, disinfec- 
 tion of, 272 
 Intelligence, seat of the, 246, 
 
 262, 263 
 
 Intermediary hemorrhage, 391 
 Intermittent fevers, causation 
 
 of, 64, 71 
 Internal iliac arteries, 181 
 
INDEX TO PARAGRAPHS. 
 
 335 
 
 Internal saphenous veins, 194, 
 196 
 
 Intestines, position of, in abdo- 
 men, 161 
 
 Inventory of effects, 14 
 
 and Inspection Reports, 17 
 
 Inversion of the foot in disloca- 
 tions of the hip- joint, 487, 
 488 
 
 Involuntary muscles, 143 
 
 lodid of potassium in chronic in- 
 flammations, 328 
 
 Ipecacuanha in poisoning, 502 
 
 Iris, 251 
 
 Iron, hydrated oxid of, as an 
 antidote in poisoning, 504, 509 
 
 Irreducible hernia, 163 
 
 Irrigation of wounds, 362 
 
 Irritant poisons, 509-518 
 
 poisons having a specific ac- 
 tion, 519-522 
 
 Ischium, 164 
 
 Isolation in infectious diseases, 
 546 
 
 Issues, counter-irritation by, 319 
 
 Itch, 543 
 
 J. 
 
 Joints, 153 
 
 Jugular veins, 190, 193 
 
 K. 
 
 Kidneys, position of, 161 
 hemorrhage from, 295 
 regulators of the animal 
 
 heat, 243 
 Killed, proportion of, to 
 
 wounded in battle, 27 
 Kitchen refuse of regimental 
 camps, 103 
 
 Kitchen sinks, connection of, 
 
 with soil-pipes, 124 
 Kitchens of General Hospitals, 
 
 114, 115 
 
 Knapsack-room of hospitals, 114 
 Knee-cap, 166 
 
 dislocation of, 496 
 Knee-joint, 166 
 
 dislocation of, 497 
 
 sprains of, 338 
 
 Lacerated wounds, 358 
 
 wounds, relative infre- 
 quency of bleeding from, 
 385 
 
 Lacteals, 218, 220 
 Lactose, 200 
 Large intestine, 161 
 Larynx, 150 
 
 foreign bodies in, 431 
 in scalds of throat, 333 
 suffocation in diseases of 
 
 the, 227 
 Latrines, 131 
 
 of general hospitals, 121 
 Laughing-gas, inhalation of, 276 
 Laundresses, liability of, to ty- 
 phoid infection, 558 
 Laundry, connections with soil- 
 pipes, 124 
 
 of general hospitals, 114, 115 
 Lavatories, company, in winter 
 
 camps, 100 
 
 Lead lotions in rubefacience, 329 
 pipes, action of drinking- 
 water on, 120 
 
 subacetate, in eye inflamma- 
 tions, 424 
 
336 
 
 INDEX TO PARAGRAPHS. 
 
 Leaks in plumbing work, 126 
 
 Leather splints, 437 
 
 Leavened bread, 574 
 
 Leeches, 311 
 
 Leg, fractures of, 470-472 
 
 Lemon juice in cases of poison- 
 ing, 500 
 
 Lice, 544, 545 
 
 Ligaments, 153 
 
 Ligation of arteries, 388, 389 
 
 Ligatures in poisoned wounds, 
 375, 377 
 
 Limbs, triangular bandage for, 
 370 
 
 Lime-water test for air, 229 
 
 Line of battle, first aid given on, 
 39, 40 
 
 Liniments, use of, 328 
 
 Lint as padding for splints, 438 
 
 Liquor ferri subsulphatis as a 
 
 styptic, 383 
 potassse in poisoned wounds, 
 
 378 
 sanguinis, 170 
 
 Liston's splint, 467 
 
 Liver, actions of, 240 
 blood-vessels of, 192 
 position of, 161 
 
 Location of field hospitals dur- 
 ing battle, 35, 36 
 
 Log huts as quarters, 93, 96 
 
 Loins, sprains of, 339 
 
 Long-sightedness, 256 
 
 Looking-glass, evidence of life 
 by means of a, 421 
 
 Loop bandage, 438 
 
 Loss, percentage of, in battle, 
 27 
 
 Lower jaw, dislocation of, 476 
 
 Lower jaw, fracture of, 448 
 
 Lumbar nerves, 248 
 vertebrae, 146 
 
 Lungs, capillaries of, 197 
 
 hemorrhage from the, 383 
 to remove water from, in 
 cases of drowning, 420 
 
 Lymph, 220 
 
 Lymphatics, inflammation of, 
 "375 
 
 Lymphatic system, 220 
 
 M. 
 
 Maggots in the nose, 428 
 Magnesia in cases of poisoning, 
 
 500 
 
 Malaria, diseases caused by, 64 
 generation, evolution, and 
 
 diffusion of, 64-71 
 generated in huts, 95 
 Malleoli, internal and external, 
 
 167 
 
 Manipulation in reducing dislo- 
 cations, 473 
 
 Many-tailed bandage, 441 
 March, field hospital on the, 
 
 31-34 
 
 Marches in hot climates, 109 
 Marshall Hall's method of arti- 
 ficial respiration, 418 
 Massage, 328 
 Mastication, 204 
 Mattresses, disinfection of, 541 
 Measles, 556 
 
 malignant, in overcrowded 
 
 quarters, 85 
 
 susceptibility of young sol- 
 diers to, 84 
 Meat, cooking of, 566 
 
INDEX TO PARAGRAPHS. 
 
