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Volume 1

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DOMESTIC MEDICINE AND SURGERY.

INTRODUCTORY

MEDICAL men have a natural prejudice against systems of domestic medicine. They know, better than anybody else can know, the difficulty of understanding the very simplest medical facts. They know how often, with all their special knowledge, acquired by years of study and close observation of disease, they are themselves puzzled in trying to explain fully the cases which they meet with. [-8-] It is not to be wondered at, then, that they should have a distrust of domestic medicine, and have a strong tendency to advise people that are not well, not to take this medicine or the other, but "to send for the doctor." And yet a little reflection will show that there must be more or less of domestic medicine. People will try their hands at curing themselves or their children; and for two or three reasons such experiments are not to be altogether discouraged. In the first place, there are some ailments that are really very trifling and require for their treatment only a little care and common sense. They are not grave enough to need medical science or to be materially helped by it. It seems scarcely respectful to the profession to call it in to cure a common cold, or the stomach-ache which clearly comes of having eaten forbidden fruit. Then there is another good reason for trying to help people to understand the rudiments of medicine for domestic purposes. They are often so situated as to be out of the reach of immediate assistance. A sudden faint 

may happen, or a vein or artery may be bleeding fast, and  even a near doctor may be too far off; or the doctor may  live at a great distance; and a little wise instruction would save hours of pain to the patient and anxiety to his friends. Many of the mistakes of domestic medicine would be avoided if it could be restricted to simple cases. But here the difficulty arises of distinguishing between cases  that are simple, and cases that are serious. In an early number, we shall try to enumerate a few symptoms which show disease to be important, and therefore beyond the proper province of domestic treatment. The chief information that we shall pretend to give concerning such serious diseases, will be such as will enable our readers to  form some intelligent notions of their nature, their course, and their symptoms; and, what is perhaps of most importance, to understand the onset of them, and the kind of symptoms which indicate a severe attack.
    The object of the articles on Domestic Surgery will be, not the perfectly futile and mischievous one of attempting to make every one his own surgeon, but only to furnish our readers with such simple rules for the treatment of the slight accidents and emergencies of every day life as are commonly treated without resorting to medical advice.
    At the same time, opportunity will be taken to point out those circumstances that indicate the necessity for immediate recourse to a medical man, and the rules laid down must be regarded as only preliminary to his arrival, and on no account to be insisted on should he, from the special nature of the case, see fit to carry out some different mode of treatment. Great harm may be done to a patient by injudicious meddling on the part of a well- meaning, but only partially-informed friend, who, finding the treatment being pursued under medical advice different from that here laid down, should venture to express disapproval, and shake the confidence of the patient or his friends in their medical adviser. When a patient's case has once been undertaken by a medical man, it is only just, and for his own interest, that the surgeon should be treated honestly, his directions fairly carried out, and his prescriptions attended to. If a patient or his friends are dissatisfied with their medical attendant, it is always open to them to have further medical advice.
    There are certain affections which are commonly de- nominated "surgical," because they require some manual attention on the part of the attendant. These will be briefly discussed, in order to point out how far they may with safety be treated domestically, and when it will be desirable, and even essential, to have professional advice. Opportunity will be taken, in connection with these subjects, to describe the mode of preparation of poultices and other applications of household surgery, which, though they are in fact matters of every day requirement, are frequently mismanaged.
    It may be here remarked how essential for relief in these surgical affections it is that there should be no concealment of symptoms from one's medical adviser, on account of scruples, no doubt honourable, but misplaced, because of the so-called "delicacy" of some of the subjects involved. Valuable lives (as for instance, that of Caroline, queen of George II.) have been lost from the concealment of the existence of a rupture; and many persons live a life of discomfort for years, and even allow their health to be undermined, through the concealment of some affection of the lower bowel which could be readily remedied by medical advice.

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DOMESTIC SURGERY.-I.

HAEMORRHAGE.

BLEEDING, which is a constant accompaniment of accidental cuts and wounds, is always very alarming to nonprofessional bystanders, and it occasionally happens that for want of knowing how to arrest it readily, serious results occur before the arrival of professional aid. In order to be able to stop bleeding the reader must understand that blood may be poured out in two ways 1st, pumped out in jets of a bright red colour, in which case one of the arteries which convey the blood from the heart to the surface is wounded; or, 2ndly, it may flow out in a dark-coloured continuous stream from the veins which return the blood from the limbs to the heart.

    It is evident, then, that the wound of an artery of large size will give rise to the most serious form of bleeding, and as the blood in this case is flowing from the heart to the circumference, we must arrest it between the trunk and the wound by compressing the main artery. On the other hand, if the bleeding is from the wound or rupture of a large vein, the point for the application of the pressure will be either upon or below the wound. In the case of the upper arm the principal artery runs along the inner side of the limb, where it may easily he felt beating, and in the case of arterial bleeding from the hand or arm, pressure can be efficiently obtained by tying a strong tape or handkerchief around the arm and tightening it by twisting a stick in it on the outer side of the limb, as shown in the cut, Fig. 1. In the thigh the main artery runs down the middle of the front of the limb, and can be controlled in the same way as in the arm. In both cases, the introduction of a wine cork beneath the handkerchief in the situation of the vessel will lead to more efficient pressure upon it, and without so much tightening of the bandage as would be otherwise necessary.
    This mode of extemporising what is surgically called a tourniquet, is of course only for temporary employment; and any case in which the bleeding has been severe enough to require its use should be seen as soon as possible by a medical man, and the bandage should on no account be interfered with before his arrival. 
    Before explaining the mode of applying the dressings necessary to restrain haemorrhage of an ordinary kind, it will be advisable to say a few words about bandages. A bandage or roller is simply a strip of calico, six yards in length, and from two to three inches in width. Soft unbleached calico or coarse cambric is the best for this purpose, but on an emergency any suitable material may be employed; and for binding up fingers broad tape or narrow ribbon is very convenient. In order to use a bandage properly it must be rolled neatly and tightly from one or both ends, as seen in Fig. 2 ; but it is only the "single-headed roller," or that rolled from one end, which can be required in domestic surgery. A bandage may either be rolled by keeping it tight with the thumb and fingers of the left hand, whilst being rolled with the right, as shown in Fig. 3; or this may be more conveniently and rapidly done by using both hands for rolling, whilst the bandage is kept on the stretch by an assistant, as shown in Fig. 4.
    In bleeding from slight cuts about the fingers and hand, plaister (either court or adhesive) may be conveniently employed if a bandage is used over it at first, and until the plaister has become firmly fixed; but when the wound is considerable it is better to use other means. A piece of lint or soft linen should be placed over the wound, and over this a bandage should be firmly applied, and should extend if possible a little above and below the seat of the injury. In the case of a finger a roll of tape may be taken, and ten or twelve inches being drawn out and left loose, the finger should be rolled in a series of spiral turns from the web to the nail, where the spiral arrangement being reversed, the tape can be carried back again and across the back of the hand, and tied round the wrist with the end left out as in Fig. 5. If the wound is in the ball of the thumb the bleeding is often sufficiently severe to require medical attendance, and this should be obtained, if possible; though the vulgar fear of "lock-jaw" from an injury of this kind is unfounded. When it is necessary to bind up the thumb the broad tape [-10-] may be conveniently used, and a turn having been taken round the wrist to fix the bandage, a series of figure of eight loops around the thumb and wrist should be made, beginning as low down on the thumb as may be necessary, and making each fold of the bandage overlap that which preceded it, as shown in the illustration, Fig. 6.
    Wounds of the palm of the hand, if severe, should be immediately seen by a surgeon, but as a temporary measure a slice of cork wrapped up in a piece of linen may be firmly bound upon the bleeding point with a bandage. This should be applied in figure of eight loops around the wrist and hand, being made to cross at the point where the pressure is required, as shown in the illustration, Fig. 7, and this should be repeated a few times so as to control the bleeding. It may be advisable where assistance is not readily obtainable, to bandage the forearm in addition, and this may be done by carrying the bandage once or twice round the wrist alone, and then proceeding up the arm, turning down the bandage in the manner shown in the illustration, Fig. 8, when the shape of the arm does not allow it to lie flat and close upon the injured limb.