 337 
 
 Meat, dried, 564 
 
 fresh, constitution of, 198, 
 
 199 
 spoiled, bad effects from, 
 
 532 
 
 Medical History of Post, 16, 18 
 officer the sanitary officer of 
 
 military camps, 107, 109 
 officer, visits of, to the post 
 
 hospital, 11 
 officers, duties of, on the 
 
 line of battle, 41 
 officers, duties of, at ambu- 
 lance stations, 42 
 officers at field division hos- 
 pitals during battle, 43, 44 
 officers in charge of wounded 
 
 en route to base, 46, 47 
 officers supervise the instruc- 
 tion of the members of the 
 Hospital Corps, 12 
 Medullary matter of the brain, 
 
 246 
 
 Mercurial vapor-bath, 328 
 Mercury absorbed by the skin, 
 
 237 
 
 administration of, in syph- 
 ilitic diseases, 238 
 Mesenteric glands, 218 
 Mesentery, 214 
 Metacarpal bones, 158 
 
 bones, fracture of, 464 
 Metatarsal bones, 168 
 Meteorological report, 16, 18 
 Miasms from the human body, 85 
 
 generated in huts, 95 
 Middle ear, 259 
 
 Milk in cases of poisoning, 500, 
 510, 514, 522 
 
 Milk, a perfect food for the 
 
 child, 200 
 teeth, 205 
 Mineral salts in water supplies, 
 
 119 
 
 Mists, connection of, with ma- 
 laria, 67 
 
 Moisture needful for the genera- 
 tion of malaria, 65 
 Molar teeth, 205, 206, 209 
 Monsel's solution, 383 
 Monthly Personal Reports, 14 
 Reports of Personnel and 
 
 Transportation, 14 
 Reports of Physical Exam- 
 ination of Recruits, 15 
 Reports of Sick and Wound- 
 ed, 15, 59 
 
 Sanitary Reports, 16 
 Morning Report Book, 18 
 
 Report of the Hospital 
 
 Corps, 14, 18 
 
 Report of Sick and Wound- 
 ed, 15, 18 
 
 Morphia in cases of poisoning, 
 500, 506, 509, 515, 517-519, 
 521, 529 
 
 Motor nerves, 249 
 Mucilaginous drinks in poison- 
 ing, 500, 506, 509, 519, 521 
 Mucous membrane of air pas- 
 sages, 222 
 
 membrane of alimentary ca- 
 nal, 204 
 membrane of small intestine, 
 
 214, 218 
 
 membrane of stomach, 211 
 membrane of the urinary 
 bladder, 239 
 
338 
 
 INDEX TO PARAGKAPHS. 
 
 Mucous membrane, stimulant 
 
 treatment of, 328 
 Mucus, 204 
 Mud in camps, 73 
 Multicuspids, 206 
 Muscles, 143 
 
 disintegration of, by use, 240 
 spasmodic quivering of, as 
 
 evidence of life, 420 
 Muscular coat of arteries, 184, 
 
 185, 385 
 
 contraction in cases of frac- 
 ture, 468 
 
 Mushrooms, poisoning by, 532 
 Musicians during battle, 38 
 Mustard, counter-irritant action 
 
 of, 329 
 as an emetic in poisoning, 
 
 502 
 
 plasters, 316, 313 
 Muster and Pay Rolls, 14 
 Myopia, 255 
 
 N. 
 Narcotic poisoning, 523-525, 
 
 508 
 
 Nasal cavity, maggots in, 428 
 Nauseants as febrifuge remedies, 
 
 321 
 
 Navel, 161, 162 
 Nerves, 244 
 
 of motion, 249 
 of sensation, 249 
 Night air, harmful influence of, 
 
 71 
 Nitrate of silver as a poison, 
 
 512, 504 
 
 of silver in poisoned wounds, 
 375-376 
 
 Nitrate of silver to proud flesh, 
 
 361 
 
 of silver eye-drops, 424, 425 
 Nitric acid, burns by, 332 
 Nitrite of amyl in poisoning, 508, 
 
 531 
 
 Nitrogenous food, 198 
 Nitrous oxid gas, inhalation of, 
 
 276 
 
 Non-nitrogenous food, 198 
 Nose, bleeding from the, 383 
 
 foreign bodies in, 427 
 Nurse, value of, depends upon 
 
 his knowledge, 269 
 Nurses of field hospitals, duties 
 
 of, 31, 34, 37 
 
 O. 
 Oakum as padding for splints, 
 
 438 
 
 Obstruction of veins, 195, 196 
 Odors, foul, bad effects of, in 
 
 camps, 76 
 
 (Esophagus, 150, 204 
 Officer of the Day of general 
 
 hospitals, 136 
 of the Day in military 
 
 camps, 101 
 
 Officers' quarters at general hos- 
 pitals, 114 
 Oil of bitter almonds as a poison, 
 
 526 
 olive, in injuries of the eye, 
 
 332 
 in cases of poisoning, 500, 
 
 506, 507, 519, 521 
 of vitriol, burns by, 332 
 Olecranon process, 156 
 Olfactory nerve, 260 
 
INDEX TO PARAGRAPHS. 
 
 339 
 
 Operating-room in general hos- 
 pitals, 114 
 
 staff of field hospitals, 43-45 
 Ophthalmia, purulent, 425 
 Opium as a poison, 523, 508 
 as a remedy in cases of poi- 
 soning, 500, 506, 509, 515, 
 517-519, 521, 529 
 Order and Letter Book, 18 
 Organic matter in drinking- 
 water, 106, 118 
 matter in the generation of 
 
 malaria, 65 
 matter in the perspiration, 
 
 236 
 
 matter in respired air, 228 
 Organization for war service, 22 
 Organs of the body, 141 
 
 of the senses, 250-261 
 Overcrowding, progressive ef- 
 fects of, 85, 86, 97 
 Overflow-pipes to plumbing fix- 
 tures, 124 
 
 Oxalic acid as a poison, 516, 504 
 Oxygen carried by red corpus- 
 cles of blood, 171, 188, 197 
 
 P. 
 Pain, cause of, in inflammation, 
 
 305 
 Palmar arterial arch, 180 
 
 arches controlled by pres- 
 sure, 367 
 Pancreas, 217 
 Pantry sinks, connection of, 
 
 with soil-pipes, 124 
 Pan, water-closet, 123 
 Papillae of the skin, 234 
 of the tongue, 261 
 
 Paralysis in apoplexy, 401, 403 
 of face, 249 
 in fracture of the spine, 449, 
 
 450 
 
 in sprains of loins, 339 
 from sunstroke, 404 
 Paraplegia, 290 
 Passive motion in fractures of 
 
 the leg, 471 
 Pasteboard splints, 437 
 Patella, 166 
 
 dislocation of, 496 
 Pathways in camps, 98, 103 
 Patient, disinfection of, 272 
 examination of, in accidents, 
 
 264 
 preparation of, for bed, 268, 
 
 270 
 
 Pavilion wards of general hos- 
 pitals, 112 
 
 Pay accounts of enlisted men, 14 
 Pectoral muscles, 153, 154 
 Pediculi, 544, 545 
 Pelvis, 160 
 
 fracture of, 466 
 Penetrating wounds of the chest, 
 
 397, 398 
 
 Pensions based upon medical rec- 
 ords of war service, 58 
 Peppermint test for leaky soil- 
 pipes, etc., 126 
 Peptone, 211, 217 
 Percussion, 161 
 Pericardium, 177 
 Perineal band infractured femur, 
 
 467, 468 
 Periosteum, 142 
 
 Peristaltic movements of the in- 
 testines, 216 
 
340 
 
 INDEX TO PARAGRAPHS. 
 
 Peritoneum, 161 
 Personal reports of medical offi- 
 cers, 13 
 
 Perspiration, 236 
 Persulphate of iron as a styptic, 
 
 383 
 Phalanges of the fingers, 158 
 
 of the toes, 168 
 
 Pharmacy, knowledge of, re- 
 quired, 561 
 
 Pharynx, foreign bodies in, 432 
 Phosphates of the urine, 297, 299 
 Phosphorus, a constituent of ner- 
 vous tissues, 241 
 as a poison, 521, 504, 508 
 Phrenic nerve, 248, 290 
 Pia mater, 247 
 Piles, 196 
 Pioneers of field hospital, 34, 37, 
 
 43 
 
 Pit of stomach, 151, 161 
 Plans of general hospitals, 111 
 Plantar arch, 182 
 Plasma, 170 
 Plaster, application of, to close 
 
 wounds, 356, 357 
 of Paris in fractures, 443, 471 
 strapping of sprained joints, 
 
 338 
 strips in contused wounds, 
 
 363 
 
 Pleura, 221 
 Pleurisy, character of respiration 
 
 in, 227 
 
 Plunger water-closets, 123 
 Pneumonia, condition of air 
 
 cells in, 227 
 Pneumothorax, 397 
 Poisoned wounds, 374, 379 
 
 Poisoning by articles of food, 
 
 532 
 
 by Rhus toxicodendron, 533 
 Poisons, classification of, 501 
 Police, company, 99 
 
 general, of regimental 
 
 camps, 101, 103 
 of general hospitals, 136 
 Popliteal artery, 182 
 
 artery controlled by pres- 
 sure, 367 
 
 Pork, food principles of, 199 
 Portal circulation, 192 
 ' Posterior tibial artery, 182 
 
 tibial artery controlled by 
 
 pressure, 367 
 
 Post Hospital, service of, 3-21 
 Potassa as an escharotic, 319 
 Potassae, liquor, as a remedy in 
 
 cases of poisoning, 507 
 Potatoes, boiling of, 566 
 Pott's fracture, 498 
 Poultices, 310 
 
 in abscesses, boils, etc., 340, 
 
 343 
 
 after application of a fly- 
 blister, 318 
 in corns and bunions, 351, 
 
 352 
 in frost-bites and chilblains, 
 
 335, 336 
 
 in sloughing burns, 330 
 in whitlow, 344 
 in the treatment of wounds, 
 
 361, 375 
 Presbyopia, 254 
 Pressure, arteries which may be 
 
 controlled by, 367 
 a cause of inflammation, 352 
 
INDEX TO PARAGRAPHS. 
 