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DOMESTIC SURGERY.- II

HAEMORRHAGE (continued from p.10).

IN all cases of bleeding from the hand or arm it is important that the limb should be kept quiet, and in a raised position. For this purpose, and for many others, a sling is most conveniently made of a silk handkerchief, which should be folded like a cravat, and of a convenient width. The limb being placed in the loop of the sling, the front end is to be brought forward over the opposite shoulder, and the other end over the shoulder of the same side to meet it at the back of the neck, as seen in the illustration. In this way the arm will be drawn forward, and can be easily raised to any height, and the sling will not slip as it always does if tied in the opposite way (Fig. 9).
    Bleeding from cuts about the face is seldom serious, 

unless the lip should be divided by a blow upon the mouth, in which case a surgeon should be immediately consulted, or the resulting deformity may be great. Collodion is a very useful application to cuts about the face, and in applying it the part should be firmly pinched with the fingers for a few moments, so as to stop the bleeding, then having been wiped dry, the collodion may be painted on, and after a few minutes, when it has dried, the part may be released from the fingers. Court plaister may be applied with the same precautions, care being taken that both sides of the plaister are thoroughly wetted, without removing the adhesive material. In extensive cuts upon the face, it is advisable to have recourse to stitches of silk, in order to reduce the resulting scars to a minimum. In cases when the assistance of a medical man cannot be obtained, an ordinary stout sewing needle, with purse-silk or stout cotton, may be pushed through the whole thickness of the skin on each side of the cut, and an eighth of an inch from the margin, and the silk be tied in a double knot when the loop has been drawn tight, so as to bring the edges together. One stitch will be required for a cut an inch long, and so on in proportion; and a strip of plaister should be put across the wound on each side. Stitches should not be left in the skin of the face more than two days, and should then be cut close to the knot with a sharp pair of scissors, and drawn out gently. Narrow strips of plaister applied across a wound, and slightly overlapping one another, will, in many cases, obviate the necessity for stitches.
    In wounds about the head, a little of the hair on each edge of the wound should be cut away, and a pad of lint be placed over it, and be bound on firmly with a bandage. This will of course vary somewhat according to the position of the cut, but will consist essentially of one or two turns round the front and back of the head, which should be secured with a pin, followed by a turn beneath the chin and over the top of the head, which will keep the other tight, as in the illustration (Fig. 10). 
    The trunk and lower limbs are seldom wounded, unless the injury is a severe one, which would necessitate immediate medical attendance. Before this arrives, the only assistance bystanders can give is to stop any bleeding, either by making pressure upon the bleeding spot, or by encircling the limb with a handkerchief tourniquet as already described.
    A burst varicose vein in the leg gives rise to serious bleeding, which will be dangerous if not rapidly checked. As the accident ordinarily happens when the patient is standing, she (for it is usually women who suffer from varicose veins) should immediately lie down, and the leg should be raised, whilst a bystander presses the finger upon the bleeding point. A pad of lint and a firm bandage should then be applied, and the patient should rest the leg for a few days, and continue the use of the bandage as long as the veins are swollen.
    To bandage a leg properly, the foot must be raised and the bandage secured round the ankle by crossing the ends in front of it, as represented in Fig. 12. The bandage is then carried beneath the foot, and again around the ankle once or twice, and then round the leg, each turn over-[-30-]lapping the preceding one. When the calf is reached, it will be necessary, in order to make the bandage fit properly, to turn it down on the outer side of the limb each time it surrounds it ; and in order to do this neatly, the bandage should not be drawn tight until after the "turn" has been made. It will assist in doing this neatly if the finger is laid upon the bandage to fix it at the point where the turn is to be made, as shown in the illustration (Fig.11).
    Bleeding Piles may depend upon plethora, and be salutary, if slight; but if severe, and much blood is habitually lost, medical advice should be sought, in order that they may be permanently relieved. To check the bleeding temporarily, the injection of cold water, or cold decoction of oak-bark, is the best remedy.
    Wounds.- The immediate treatment of ordinary wounds of a slight character has been sufficiently indicated in the sections relating to haemorrhage. The after-treatment of a wound cannot be of too simple a character. Where there is no pain or discomfort about the wounded part, there can be no object in disturbing the first dressing applied, and this should be left undisturbed for from two to four days, according to the severity of the injury. It all has gone well, it is quite possible that a skin-wound may heal at once, and merely require the application of a piece of plaster over it, to protect it for a few additional days. If, however, it is found on carefully soaking off the original dressing that the wound is open and discharging, the best application will be the "water-dressing." This consists simply of a double fold of lint or soft linen suited to the size of the wound, and wetted with warm water, over which a piece of oiled silk, slightly larger than the lint itself is secured with a strap of adhesive plaister or a bandage. The lint should be changed twice a day, but the oiled silk will serve for many days in succession. If a simple wound fails to heal in a few days under this treatment, medical advice should be had recourse to. If on removing the first dressing, a wound is found to have its edges red and tender, and the part is painful, a poultice a of bread or linseed-meal may be applied for a day or two  before the water-dressing is begun. The vulgar dread of what is termed "proud flesh" may be mentioned here, simply for the purpose of stating that the so-called proud flesh is only a slight exaggeration of the ordinary process of healing and is of no moment unless it rises high above the general surface, in which case the occasional application of a piece of blue-vitriol (sulphate of copper) will soon reduce it to proper dimensions.

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DOMESTIC SURGERY.-III.

WOUNDS, BRUISES, AND SPRAINS.

Poisoned Wounds.-The form of poisoned wound most familiar in domestic surgery is in the finger of a cook who has pricked herself whilst trussing game or cleaning fish. The slight prick, which is not noticed at the moment, becomes painful in the course of a few hours, when the finger becomes hot and swollen, and a red blush is seen to be extending up the finger to the hand. This state of things, if taken in time, may be effectually checked by the application of a wetted stick of lunar caustic over all the inflamed surface, and for some little distance beyond it. The caustic, of course, causes a [-52-] smarting pain, and turns the finger black, but this wears off in a few days. A solution of caustic answers as well, or even better, than the solid caustic in these cases, and the ordinary "nitrate-bath" of photography, to be found in so many houses, is very good for the purpose. Instead of the inflammation spreading in the above described way, it may be concentrated in the wounded spot, and give rise to a whitlow. In this case, fomentation of the whole hand, hot linseed-meal poultices, and support in a sling, will be the proper treatment; but if matter forms, it will probably require an incision, in order to save the finger, and therefore early recourse should be had to a surgeon. Bites of animals may give rise to poisoned wounds, without there being any risk bf hydrophobia; and this is seen in the case of pet dogs, cats, squirrels, &c. The same treatment as for ordinary wounds, followed by that indicated for poisoned wounds, if occasion arises, would be proper in such cases. When there is the least reason to fear hydrophobia in the animal which has bitten, every precaution should be taken, which should include thorough cauterisation or extirpation of the wounded part; but this it is impossible for a non-medical person to carry out effectually. The bite of the adder is the only example of snake-poison met with in this country, and its effects, though serious, are not ordinarily fatal. In order to prevent, as far as possible, absorption of the poisonous material into the system, a string should be tied tightly above the wounded spot, which should be well sucked, the operator taking care to rinse his mouth out with a little brandy and water, and not to swallow any of the poison. After this, hot fomentations and a poultice will be the proper treatment. If the poison has spread up the limb, it gives rise to great swelling of the part, and this may even extend to the trunk. Friction with warm oil is the best remedy for this state of things, but it often does not subside for some days. The stings of wasps or bees are painful, but not dangerous, unless some vital part, such as the inside of the throat, is stung. The stings, which are often left in the part, should be extracted with fine forceps or tweezers, and the smarting pain may be allayed by a little moistened carbonate of soda being laid over, or some sal-volatile and oil rubbed on the part.
    Penetrating Wounds of a slight character arise from the incautious use of some common articles of domestic use, such as an ordinary sewing-needle, a crochet-needle, or a fish-hook. The ordinary needle, if buried beneath the skin of the hand or other part, may be readily extracted if so placed that both ends can be felt. In that case, it is only necessary to press the end nearest the surface through the skin, and it can be easily withdrawn. If, however, as more frequently happens, only one end can be felt, and it is uncertain what length of steel is in the tissues, attempts to force the needle out lead generally to its being buried deeper; and it is better, therefore, to have recourse to medical advice at once, in order that the surgeon may, if he think it advisable, at once cut down upon the foreign body. Operations of this kind, though apparently trivial, should never be undertaken by amateurs, since the hand is too important an organ to be cut into lightly by one unacquainted with its anatomy; and, besides, there is usually no great urgency in the case, and the needle may very well be left alone until, in process of time, it makes its way to the surface, as it is pretty sure to do. Crochet-needles are more difficult to manage than ordinary needles, owing to the hook at one end. If merely driven accidentally into the skin, the wound may be cautiously enlarged with a lancet or sharp and clean penknife, so as to allow of the withdrawal of the barb; but if deeply embedded in a finger, or, as has happened, in the tongue of a child, it will be necessary to push the point through in order to cut the hook off with a pair of wire-pliers, and for this medical assistance should, if possible, be obtained. Fish-hooks are to be treated on a similar plan, except that the disciple of Walton, being generally alone and at a distance when the accident happens, must be content to cut the line from the mischievous hook, and having forced the barb through the nearest point of skin, should draw the hook through the wound thus made.
    Bleeders are persons who suffer from what is scientifically called a "haemorrhagic diathesis"-i.e., they bleed profusely with the slightest scratch, and the blood is so peculiar that there is the greatest difficulty in stopping its flow. This disease is found to affect sometimes only one or two members of a family, is often hereditary, and may be traced through many generations. It is, fortunately, of not very common occurrence, and is only mentioned here in order to warn parents of children who suffer from a tendency to bleed, that they should always inform their medical man and their dentist of the fact, so that, as far as possible, all sources of bleeding may be avoided; and should haemorrhage accidentally occur, immediate medical assistance should be obtained, since every hour's delay renders it more difficult to stop the bleeding.
    Bleeding from the Nose is sometimes violent, and usually an evidence of some derangement of the general health, for which medical advice should be sought. In order to check the bleeding, cold water may be employed to bathe the face and head; or ice-water may be injected with a syringe or india-rubber bottle into one nostril, when, if the patient will keep the mouth open, the water will flow round the nose and out of the opposite nostril. In slight cases, merely sniffing up cold air forcibly will often check the bleeding, and, in addition, powdered alum or tannin may be used as snuff. When the bleeding continues for any time, the surgeon should be called in to plug the nostrils.
    Bruises and Contusions are common accidents where there are children, and fortunately a child is able to sustain, without serious after-consequences, a bruise which might be of importance to an older person. A severe bruise is alarming to the bystanders on account of the rapid swelling which takes place, and is annoying, in addition, to the recipient on account of the ecchymosis or discoloration left for some days after. The application of cold in any form has a tendency to check the swelling and sub-cutaneous extravasation of blood constituting a bruise, and this may be applied in any form most convenient - cold vinegar and water, iced water, or the favourite cold metal spoon. Raw beef-steak is popularly supposed to have a great controlling effect upon bruises, but apparently without good foundation. There is a medical remedy of recognised utility in these cases, however, and this is the tincture of arnica; and this may be painted on the skin, if not broken, or applied diluted with water, if the skin is torn. There is, however, one caution to be observed in the use of arnica-that in some persons it excites an irritation of the skin closely resembling erysipelas, particularly if applied to a broken surface. Some caution should, therefore, be used in its first application, though the frequency of the occurrence of any untoward result is probably very greatly exaggerated. Contusions are more severe accidents than mere superficial bruises (with which. however, they may be combined), since they may endanger the life of the sufferer from injury to deep-seated and important organs. The immediate effect of a severe contusion of any part is ordinarily to produce faintness and nausea, and for this the patient should be laid in an horizontal position, should be allowed. plenty of fresh air (and consequently should not be crowded upon by bystanders), and may, if able to swallow, drink a small quantity of weak brandy and water or wine. On recovering from the first faintness, no other symptoms may appear, and the patient may have received no further injury than the "shock" of the accident; but if, from the [-53-] mature and severity of the injury itself, it may be suspected that some internal injury has been received-as shown by long-continued faintness, by hiccup, or pain in the abdomen or chest-immediate recourse should be had to medical aid.
    Concussion of/he Brain is the common result of a contusion of the head, and cannot be too seriously regarded. In any case of injury to the head, where insensibility has occurred, a doctor should be sent for; but even in slighter cases, when the concussion has apparently only produced a temporary dizziness, careful treatment, both at the time and after the injury, will be necessary to restore the patient to a healthy state of both mind and body. In any case of insensibility from injury to the head, no harm can possibly be done by cutting the hair close, and applying cold to the head until the surgeon's arrival; or should this be delayed, and the patient's body be cold and the skin clammy, hot bottles may be put to the feet in addition. Beyond this, however, it is never safe for a non-professional person to go in a case of severe injury to the head; and most particularly ought the administration of stimulants in any form to be avoided.
    Sprains-A severely sprained ankle is a common, and at the same time a serious, accident. As it is very possible that the accidental twisting of the foot to one side may have broken the small bone of the leg near the ankle such a case should always be seen as soon as possible by a medical man. But if the sprain is of a sufficiently slight character to be treated domestically, it should be borne in mind that complications may occur at a later period, for which medical advice should not be too long delayed. In the case of a sprained ankle, it is of the first importance to get the boot off before the swelling, which invariably follows, has come on. If the accident has happened at a distance from home, the foot should then be firmly bound up with a bandage applied round the ankle in a series of figure of 8 loops, and the foot kept in an elevated posture during the conveyance of the patient to his home. On reaching home, the bandage is to be removed, and the foot assiduously fomented with water as hot as can be borne, until the pain is relieved; some tincture of arnica or poppy-heads being useful adjuncts to the fomentation. The application of leeches to bad sprains is often service, but it is not safe to have recourse to them without medical sanction. The use of cold applications to sprains, though popular, is not to be recommended. The cold lowers the vitality of the part. and tends to prevent the very repair which it is our object to bring about. Support and rest are the points to be insisted on, and these are most readily obtained by strapping the joint firmly with adhesive plaister, so that no movement of the ankle is possible. In order to do this, it is necessary to have a yard or two of good "strapping" or "soap plaister," so that the pieces required may be cut "in the length" of the calico. Strips long enough to encircle the foot and cross by some inches, are to be Cut, and must be thoroughly warmed, one by one, either by holding them with the plain side to the fire, or, better, by plunging them for a moment into a basin of hot water. The foot being then brought to a right angle with the leg, and supported on the heel at a convenient height, the strips of plaister are to be applied as follows:- Beginning near the roots of the toes, the first strip is to be passed beneath the sole, and the ends crossed over the instep, and each strap is to be placed nearer the heel, and to overlap its predecessor for about half its width. When half a dozen straps have thus been applied, another series is to be made to pass around the upper part of the joint horizontally, crossing the first set on the instep, and thus the whole joint will be supported and compressed, and the patient will be able to get about (Fig. 13). A bandage should be applied over the plaister, to keep it from slipping. In a couple of days the plaister will have become loose, owing to the subsidence of the swelling, and must be renewed, the old plaister being most easily removed by slipping the blunt end of a pair of scissors beneath it on one side of the foot, and dividing it so that it can be taken away in one piece. For a sprain of moderate severity the plaister will require renewing three or four times; but even when its use is abandoned, it will be advisable to employ a bandage or an elastic "foot-piece" for some time, as the foot will still require support. A sprain of one of the larger joints, and especially of the knee, is a serious injury; and if any severe symptoms show themselves, immediate recourse must be had to medical aid. When a knee merely gives way occasionally under a person when walking, and there is no swelling or heat about the part, it will often be of service to support the joint with a knee-cap, which may be of elastic material, and is better made to lace up than to draw over the leg. When the joint continues weak for some time, it may be advantageously treated like an ankle by "strapping," the plaister being cut long enough to go once-and-a-half round the joint, and about an inch in width. The straps are then made to overlap in regular series, from below upwards, crossing in front until the joint is completely covered, as seen in the illustration, Fig. 14.
    A Strain is much the same as a sprain, except that it does not necessarily occur in the neighbourhood of a joint. It consists in the tearing of some tendinous or muscular fibres, and is generally the result of some violent and unwonted exertion. The treatment consists in obtaining rest and support for the part by careful bandaging, the use of a sling, &c. The term "a strain" is sometimes applied by the lower classes to the occurrence of a rupture from some violent exertion. If any swelling should be noticed in the neighbourhood of the groin after some exertion or athletic exercise, a surgeon should be immediately consulted, as the case may be a serious one, and a little delay be a matter of life or death.