 341 
 
 Pressure, as promotive of ab- 
 sorption, 328 
 
 in the treatment of inflam- 
 mation, 309 
 Preventability of camp diseases, 
 
 74 
 
 Prickly beat, 544 
 Primary dressing of gunshot 
 
 wounds, 369 
 hemorrhage, 390 
 union of wounds, 357 
 Prison fever, 85 
 
 Privy vaults, disinfection of, 537 
 Processes, spinous, 146 
 Pronation, 157 
 
 danger of impairment of, in 
 
 fractures, 463 
 Property purchased with the 
 
 hospital fund, 14 
 of field division hospital, 
 
 cared for by, 29 
 destroyed, 17, 541 
 Prostration from loss of blood, 
 
 368 
 
 Proud flesh, 361 
 Prussic acid as a poison, 526, 
 
 508 
 
 Ptyalin, 210 
 Pubes, 164 
 
 Pulleys, use of, in reducing dis- 
 locations, 473, 491 
 Pulmonary arteries, 197, 222 
 circulation, 175, 197 
 valves, 197 
 veins, 222 
 
 Pulp of tooth, 208, 209 
 Pulse, 186, 180 
 
 influence of muscular action 
 on, 324 
 
 Pulse, reduction of, by medica- 
 tion, 326 
 
 and respiration, relative fre- 
 quency of, 223 
 Punctured wounds, 355, 399 
 Pupil of the eye, 251 
 Pupils in conditions of insensi- 
 bility, 405, 523 
 Purgatives in inflammation, 321, 
 
 326 
 
 Purulent conjunctivitis, 425 
 Pyloric end of stomach, 211, 213 
 
 Quarantine restrictions in chol- 
 era and yellow fever, 559, 109 
 
 Quarterly report of property, 
 17 
 
 Quiet as a remedial measure, 324 
 
 Quinine, use of, 109 
 
 R. 
 
 Radial artery, 180 
 
 artery controlled by pres- 
 sure, 367 
 Radius, 156 
 
 fractures of, 460 
 Rain conductors, connection of, 
 
 with main drain, 128, 132 
 Ration returns, 14 
 Rations, 201 
 
 for the wounded during and 
 
 after an engagement, 30 
 Reaction, general, 304, 305 
 Record books of a post, 18 
 Records of field hospitals, 58-60, 
 
 30 
 medical, importance of, 58 
 
342 
 
 INDEX TO PARAGRAPHS. 
 
 Recruits, report of examination 
 
 of, 15 
 
 Rectum, absorption from, 219 
 Recurrent bandage for the head, 
 
 393 
 
 Red-blindness, 258 
 Red corpuscles of blood, 170, 
 
 171, 173 
 
 Cross Society, 56 
 Redness, cause of, in inflamma- 
 tion, 305 
 
 Reducible hernia, 163 
 Reduction of "dislocations, 473 
 Reef-knot, 389 
 Reflex action, 262, 263 
 Refuse matters of camp, dis- 
 posal of, 103 
 Regimental hospitals, defects of, 
 
 in war service, 24 
 medical officers, availability 
 
 of, for special duties, 59 
 medical officers, duties of, 
 
 after a battle, 58 
 Registers of Patients, 15, 18 
 Examination of recruits, 18 
 Hospital fund, 18 
 Remittent malarial fevers, causa- 
 tion of, 64-71 
 Remittents simulating typhoid 
 
 fever, 85 
 Reports and papers from the 
 
 post hospital, 13-18 
 and papers during field 
 
 operations, 58, 59 
 and papers from general hos- 
 pitals, 134 
 Requisitions for supplies, 17, 46, 
 
 50 
 Resonance on percussion, 161 
 
 Respiration, 223 
 
 artificial, 416-421 
 Respiratory murmur, 225 
 Rest in the healing of wounds, 
 
 359 
 
 in the treatment of inflam- 
 mation, 308, 324 
 Rests during marches, 415 
 Retching, dry, treatment of, 285 
 Retina, 251 
 Retractor, 273 
 Returns of Medical Property, 
 
 17 
 
 Revaccination, 549 
 Reverses in bandaging, 439 
 Rheumatic inflammations, 327 
 Rheumatism simulated by 
 
 scurvy, 77 
 
 Rhus, poisonous species of, 533 
 Ribs, 151 
 
 fracture of, 451 
 Ridge ventilation, 112 
 Rigor mortis, 421 
 Rima glottidis, 224 
 River water, 106, 117 
 Roasting as a cooking process, 
 
 572 
 
 Rochelle salt in bread, 575 
 Roller bandage, 439 
 Roseola, 555 
 Rotheln, 557 
 Rubefacients, 329 
 Rupture, 162, 163 
 
 8. 
 
 Sacral nerves, 248 
 Sacrum, 147, 160 
 Saline purgatives, action of, 321 
 substances in fresh meat, 199 
 
INDEX TO PARAGRAPHS. 
 