[-71-]

DOMESTIC SURGERY.-IV.

FRACTURES, DISLOCATIONS, BURNS, AND SCALDS.

    Fractures.-The treatment of broken bones is much too important to be entrusted to any but professional hands, but there are some points connected with the early care of such cases which may be advantageously insisted on. The great majority of fractures are what is technically called "simple," ie., there is no wound of the skin communicating with the broken bone; the more serious cases, where there is a wound, and possibly laceration of the soft tissues of the limb, are termed "compound;" and when the bone is broken into several pieces, the fracture is said to be "comminuted." In all cases of fracture it is most important to avoid all rough manipulation of the limb, lest the "simple" fracture should become "compound," by the end of the broken bone being thrust through the skin; and as the muscles of the limb itself, if excited to action, have a direct tendency to produce this undesirable result, the patient should not only abstain from all voluntary effort, but means should be taken to restrain all involuntary contraction of the muscles of the limb, as will be afterwards explained.
    The immediate effect of a severe injury likely to produce a fracture is ordinarily a certain amount of faintness, and this need give no alarm if the patient is not losing blood at the same time. The only treatment required will be fresh air, with perhaps a little cold water sprinkled on the face, the head being kept low until the faintness has passed off, when a little brandy may be given if the patient continues exhausted.
    Since severe accidents usually happen in the open air, the next requisite will be to place the patient under shelter; and the method of conveying an injured person safely for some distance is a matter of no small moment.
    In the case of a broken arm the sufferer will naturally support the injured limb with the opposite hand in the position least painful to himself. When this has been ascertained, and if there is any distance to travel before a surgeon can be seen, the arm should be supported both by handkerchiefs arranged so as to sling it, and also by a handkerchief or bandage bound - not too tightly - round the arm itself, so as to support the parts. A piece of card-board (such as is used for tying up gloves), or a piece of a common hat-box, four inches wide, may be advantageously placed on each side of the broken bone and secured with the bandage which envelops it. The patient may then be safely driven some miles in a carriage; and a four-wheel conveyance with good springs is to be preferred.
    If one of the bones of the leg is broken the patient is immediately rendered helpless, and the greatest care will be requisite, lest in moving him great pain should be inflicted.
    By far the most satisfactory way to carry a wounded man is on some form of litter borne by four bearers. A hurdle, or a small door taken off its hinges, is a very good substitute for a regular "stretcher," and either, with a mattress and pillow, will form a very comfortable temporary means of transport. When neither of these is at hand, a blanket may be used to carry a patient in for a short distance, or if four poles can be procured and fastened together to form a frame-work, the blanket can be tied to the corners, as shown in the illustration, Fig. 15, and will [-72-] then be much more efficient and easy to carry. Whatever method is adopted there are certain rules with regard to carrying a stretcher which should be carefully attended to:- A stretcher should be carried by four men rather than by two, and should always be carried by the hands and not on the shoulders ; the drawbacks to the latter proceeding are the difficulty of finding on an emergency four men of the same height, so that a level position may be secured; and also that any tilting of the stretcher may throw the patient off from such a height as seriously to aggravate his injury. Besides, the raising and lowering of the burden is not an easy matter, and is apt to frighten the patient when unskilfully performed.
    It is not advisable that the hearers of a stretcher should "keep step." If only two men are carrying a stretcher, and they march "in step," the load they are carrying will be swayed to the right and left side alternately, to the great discomfort of the patient ; but if one advances his right foot and the other his left, the burden will be kept perfectly even. The same rule applies to the case of four bearers, only here the front and rear men of opposite sides should keep step and be out of step with their companions.
    A temporary splint may be advantageously applied to a broken leg before the patient is moved on to the litter, as has already been advised in the case of a broken arm, and for this purpose nothing answers better than some clean wheaten straw laid along each side of the broken limb, and bound to it by two or three handkerchiefs.
    In the case of a badly-sprained ankle, or a crushed foot, it will be sometimes convenient to carry a patient between two bearers in a sitting position, or semi-recumbent. The first method is shown in the accompanying illustration, Fig. 16. the opposite hands of the bearers being interlaced under the thighs and behind the loins, and the patient putting his arms round the bearers' necks. This method is very trying to the bearers, and could only be endured for a short distance. A patient is much more easily carried in the semi-recumbent position, if placed in the arms of two men, arranged as shown in the illustration,. Fig. 17, their opposite hands firmly interlacing in front, and their other hands being placed on each other's shoulders, so as to support the patient behind; thus the weight of the patient falls chiefly on the two arms behind him, and he can be carried for some distance without fatigue.
    Another way of carrying a patient is upon what is known among schoolboys as a "sedan-chair," each bearer grasping his own fore-arm and that of his fellow about its middle, as shown in the illustration, Fig. 19, and the patient grasping the bearers' necks, as shown before in Fig. 16. This is a convenient way to carry ladies over shallow streams, &c., in the course of country walks or at picnics; and as on those occasions sprained ankles are not altogether unknown, a disabled member of a party may [-73-] thus be transported for a long distance with relays of bearers, the two working together being as nearly at possible of a height 
    Dislocations. -A dislocation, like a fracture, should always be submitted to the care of a surgeon as soon as possible. When a bone has slipped from its socket the limb is useless, and there is more or less pain, and the neighbourhood of the joint is deformed.
    A dislocation of the shoulder is at once the most common, the most painful, and the most readily reduced of these accidents, and we venture, therefore, to give a few hints for its treatment. A fall into a ditch is a common cause of this accident, the elbow being caught on the bank and suddenly thrust upwards, when the head of the bone slips out of its socket and into the arm-pit, giving rise to excruciating pain from its pressure upon the large nerves. This being an accident which may happen to a rider when hunting, or when unable to obtain assistance, he may safely make an attempt to reduce the arm himself, by using a gate for the purpose of a fulcrum, as shown in Fig. 18. Here, lifting his arm over the gate with the other hand, the patient grasps the lowest bar he can reach, and allows the weight of his body to hang on the other side of the gate until by the pressure of the top bar the bone is forced into its socket with a snap.
    Another method, which may be safely employed by a bystander, is to seat the sufferer in a strong chair and to put the foot on the seat with the bent knee under the dislocated shoulder, as shown in Fig. 20. The arm is then to be grasped and forcibly bent over the knee, when the dislocation will probably be reduced no more violent efforts are justifiable in the hands of non-professional persons, and in any case, even of reduced dislocation, the patient should be seen by a surgeon as soon as it is convenient, lest any other injury which he may have sustained at the same time should have been overlooked.
    Burns and Scalds.-Burns are probably not quite so frequent as scalds, but are much more alarming at the time of their occurrence, and, if severe, are much more serious in their results than scalds. The slightest form of burn, viz., a superficial burn or scorch, merely reddening without destroying the skin, maybe produced by a slight explosion of gas, or the ignition of some article of clothing, which has been rapidly extinguished. Here the pain is severe for the moment, but rapidly subsides as soon as the surface burnt is protected. This can be readily effected by dredging flour over the part, and wrapping it up in cotton wadding ; or, should the part burnt be one not readily covered in this way, e.g., the face, by painting it over with a mixture of equal parts of collodion and castor- oil, or with a solution of nitrate of silver, such as the nitrate-bath of photography. When the burn is more severe, little blisters rapidly form on the burnt part, and these vesicles, as they arc surgically termed, require careful treatment. If, as is sometimes recommended, these vesicles are left to themselves, the contents solidify, and a jelly-like mass is left, which has afterwards to be got rid of by poulticing, to the great discomfort of the patient; or, even if this coagulation does not take place, the thin scarf-skin or cuticle raised by the blister is apt to be torn away and leave a tender surface beneath. The best plan, therefore, is at once to prick the blisters on one side with a needle, or to make a small opening with a sharp pair of scissors, and then carefully to squeeze out the watery contents, pressing down the skin gently but firmly with a piece of cotton wool. When this has been done, the case may be treated by any of the methods already given for slight burns, but it must be borne in mind that fresh vesicles may form after the first dressing, and hence great care must be taken, in the subsequent dressings, not to tear open the blisters unintentionally. Scalds closely resemble slight burns in both their symptoms and treatment, and need not, therefore, be treated of at greater length. Severe burns, such as arise from the clothes taking fire - crinoline accidents, as they used to be called - are very serious, both as regards the life of the patient, and her future comfort, should she survive ; and medical attendance should be immediately obtained. Lacking this, however, it may be noted that the immediate danger to the sufferer's life is due to the violent "shock" which the system sustains, as is shown by the faint, semi-conscious, and pallid condition in which the patient is left when the conflagration is extinguished. The proper treatment will [-74-] be to restore warmth and vitality to the sufferer, and this can be best done by wrapping her in a blanket, and placing her in bed (or before a fire, if it is winter), with hot bottles or bricks so arranged about the legs and trunk as to impart warmth without interfering with the burnt surface. In the case of a child (and of an adult too, if conveniences are at hand), a warm bath is at once the most soothing and appropriate treatment, since the warm water (the temperature of which must be carefully maintained at 90?) soaks off all the charred clothing, &c., and leaves the burns in the most healthy condition for dressing. At Vienna, baths are so contrived that patients suffering from burns or obstinate skin diseases, can spend days or even weeks in them, and anywhere, with care and attention, the temperature of a bath could be kept up for some hours, at least. In addition to external warmth, a severely-burnt patient will bear the administration of some hot cordial drink, and then, pending the arrival of a medical man, no harm can possibly be done by enveloping the burnt parts with cotton wadding.
    Burns are dangerous, not merely from their immediate effects, but from the complications which are apt to follow in their train. Thus, in children especially, inflammation of the lungs is very apt to follow a burn about the trunk; and again, ulceration of the bowel is found to be a frequent cause of death in these cases. The friends of a patient who has been burnt should, therefore, be careful to call the attention of the medical man in attendance to any cough or difficulty of breathing on the one hand, or to the occurrence of any diarrhoea on the other.
    With the best care, burns are, undoubtedly, very fatal accidents, and, as prevention is better than cure, it may not be out of place to urge the necessity for wire fire-guards over all fire-places to which children or females have access. Men, from the nature of their clothing, are much less liable to burns than women, unless, indeed, they indulge in the pernicious practice of "reading in bed" by candle-light. Even when the first dangers of a severe burn are surmounted, the patient will have much to undergo in the healing of the wound, and here a fresh danger comes in-that of the contraction of the tissues in healing, so as to leave great deformity behind. Patients and their friends are sometimes more to blame than their attendant for terrible contractions of the neck, arms, &c., frequently seen after burns; and they do not carry out fully the surgeon's instructions, from not understanding their importance, and, being intent only upon healing-up the wound, cannot understand the necessity for care and attention. It may be laid down as an axiom that the quicker a wound heals, the more it contracts, and it is evident, therefore, that the slower a wound can be made to heal, the less likely it is to leave unsightly contractions behind. In order to prevent contractions, it is often necessary to confine the patient to an irksome position, so as, e.g., to stretch the neck, or to apply a splint to keep out the arm; and these inconveniences should be cheerfully borne, when they are ordered by a competent medical man.
    It may not be inappropriate here to give a few hints as to the best method of extinguishing the flames, when a woman's or child's dress has unfortunately caught fire. If the sufferer has presence of mind enough to throw herself on the ground and roll over and over until the by-standers can envelop her with some thick and non- inflammable covering, her chances of escape from serious injury will be much increased ; but, unfortunately, the terror of the moment ordinarily overcomes every other feeling, and the sufferer rushes into the open air-the very worst thing she could do. The first thing for a by-stander to do is to provide himself with some non-inflammable article with which to envelop the patient, and a coat or cloak - or, better, a table-cloth or drugget - will answer the purpose. Throwing this around the sufferer, he should, if possible, lay her on the ground and then rapidly cover over and beat out all the fire, keeping on the covering until every spark is extinguished. To attempt to extinguish fire by water is useless, unless the whole body of flame can be put out at one blow ; and for one lightly-clad female to attempt to succour another, when other persons are at hand, is simply to imperil two lives instead of one. In the case of a house on fire, it is to be remembered that death is more frequently the result of suffocation from smoke than from contact with flame, and every effort should be made to reach the open air by crawling along the floor (where there is usually breathing space) so as to reach a window, or, if necessary, by enveloping the head in a thick shawl to exclude the smoke while making a rush along a passage or down a staircase.