 343 
 
 Saliva, action of, on starch, 210 
 Salt, Epsom, 504, 511, 521, 523 
 
 Glauber, 504, 511 
 
 table, as an article of food, 
 198 
 
 table, in poisoning, 504, 512 
 Salts of the urine, 241, 299 
 Sand -bags as a support in frac- 
 ture, 468 
 
 Sanitary Report, Monthly, 16 
 Sanitation of camps, underlying 
 
 principle of, 74, 85 
 Saphenous veins, 194 
 Saw, use of, in amputations, 273 
 Scabies, 543 
 Scalds, 330 
 
 of the throat, 333 
 Scalp wounds, 393 
 Scalpels, 274 
 Scapula, 152 
 
 fracture of, 454 
 Scapular muscles, 153, 154 
 Scarf-skin, 233 
 Scarification of the conjunctiva, 
 
 425 
 
 Scarlatina, 554 
 Scarlet fever, 553 
 Sciatic nerve, 248 
 Sclerotic, 251 
 Scorpion stings, 378 
 Screw tourniquet, 387 
 Scurvy, 77 
 
 Sebaceous glands, 235 
 Secondary hemorrhage, 392 
 
 union of wounds, 359 
 Sediments in urine, 299 
 
 in water cisterns, 116 
 Sensations, 244 
 Sensory nerves, 249 
 
 Sequelae of measles, 84 
 Serpent bites, 377 
 Serum, 170 
 Sewage, 122, 127 
 
 in drinking-water, 106, 118 
 Sewerage, 127 
 
 Sewers of general hospitals, 121 
 Shampooing in chronic inflam- 
 mations, 328 
 
 Sheets, renewal of, under help- 
 less patients, 292 
 Shell-fish, poisoning by, 532 
 Shelter, inadequate, a cause of 
 
 camp diseases, 75, 76 
 Shelter-tents, 88 
 
 in field hospitals, 43 
 Ship fever, 85 
 Ships, fumigation of, 540 
 Shock, 302-304 
 
 in burns, 331, 332 
 in wounds, 366-368, 397 
 death from, 500 
 Shoes, narrow -toed, bad effects 
 
 of wearing, 352 
 Shortening of limb in fracture, 
 
 145 
 
 Short-sightedness, 255 
 Shoulder-blade, 152 
 fracture of, 454 
 Shoulder-joint, 153 
 
 dislocations, 478 
 Sibley tent, 90 
 Sick and Wounded, Reports of, 
 
 11, 15 
 
 and wounded, transporta- 
 tion of, 31, 32, 46 
 Sieges, field hospitals during, 
 
 57 
 Signs of death, 421 
 
344 
 
 ItfDEX TO PARAGRAPHS. 
 
 Silicate of soda bandage, 442 
 Silk ligatures for arteries, 388, 
 
 389 
 Silvester's method of artificial 
 
 respiration, 417 
 Simmering as a cooking process, 
 
 566, 568, 569 
 Sinews, 434 
 Sinks in military camps, 103, 
 
 104, 109 
 
 Siphonage of traps, 130 
 Six-tailed bandage for the head, 
 
 395 
 Skin, action of, in regulating 
 
 heat of body, 243 
 desquamation of, in scarlet 
 
 fever, 329, 554 
 inflammation of, in teething 
 
 children, 205 
 Skull, bones of, 148 
 fracture of, 445-447 
 depressed fracture of, 401 
 Slaughter-house offal in camps, 
 
 disposal of, 103 
 Sleep, necessity for, 174, 263 
 Sleeplessness, caused by hunger, 
 
 203 
 Sling for the upper extremity, 
 
 370 
 Sloughing, in burns, 330 
 
 in frost-bite and chilblains, 
 
 334-336 
 
 in contused wounds, 363, 392 
 Sloughs in boils, 341 
 Small intestine, 161, 214 
 Small-pox, 83, 546-550 
 Smell, the best method of detect- 
 ing impurity in air, 229 
 Smith's anterior splint, 469 
 
 Smothering, artificial respira- 
 tion for, 420 
 Snow-blindness, 426 
 Snow as remedial in frost-bite, 
 
 334 
 Soap, action of hard water on, 
 
 119 
 
 and water in poisoning, 500 
 Soda, baking or washing, in 
 
 poisoning, 500 
 Sod-cloth of tents, 89 
 Soft corns, 351 
 Softness of waters, 119 
 Soil-pipes, 125, 122 
 
 ventilation of, 129 
 Soils, as relating to the site of 
 
 camps, 63-73 
 
 Sore throat in scarlet fever, 553 
 Sounds of the heart, 177 
 Soup, 568 
 Specific gravity of urine, 296, 
 
 298 
 Spinal cord, 244, 248, 146 
 
 cord, reflex action of, 262, 
 
 263 
 
 nerves, 244 
 
 Spine, fracture of, 449, 450, 290 
 bed-sores in fractures of, 
 
 293 
 
 Spinous processes of the verte- 
 brae, fractures of, 449 
 Spirit of camphor in chilblains, 
 
 336 
 
 Spleen, 215, 161 
 Splinters in wounds, 356 
 
 a cause of abscess, 340 
 Splints, 437 
 
 extemporized in field ser- 
 vice, 371 
 
INDEX TO PARAGRAPHS. 
 