[-111-]

DOMESTIC SURGERY.-V.

SUSPENDED ANIMATION.

UNDER the head of suspended animation are included all those cases of apparent death in which, by the judicious application of appropriate remedies, the patient may be restored to vitality and health. The simplest form of suspended animation is that seen in fainting, when, from the effects of heat or over-exertion (combined possibly with tight lacing), a young lady becomes pale, falls down insensible, and appears scarcely to breathe. The admission of fresh air is of the first importance, and she should be immediately placed near an open window, and in the recumbent position. so that the flow of blood to the head may be accelerated. At the same time, any tightness of dress should be at once remedied, and a little cold water sprinkled in the face. The use of smelling-salts is occasionally of service in rousing a patient, but care must be taken not to apply them too vigorously, for fear of irritating the nose. If, as sometimes happens, a fainting-fit is only the prelude to a fit of hysterics, the patient should be thoroughly roused by the free application of cold water, so soon as the hysterical sobbings begin to show themselves, and a brisk walk up and down the room, between two not too sympathising friends, will then probably avert a domestic catastrophe which is always annoying to all concerned. Persons with a feeble circulation, and, therefore, more liable to faintness, may be glad to know that they can often avert a fainting-fit when they feel it coming on, by at once lying down flat on a sofa; or, if from position - as in church - this is impossible, then that bowing the head well down on the knees will have the same effect.
    Drowning is the most common cause of serious suspended animation, and, as accidents may happen at any moment, every well-educated person should know what to do on the emergency. In cases of drowning, every moment is of importance, and the attempts at resuscitation should, therefore, be begun as soon as the sufferer is drawn from the water, and without conveying him any long distance to a house. The great object of treatment is to rouse the heart by inducing respiration, as in the case of fainting, and, if all efforts at this have ceased, recourse must be had at once to "artificial respiration," by the following method, known as "Sylvester's." The mouth being cleared of any dirt or saliva which may be in it, the tongue should be drawn forward, and held with the finger and thumb, or secured with a piece of ribbon or an elastic band passed over the tongue and under the chin. This drawing forward of the tongue is very important, as it opens the wind-pipe, and must never be omitted. The patient being then laid on his back, with the shoulders and head slightly raised, the operator kneels behind his head, grasps the arms just above the elbows, and draws them steadily and gently upwards (as shown in Fig. 21) until they meet above the head. By this means, the walls of the chest are expanded, and air is drawn into the lungs, and a second or two should be allowed for this to take place. The operator should then lower the patient's arms to his side, and press them against his chest (as seen in Fig. 22), so as to force out the air from the lungs, and thus imitate respiration. This series of movements should be repeated twenty times a minute - not more - and the time should be taken from the watch of a bystander, or it will be found in practice that anxiety will lead to hurry and consequent damage. As it will be impossible for one person to keep up the exertion necessary for many minutes, from the fatigue consequent upon it, he should be relieved as often as may be necessary by another, who should have watched and learnt the method of proceeding ; but it is important that all directions should be given by one person, since confusion and delay is sure otherwise to occur. Whilst efforts at restoring respiration are being thus unceasingly carried out, the attention of other assistants should be given to restoring the warmth of the body of the drowned person, by removing wet clothes, applying hot blankets and bottles, and by using friction assiduously to the limbs, in an upward direction, so as to favour the flow of blood towards the heart. The utility of a warm bath is questioned by many authorities, and should only be resorted to when the patient is suffering from extreme cold. Even in this case, it is well to dash cold water over the face and chest, so as to excite respiration, and the use of the warm bath should not be continued more than five minutes, without medical sanction. Efforts at resuscitation should be continued for at least an hour, even in unfavourable cases, unless, indeed, [-112-] a medical man is able to certify that the sufferer is undoubtedly dead. Patients recovered from drowning generally require careful after-treatment for a few days, but this is best left in the hands of the medical attendant.
    Cases of Hanging; with suicidal intention, may unhappily be met with, and require treatment very similar to that appropriate for drowned cases. Of course, the first step is to cut the sufferer clown, and loosen the ligature round the neck. Cold water should then be dashed over the head and chest, and if no breathing is thereby excited, recourse should he had at once to artificial respiration, as above described. In cases of hanging, it may be necessary to bleed the patient from the jugular vein or temporal artery, in order to relieve the congestion of the head, but neither of these operations can be safely undertaken except by a medical man.
    Suspended animation from Foul Gases is most commonly met with in connection with breweries, where the carbonic acid gas is apt to collect in the large vats used for brewing; or in wells, where the same gas collects and is dangerous to any workmen descending to repair pump-tubes, &c. As in these accidents several lives are often unnecessarily sacrificed, in the well- meant but ignorant efforts made to rescue the first sufferer, it may not be out of place to say a few words as to the best method of dispersing the noxious gases, and removing those who are suffering from their influence. When one man has fallen insensible under the influence of the carbonic acid, it is simply suicide for another to attempt to rescue him without proper precautions. These consist in having a strong rope securely fastened round his waist, so that he may be drawn up at once if overcome, and another similar rope to be carried in the hand and to be attached to the first victim. The mouth and nose should be thoroughly muffled with a woollen comforter or handkerchief, and the rescuer should breathe as seldom as he can whilst attaching the rope to his fallen comrade. If sufficient assistance is at hand, efforts should at the same time be made to disperse the carbonic acid gas by throwing down buckets of water. By this means the ordinary atmospheric air will to a certain degree be mixed with the deleterious vapour, which being heavy will speedily find its way through an opening in the bottom of a vat, if such can be rapidly made by opening a trap or cutting out a plank. A garden-engine and hose, if at hand, may be used to pump fresh air to the sufferers, and a fire-engine, if obtainable, would be a still more efficient instrument. When the sufferer is at last placed in safety, every effort must be made to establish respiration in the manner already explained under the head of drowning. It is most important that a free access of fresh air should be allowed to him by avoiding all crowding of anxious relations and friends around the patient.
    Insensibility from Sun-stroke is occasionally met with in the summer months, from exposure in the hay-field, &c. The patient complains of violent pain in the head, and in bad cases becomes rapidly insensible, the face being flushed and the head hot. The treatment is to remove the sufferer into the shade and to apply cold water freely to the head and nape of the neck. The head should be supported and cold water (iced if possible) poured from a height upon it. At the same time mustard poultices may be applied to the calves of the legs, and medical aid should be immediately summoned.
    The same treatment would be appropriate to a case of apoplexy, care being taken, however, not to prolong the cold affusion, as the patient's strength might not be able to bear it. 
    Cases of insensibility from Intoxication or Poisoning should be seen by a medical man as early as possible. No harm, however, can be done in any case by inducing vomiting, and this is most readily accomplished by tickling the interior of the throat with a feather, if the patient is unable to swallow, or if he is able, by the administration of an emetic of warm mustard and water. All constriction about the neck and chest should be removed, and the patient be placed on his side with the head slightly raised.

[-154-]

DOMESTIC SURGERY.-VI.

    Frost-Bite.--The effects of cold, if severe, are scarcely less dangerous than those of heat, though not so frequently met with, in this country, at least. Probably the commonest form of frost-bite is the ordinary chilblain, and its close resemblance to a burn is shown by the fact of a vesicle forming and leaving a sore behind it just as if the part had been burnt. As the worst thing for a burn is to apply cold, so the worst thing for a frost-bite is to apply heat, and this is frequently seen in the case of people who put their cold feet to the fire, and so produce the chilblains of which mention has been made. A frost-bitten part loses its natural colour, becomes of a tallowy white, feels numbed and insensible, and, if not judiciously treated, may mortify and drop off. The proper treatment is to restore the circulation in the part, very slowly and gradually, and for this purpose, friction should be used with the hand, containing snow or dipped in ice-water. The patient should be kept from the fire, and in an airy room, until the sensation in the limb and its colour are fully restored. When a limb is really severely frost-bitten, immediate recourse should be had to medical advice, as the patient may lose a part of it, or hardly escape with his life. A person who has been long exposed to a low temperature, particularly if either very young or very aged, or in feeble health, may be so completely overcome as to be in very considerable danger. The first evidence of this is a drowsiness, which becomes after a time perfectly irresistible, but which, if indulged, is equally fatal. Every effort should be made to rouse the patient, and to keep him awake until shelter is reached, when, if already passed into an insensible condition, medical aid should be at once summoned. In the meantime, the patient should be stripped and wrapped in a blanket, and friction of the limbs with the hands should be carefully and steadily carried on. A little warm milk may be cautiously administered with a spoon pushed well back into the throat, and, if an enema syringe is at hand, some warm water or milk may be thrown up into the bowels. Recourse should be had to artificial respiration, if the patient does not breathe even slightly; but for instructions how to carry out this recommendation, the reader is referred to the chapter on the treatment of drowning, a much more common casualty than severe frost-bite.
    Gunpowder Accidents, though similarly treated to burns and scalds, must be confided to professional hands, if possible. The effect of the explosion of gunpowder upon the patient differs according to the proximity and the force of the explosion. Loose or slightly compressed gunpowder, as in a "squib," scorches the patient by its explosions and is apt to carry unburnt grains of the powder into the skin. These leave an ugly and almost indelible mark; for though it is true that the grains of powder may be picked out with a needle, few sufferers will endure the operation, which is necessarily painful. The explosion of tightly-compressed powder, as when contained in a powder-flask, is of a most violent character, and is sure to lead to such injury of the hand which holds it as to require immediate surgical attention. This accident is, in fact, only mentioned here in the hope that a hand may be saved by calling attention to the fool-hardy feat which so often recurs with the same disastrous result - the pouring powder from a flask into an open fire. Of course a complete train is thus established from the fire to the flask, with the most dreadful results to the foolish performer of the experiment.
    Gun-shot Injuries, and particularly those occurring in civil practice from the incautious use of fowling-pieces, are always most serious in their nature, and require most skilful professional treatment. As some time must ordinarily elapse between the occurrence of the accident and the arrival of the surgeon, it may be well, however, to indicate the treatment to be pursued. In the first place, the bleeding should be arrested by binding up the wound in the manner already described. Secondly, as the patient will be certain to be suffering severely from "shock," it will be advisable to keep him in the recumbent position, to apply warmth to the extremities, and-if the bleeding has been controlled-to give stimulants cautiously. We take this opportunity of calling attention to the folly - we may almost say wickedness - of pointing any weapon, whether believed to be loaded or otherwise, at another person in jest. Such jests have so frequently turned out to be miserable and irremediable mistakes, from the gun being unexpectedly loaded, that we very strongly maintain that from earliest childhood every boy should be forbidden to point even a pop-gun at a living person.
    Injuries from Chemicals are comparatively rare accidents, though they may prove most serious in their results. The application of any of the strong mineral acids - nitric, sulphuric, or hydrochloric-to the surface of the body will char the cuticle, and, if not immediately washed off, or neutralised with an alkali - soda, potash. or lime - will eat into the part, giving rise to excruciating pain and destruction of the tissue. In the same way the application of the caustic alkalies will destroy the surface, and require to be neutralised with some diluted acid, of which vinegar is a convenient form. The most serious form of accident from chemical substances is when they are swallowed by mistake, and these cases require immediate and active medical treatment. Pending the arrival of a medical man, no harm can be done in any case by administering olive oil or uncooked eggs ; but the surgeon will of course use his discretion as to the means to be subsequently adopted.
    Particles of quick-lime are occasionally blown into the. eye, and produce very serious mischief if not immediately attended to. Since it is the contact with the tears which produces the caustic effect, it is of no use to merely bathe the eye with water, and fortunately an antidote is at hand in vinegar, which, when mixed with water and applied to the eye, produces an insoluble salt of lime, and arrests the mischief. When all pain has been allayed by the use of the vinegar and water, a drop of castor-oil, placed between the lids, will give great comfort to the patient ; but medical advice should be sought if there are, as will frequently be the case, white marks left upon the surface of the eye-ball.
    Foreign Bodies introduced into various parts of the body cause more or less mischief; and, as a rule, the earlier they are removed the better for the patient. 
    Dust in the Eye is a familiar example, and is very distressing from the irritation in that sensitive organ which it immediately excites. When the foreign body is merely lying beneath the eye-lid it can often be [-155-] immediately removed by drawing the upper lid well down over the lower, and then allowing the eye to be slowly opened, when very generally the intruder will be entangled in the lower lashes and thus removed. If this little manoeuvre, repeated once or twice, does not prove successful, it will be necessary to turn the upper lid up, so as to expose its under surface. This can be accomplished by a non-professional person with a little care, and without any risk of injuring the eye, as follows:- The patient being seated, and leaning his head back against the operator's breast, the latter, holding an ordinary bodkin in one hand, presses it gently on the outside of the lid, and about half-way down. With the fingers of the other hand he then seizes the eye-lashes, and, drawing the lid a little forward, turns it up over the bodkin. This will be accomplished readily enough if the operator is steady and the patient willing, and the whole surface of the eye will then be exposed, when the foreign body can be seen and removed. If, however, the particle is of a pointed character - e.g., a piece of steel - and is embedded in the cornea, or transparent covering of the eye-ball, the assistance of a surgeon should be at once obtained to ensure its safe and early removal. In any case of injury to the surface of the eye the application of a drop of castor or other oil, as recommended in the previous section, will be found of great service.
    Foreign bodies are often introduced by children into the nose or ear, in sport, and are generally of a more or less globular form, such as beads, pebbles, cherry-stones, or beans. These, if near the orifice, may be readily hooked out with one of the common ear-picks found in ladies' dressing-cases, or with the loop of a common hair-pin but if more deeply placed, injudicious poking with instruments may do harm, especially in the ear, and it is better to have recourse to the injection of a stream of warm water with a good-sized syringe, by which the interloper may be washed out. In the case of the nostril, a violent sneeze, induced by the inhalation of a pinch of snuff or pepper, will often dislodge the obstacle, but if recourse is had to syringing, the best method is to inject the water through the opposite nostril, when, if the patient leans forward, and keeps the mouth open, the water will run round the back of the nose and out at the affected nostril, bringing the foreign body with it. The vulgar notion that "earwigs" have a tendency to find their way into the ear, is a popular delusion, but as it occasionally happens that an ant or other small insect enters the ear, and gives rise to pain and irritation, it may be well to mention that the simplest way of relieving the sufferer is to place the head horizontally and to fill the ear with water, when the insect will be at once floated out of the cavity.
    Foreign bodies in any part of the wind-pipe are always serious, and may be immediately fatal. The accident commonly happens from a child having some plaything, such as a bean, small, marble, bead, or nut-shell, in its mouth and being desired to take it out, when, either in the hurry to obey, or possibly from its disinclination to do so being quickened by a cuff, the foreign body slips into the wind-pipe, and produces serious mischief. In the well-known case of the late Mr. Brunel, the eminent engineer, whose life was endangered by an accident of this kind, it arose from his performing a conjuring-trick with a half-sovereign in his mouth, and the coin slipping into his wind-pipe. When the foreign body becomes fixed in the upper part of the wind-pipe or larynx, so as to obstruct the breathing, the patient becomes black in the face, and falls back apparently dead. This sometimes happens during a meal, from a child or grown-up person happening to cough while eating, and thus drawing a piece of food into the air-passages. Whatever the cause, a by-stander should, without hesitation, thrust his forefinger to the back of the throat, and endeavour to hook up with it the offending body, and this can often be done, when the patient will at once breathe again. If this method is not successful, the patient, if a child, should be held up by the legs and be smartly thumped between the shoulders, when not improbably the foreign body will drop on to the floor, and the child will then begin to respire and cry; but if respiration is still suspended, cold water dashed on the chest will probably rouse it, or, if not, recourse must be had to artificial respiration, as described under the head of Suspended Animation (page 111). Of course, medical aid will be summoned at once in any case of serious choking, if possible, but the majority of these cases do well without it. If, however, the foreign body is not dislodged by the efforts of by-standers, an operation will be necessary to save life, and every moment will he of importance. Even if the urgent symptoms have passed off, and the child appears to be restored to health, yet, if the foreign body has not been found, the advice of a surgeon should, nevertheless, be sought at once, as it may still be lodged in the deeper air-passages, where it may cause fatal mischief if not dislodged at an early period.
    Foreign bodies seldom lodge in the gullet, and such obstacles as fish-bones can generally be got down safely into the stomach by swallowing a large mouthful of well-masticated bread. In cases where this does not succeed in removing the bone, a medical man should be sent for, who can, by a very simple treatment, get rid of the obstruction. The most serious obstruction is a set of false teeth, since the plate upon which they are fixed is apt to become entangled in the mucous membrane, and necessitate a serious surgical operation. The best way to avoid such an accident is for the wearers of artificial teeth on no account to go to bed with them in their mouths, since it is usually during sleep that the accident happens.
    Foreign bodies, such as coins, often pass into the stomachs of children, and give unnecessary alarm to their friends. In the great majority of cases, such articles would pass through the intestines without any treatment, but certainly the worst treatment possible is to give the child purgative medicine, as is so often done. Either an emetic of mustard and water should be administered at once, so as to bring up the foreign body, or, if the case is seen too late for this, every effort should be made to cover it over with more or less adhesive food, so that it may pass readily through the bowels. Pins or needles, when swallowed, should always be treated in this latter way. The best regimen for a child, under these circumstances, is plenty of bread and milk, with common hard dumplings and bread and cheese for his dinner, and a careful avoidance of fruit, &c., until the indigestible body has come away.

[-172-]

DOMESTIC SURGERY.-VII.

TEETHING. 