 345 
 
 Splints, fixed by triangular 
 
 bandage, 370 
 use of, in sprains, 338 
 use of, in wounds, 357, 358 
 Spotted fever in overcrowded 
 
 quarters, 85 
 Sprains, 338, 328 
 Spring forceps, 273, 389 
 
 scarificator, 312 
 
 Stable manure, disposal of, 103 
 Starch as food, 198 
 
 influence of cooking on, 564, 
 
 573 
 
 use of, in burns, 329, 330 
 bandage, 441, 471 
 Steam, as a disinfectant, 272, 539 
 Sterno-mastoid muscle, 150, 193 
 Sternum, 151 
 Stewards, duties of, in the field, 
 
 29, 30, 37, 41, 47 
 at general hospitals, 135 
 Stewing as a mode of cooking, 
 
 567 
 Stimulant applications in chronic 
 
 inflammations, 328 
 applications in frost-bite and 
 
 chilblains, 335, 336 
 Stimulants in shock and syncope, 
 
 302, 303, 415 
 in prostration from bleeding, 
 
 266, 368 
 
 in internal injuries, 337 
 in wounds of the chest and 
 
 abdomen, 398 
 in poisoned wounds, 377 
 in exposure to extreme cold, 
 
 413 
 
 in concussion of the brain, 
 401 
 
 Stimulants in poisoning by al- 
 cohol, 411 
 
 in cases of poisoning, 500, 
 506, 508, 509, 515, 517-522, 
 526-530, 532 
 
 in artificial respiration, 419 
 Stomach, 211, 161 
 
 foreign bodies in, 433 
 hemorrhage from the, 383 
 pump or stomach-tube in 
 poisoning, 502, 509-512, 
 517, 520, 522-525, 527-529 
 nourishment administered 
 
 by, 396 
 Store-rooms of general hospitals, 
 
 114 
 
 Strangulated hernia, 163 
 Strangulation, artificial respira- 
 tion for, 420 
 
 Strangury in poisoning, 519 
 Strap-and-buckle fastenings for 
 
 splints, 438 
 
 Strapping with plaster to pro- 
 mote absorption, 328 
 Straw as a material for splints, 
 
 437 
 
 Streets, company, proper condi- 
 tion of, 98 
 
 Striae of voluntary muscles, 143 
 Strychnine as a poison, 531, 508 
 as a remedy in cases of poi- 
 soning, 508, 524, 528 
 Styptics, 382, 383 
 Subclavian arteries, 180 
 
 artery controlled by pres- 
 sure, 367 
 
 Subsistence officer of field hos- 
 pital, 29 
 Subsoil water, 106, 117 
 
346 
 
 IKDEX TO PARAGKAPHS. 
 
 Sudoriparous glands, 236 
 Suffocation, 420, 500 
 Sugar as food, 198 
 in urine, 296, 298 
 of lead as a poison, 511, 504 
 Sulci of the brain, 245 
 Sulphate of copper as an emetic 
 
 in poisoning, 502, 514 
 of copper as an antidote in 
 
 poisoning, 504, 514, 521 
 of copper as a poison, 503, 
 
 514 
 
 of copper to proud flesh, 361 
 
 of magnesia as a remedy in 
 
 poisoning, 504, 511, 521, 
 
 522 
 
 of soda as an antidote in 
 
 poisoning, 504, 511, 522 
 of zinc as an emetic in poi- 
 soning, 502 
 
 of zinc as a poison, 513 
 Sulphur, a constituent of albu- 
 minous tissues, 241 
 Sulphuric acid, aromatic, as an 
 antidote in poisoning, 500, 511 
 Sulphur as a disinfectant, 540 
 Sunstroke, 243, 404 
 Superior vena cava, 190 
 Supination, 157 
 
 in fractures of forearm, 463 
 Suppression of urine, 300 
 Suppuration of lymphatic 
 
 glands, 220 
 
 Surgeon in charge of field hospi- 
 tal, duties and responsi- 
 bilities, 29-60 
 
 in charge of a general hos- 
 pital, duties and responsi- 
 bilities of, 134 
 
 Surgeon's call at post hospitals, 
 
 11 
 
 knot, 389 
 
 Surgical operations, preparation 
 
 for the performance of, 271-279 
 
 Susceptibility of young soldiers 
 
 to typhoid fever, 80 
 Suspensory bandage for rupture, 
 
 163 
 
 Suture for closing wounds, 356 
 Sutures in contused wounds, 
 
 363 
 not used in wounds of scalp, 
 
 393 
 
 Sweat, 236 
 
 Swelling, cause of, in inflamma- 
 tion, 305 
 Sympathetic nerves, 244 
 
 nervous system, 262, 263 
 fever, 322-326 
 Symptoms, changes in, noted 
 
 265, 269 
 Syncope, 302, 303, 415 
 
 influence of, on hemorrhage, 
 
 385 
 
 Synovia, 153 
 Syphilis, danger of infection 
 
 from sores, 282 
 Syphilitic inflammation, 327 
 Syringing ear, method of, 430 
 Systemic circulation, 175 
 
 T. 
 
 Tannin as a styptic, 383 
 
 in cases of poisoning, 503, 
 
 515, 518, 525, 527-531 
 Tarantula bites, 378 
 Tarsal bones, 168 
 Tartar on the teeth, 209 
 
INDEX TO PARAGRAPHS. 
 
 347 
 
 Tartar emetic as a counter-irri- 
 tant, 320 
 
 emetic as an emetic in poi- 
 soning, 502 
 
 emetic as a poison, 503, 515 
 Tea, green, in cases of poison- 
 ing, 503, 515, 518, 525, 527-531 
 Teeth, 205-209 
 
 extraction of, 347-349 
 filling cavities in, 350 
 Teething, constitutional disturb- 
 ances attending, 205 
 Temperature charts, 289 
 
 loss of, as a sign of death, 
 
 421 
 needful for the development 
 
 of malaria, 65 
 normal, 286 
 
 of patients, how taken, 288 
 scales ; to change Fahrenheit 
 to Centigrade, and vice 
 versa, 287 
 
 Temporal arteries, 179 
 Tenaculum, 389 
 Tendo-Achillis, 167 
 Tendons, 144 
 
 of forearm, 159 
 
 Tent-flies for extending hospi- 
 tal shelter, 44 
 Tents, common, 89 
 shelter, 88, 96 
 Sibley, 90 
 Tepid baths, 270 
 Test for sugar, etc., in urine, 
 
 295-300 
 
 Tests for organic matter in drink- 
 ing-water, 362 
 Testicle, contusions of, 337 
 Thermometer, clinical, 288 
 
 Thigh-bone, 165 
 Thoracic aorta, 81 
 
 duct, 218 
 
 Throat, scalds of, 333 
 Thumb, bones of, 158 
 
 dislocations of, 483 
 Tibia, 166, 167 
 
 fractures of, 470, 471 
 Tibial arteries, 182 
 
 arteries controlled by pres- 
 sure, 367 
 Tin, sheet, as a material for 
 
 splints, 437 
 
 Tincture of iodine in chronic 
 inflammations, 320, 328, 
 329, 336, 352 
 of iodine in serpent bites, 
 
 377 
 
 Tobacco as a poison, 528, 508 
 Tongue, 261 
 
 appearance of, in disease, 
 
 284 
 
 position of, in artificial res- 
 piration, 416 
 Tooth, extraction of, 347-349, 
 
 345 
 socket, hemorrhage from a, 
 
 383 
 
 Toothache, 346 
 Torsion, 386 
 
 Touch, special organ of, 234 
 Tourniquet, 387 
 Trachea, 150, 222 
 
 foreign bodies in, 431 
 Transfer slips, 15 
 Transports, sanitary care of, 108 
 Traps on fixtures, soil-pipes, and 
 drains, 122-124, 128-130, 133 
 Traumatic fever, 322-326 
 
348 
 
 INDEX TO PAKAGKAPHS. 
 
 Trees, influence of, on malarious 
 
 exhalations, 67 
 
 Trenching of camps, 94, 98, 103 
 Triangular bandage, 370, 395 
 Trichiniasis prevented by cook- 
 ing, 564 
 Trochanter, 165 
 Truss, measurement of patient 
 
 for, 163 
 Trypsin, 217 
 
 Tuberosities of the humerus, 155 
 Turpentine stupes, 313, 315 
 
 in chilblains, 336 
 Tympanum, 259 
 Typhoid fever, infection of, 558 
 fever, a camp disease, 79, 
 
 109 
 
 fever, germs of, in drinking- 
 water, 106, 558 
 fever in overcrowded quar- 
 ters, 85 
 
 pneumonia due to over- 
 crowding, 85 
 seasoning of young soldiers, 
 
 80 
 Typhus fever in overcrowded 
 
 quarters, 85, 86 
 developments in dugouts 
 and badly constructed 
 huts, 95 
 
 prevented by a free allow- 
 ance of air space, 113 
 
 U. 
 
 Ulceration of a blood-vessel, 392 
 
 of bunions, 352 
 
 of chilblains, 336 
 Ulna, 156 
 
 fractures of, 461 
 
 Ulnar artery, 180 
 
 artery controlled by pres- 
 sure, 367 
 
 Umbilical cord, 162 
 Umbilicus, 161, 181 
 Unguents, use of, in burns, 329, 
 
 330 
 
 Uniform of Hospital Corps, 21 
 Union by the first intention, 357 
 by the second intention, 359 
 Units of hospital organization 
 
 for war service, 22 
 Ursemic convulsions, 300 
 Urates in urine, 299 
 Urea, 242 
 Ureter, 238 
 
 Ureters, hemorrhage from, 295 
 Urethra, 239 
 
 hemorrhage from, 295 
 Uric acid, 240 
 
 Urinals for winter camps, 105 
 Urinary sediments, 299 
 Urine, 240-242, 295-300 
 albumin in, 297, 109 
 blood-colored, by medicines, 
 
 etc., 295 
 
 bloody, in cases of poison- 
 ing, 519 
 bloody, in sprains of loins, 
 
 339 
 involuntary discharge of, in 
 
 epilepsy, 407 
 .retention of, 300 
 retention of, in apoplexy, 
 
 403 
 retention of, in fractures of 
 
 the spine, 450 
 sugar in, 298 
 suppression of, 300 
 
INDEX TO PARAGRAPHS. 
 
 340 
 
 Urine, suppression of, in poison- 
 ing, 509 
 
 V. 
 Vaccination, 547-549 
 
 of recruits, influence of, on 
 
 small-pox, 83 
 Valve water-closet, 123 
 Valves of aorta, 176, 184 
 
 of heart, 176 
 
 of veins, 195 
 
 Vapor-bath, mercurial, 228 
 Varicose veins, 196 
 Varioloid, 549 
 
 Vegetation, relations of, to ma- 
 laria, 69 
 Veins, 189-197 
 Venae cavse, 190-192 
 Venous blood, 176, 188, 197 
 
 hemorrhage, 384 
 Ventilation, 230 
 
 of log huts, 93, 94, 96 
 
 of pavilion wards by the 
 ridge, 112 
 
 as a preventive of erysipe- 
 las, 372 
 
 of soil-pipes, 129 
 
 of ward in typhoid fever, 
 
 558 
 Vent-pipe in trap to prevent 
 
 siphonage, 130 
 Ventricles of the brain, 246 
 
 of the heart, 176 
 Vertebral column, 146 
 Vesicants, 314 
 Vesication in burns, 330 
 Vesicular breathing, 225 
 
 matter of the brain, 246 
 Villi of small intestine, 218 
 
 Vinegar in cases of poisoning, 
 
 500 
 
 Vocal chords, 224 
 Voluntary muscles, 143 
 Vomiting in alcoholic coma, 411 
 in concussion of the brain, 
 
 401 
 
 in contusions of the abdo- 
 men, 337 
 
 during inhalation of anaes- 
 thetics, 277-278 
 
 W. 
 
 Wagons, army, for transporta- 
 tion of wounded, 46 
 field hospital, 30, 31 
 Walking supervised by reflex 
 
 action, 262 
 
 Wards, fumigation of, by burn- 
 ing sulphur, 540 
 Wardmasters in general hospi- 
 tals, 138 
 
 Ward Surgeons of general hos- 
 pitals, duties of, 136 
 Warm baths, 270 
 Warm-water dressings, 310 
 Warming of general hospitals, 
 
 112 
 Warmth obtained at expense of 
 
 ventilation, 91 
 when applied in artificial 
 
 respiration, 419 
 Wash-basin, connection with 
 
 soil-pipe, 124 
 Washing of clothes in camps, 
 
 106 
 
 Wasps, stings of, 379 
 Water, boiled or filtered, to be 
 used, 106, 109 
 
350 
 
 INDEX TO PARAGRAPHS. 
 
 Water, called for in cases of 
 
 hemorrhage, 368 
 cistern, 116 
 
 disinfection of, 106, 109 
 dissipation of, in lungs, 197, 
 
 226 
 
 douches in narcotic poison- 
 ing, 523 
 
 natural purification of, 116 
 subsoil, 116 
 surface, 117 
 tests of purity, 118 
 use of, in sunstroke, 405, 
 
 406 
 
 use of, in syncope, 415 
 well, 117 
 
 Water-carriage for sewage, 122 
 Water-closets, 123 
 Water-gas, accidents from, 420 
 Water-seals, 122-124, 128-130 
 Water-supply of general hospi- 
 tals, 115 
 of camps, 106 
 necessity for as a cooling 
 
 agency, 404 
 
 a cause of camp diseases, 76 
 in cholera and yellow fever, 
 
 559 
 
 propagation of typhoid fe- 
 ver by, 79, 558 
 Wedge-tent, 89 
 Weekly Report of Sick and 
 
 Wounded, 59 
 Wells, 117 
 
 in camps, 106 
 Wet cupping, 312 
 Whiskey, harmfulness of, in 
 
 camp, 77 
 White corpuscles of blood, 17 8 
 
 White matter of the brain, 246 
 matter of the spinal cord, 
 
 248 
 Whiting in cases of poisoning, 
 
 504, 516 
 Whitlow, 344 
 Winds, protection from, in 
 
 camp, 73 
 Wire mattress as a surgical bed, 
 
 467 
 
 Wisdom teeth, eruption of, 206 
 Wooden splints, 437 
 Worms, intestinal, prevented by 
 
 cooking, 564 
 convulsions from presence 
 
 of, in intestine, 409 
 Wounded, lists of, required after 
 
 an engagement, 59 
 transportation of, to base of 
 
 supplies, 46 
 left to the care of the enemy, 
 
 50 
 Wounds, 355-399 
 
 treatment of, at field dress- 
 ing-stations, 41, 365 
 Wrist, fracture of, 460 
 Wrist- joint, dislocation of, 482 
 
 Y. 
 
 Yellow fever, 82, 109, 559 
 
 Z. 
 
 Zinc, action of drinking-water 
 
 on, 120 
 
 salts of, as poisons, 513 
 sheet, as a material for 
 
 splints, 437 
 sulphate of, as an emetic in 
 
 poisoning, 502 
 
TECS BOOK IS DUE ON THE LAST DATE 
 STAMPED BELOW 
 
 AN INITIAL FINE OF 25 CENTS 
 
 WILL BE ASSESSED FOR FAILURE TO RETURN 
 THIS BOOK ON THE DATE DUE. THE PENALTY 
 WILL INCREASE TO 5O CENTS ON THE FOURTH 
 DAY AND TO $1.OO ON THE SEVENTH DAY 
 OVERDUE. 
 
 OEC 26 
 
 LD 21-100m-7,'40 (6936s) 
 
M81843 i ...-, ^ H 
 
 8'OLOGV 
 
 THE UNIVERSITY OF CALIFORNIA LIBRARY