The Gums and Teeth.-The proper care of the teeth as organs most essential for the preservation of health, cannot be too strongly impressed upon parents. Many of the illnesses of childhood are directly connected with the eruption and development of the teeth; and these will be more particularly referred to in other papers, the object of the present article being only to point out those facts in connection with the teeth which every well-educated father and mother should be acquainted with. Each individual has two sets of teeth, the temporary and the permanent; the former being contained in the jaws at birth, and taking their proper positions within the first three years of childhood, the latter being at the same time developed in the jaws and appearing from the sixth to the twenty-first years. The temporary teeth are twenty, and the permanent thirty-two in number. In the illustration (Fig. 23), taken from the jaws of a child of from six to seven years old, the whole of the temporary teeth are seen in their proper positions, and in addition, the crowns of four of the permanent teeth have appeared through the gum at the back of the temporary set. The remaining permanent teeth are those embedded in the jaws, and at present imperfectly developed.
    The teeth of the two jaws correspond in number and form, and the temporary teeth are as follows:- In the centre of each jaw are four cutting or incisor teeth ; on each side of these is a pointed canine or eye tooth; and beyond these again two grinding or molar teeth. In the permanent set the teeth are of course larger, and are the following:-There are four incisors, two canine, and four small pre-molar or bicuspid teeth, as in the child; but, in addition, there are on each side three large grinding or molar teeth, the last of which is called the wisdom-tooth, from its being cut only when years of discretion are supposed to have been reached.
    The period at which each tooth makes its appearance through the gum is pretty constant, though it will depend somewhat upon the growth and health of the child. On an average, the central incisors are cut about the seventh month ; the lateral incisors from the seventh to the tenth month the front molars from the twelfth to the fourteenth month; the canines from the fourteenth to the twentieth month; and the back molars from the eighteenth to the thirty-sixth month. The permanent teeth appear in a different order, the earliest being the first molars ; and these appear in the sixth year, and take their places immediately behind the temporary teeth. The two middle incisors are cut about the seventh year, and these necessarily displace all four of the temporary teeth; the two lateral incisors appear in the eighth year ; the first bicuspids in the ninth year; the second bicuspids in the tenth year; the canines from the eleventh to the twelfth year ; the second molars from the twelfth to the thirteenth year; and the wisdom-teeth from the seventeenth to the twenty-first year. It is to be understood that the above enumeration applies to both jaws, but that the teeth of the lower jaw are usually a little earlier in their appearance than those of the upper jaw. 
    Lancing the Gums. - When an infant is cutting its teeth its mouth is hot, and the gum is swollen and tender. Great relief may be afforded, and even its life may be saved, should it be subject to convulsions, by freely lancing the gums. This operation should of course be performed by a medical man, if one can be procured, but, in case of urgent need, a parent would be justified in performing it himself, if provided with a proper instrument, and having some knowledge of the subject. The gum-lancet is a steel instrument of the shape shown in Fig. 24, and may be  procured of any surgical instrument-maker. In lancing the gums of the lower jaw it will be most convenient to have the infant held against the breast of a nurse, and in the sitting position, when the operator, sitting or kneeling in front, must steady the jaw with the left hand, as shown in Fig. 25, and with the right make a steady cut on the top of the inflamed gum down to the crown of the tooth, against which the edge of the Lancet should be made to grate. In lancing the gum of the upper jaw, the infant may be most conveniently held on the knees of a  nurse, and with the head fixed between the knees of the operator, who can then lean over and see clearly what he is about. Lancing of the gums should only be resorted to, when the tooth makes a prominence through the gum, and it will therefore usually make its appearance in a day or two. If, however, the gum has been lanced a little prematurely, no harm will have been done, the gum being more yielding after than before the operation, and the haemorrhage, which is never of any amount, serving to  relieve the over-distension of the part. 
    Care of the Teeth.-The temporary teeth require some supervision on the part of the parent, as the child is too young to do more than complain if he is in pain. Children who have suffered much from infantile diseases almost invariably have badly-developed and unsound first teeth, but may, if well cared for, grow up strong and vigorous, and with sound permanent teeth. It is a common error to suppose that the administration of medicine has caused the early decay of the first set, or the unsightly markings sometimes present on the second set of teeth ; whereas it is the disease for which the remedies were given which has left its trace behind. The molar teeth, both of the first and second set, are most liable to decay, and a child's mouth should be carefully examined from time to time to see if any of these teeth are discoloured or hollowed out. If they are, the child should be at once taken to a dentist, to have the diseased tooth stopped before it becomes  painful, so that it may not become necessary to extract it before its full time. As the permanent molar teeth take up their position behind the temporary teeth, it is most important, for the full development of the jaw and the proper arrangement of the teeth, that the temporary teeth should not be extracted too early. At the same time, if the jaw should be small, and the teeth are taking up irregular, and perhaps too prominent positions, it may be necessary to extract even some of the permanent teeth at [-173-] once, in order to allow the others to take their proper places. For this purpose a parent should consult some respectable dentist, carefully avoiding all unqualified practitioners, and should be careful to see that all the directions he gives are carried out, and particularly that any mechanical arrangement which may be necessary in order to bring irregular teeth into position, is fairly and fully attended to.
    Later in life, in addition to the ordinary cleaning of the teeth with tooth-brush and powder, or soap, it is well to pay an occasional visit to the dentist to have the " tartar," or earthy matter deposited by the saliva, removed from the front teeth. Even in the most cleanly mouths this is apt to collect and injure the gums, if it does not the teeth also; and, as it is very tenacious, it requires some skill for its removal. At the same time the dentist should be requested to inspect all the teeth, in order to detect the first inroads of disease, so that by careful "stopping" the mischief may be arrested. The nature of the stopping to be applied in each case must of course be left to the discretion of the dentist, but a patient should on no account consent to the insertion of a cheap "amalgam" stopping into any of the front teeth, since this always leads to great discoloration of the teeth, and consequent disfigurement. When toothache supervenes upon decayed teeth, recourse must of course be had to the dentist, who may, in favourable cases, contrive to save the tooth by destroying the nerve and then carefully stopping the cavity. Extraction is the last remedy, and has recently been robbed of nearly all its horrors by the introduction into dental practice of the administration of the nitrous-oxide gas as an anaesthetic. This gas, when carefully administered in its pure state, has the power, like chloroform, of rendering the patient perfectly insensible, but has this advantage over chloroform, that the insensibility is much shorter, and that recovery from its influence is immediate, and unattended with sickness. Many dentists are in the habit of administering this agent for all cases of extraction of teeth, but no person should take this, or any other anaesthetic, without first consulting his ordinary medical attendant.
    Toothache is perhaps the most agonising pain to which one can be subject. If, from circumstances, immediate recourse cannot be had to a dentist, relief may sometimes be obtained temporarily by the insertion of a pledget of cotton-wool soaked in Iaudanum into the hollow tooth, and by the application of warm fomentations to the face. Several specific remedies are sold, which are certainly efficacious as a temporary application in cases of toothache, and the introduction of a few drops of warm laudanum into the ear often does good. The formation of an abscess around a tooth may be known by the deep-seated throbbing pain it gives rise to, and the extraction of the tooth is the only certain way of obtaining relief.
    False Teeth are exceedingly healthful, by supplying the lost power of mastication; and no one who has lost his back teeth should hesitate to have the want supplied artificially, both for his own comfort and also for the preservation of the front teeth, upon which an undue amount of work would otherwise be thrown. Artificial teeth can be had of every price, but here, as elsewhere, we would say, avoid an unqualified dentist, whose cheap teeth would be dear at any price, since the purchaser would have no comfort in wearing them. The question of the necessity for extracting the stumps of teeth must be left to the judgment of, the dentist; but if, as often happens, it is advisable to remove some, it will be necessary to wait some weeks before the model of the mouth can be properly taken so as to ensure a proper fit. One caution only need be given with regard to false teeth, that they should always be removable at will, and should invariably be removed from the mouth when the wearer goes to bed.
    Inflammation of the Tonsils constitutes one of the common varieties of "sore throat.'' The sufferer experiences pain and difficulty in swallowing, and talks with a peculiar thick voice, which is very characteristic. On looking into the throat the back part of it is seen to be red and inflamed, and the tonsils are found to be almost blocking up the passage. If there is much fever and constitutional disturbance a medical man should be consulted at once, but the best domestic treatment consists in frequently gargling the throat with hot milk and water, and the application of linseed-meal poultices round the throat. The bowels should be thoroughly relieved with an ordinary aperient, and the patient should be fed with nourishing food, in the form of soup or broth, and will probably be the better for a glass or two of port wine. If an abscess forms in the tonsil, it may produce alarming symptoms of suffocation by its presence, and a surgeon should be at once called in to open it. An abscess may burst of itself into the throat, and thus give relief, but only after many hours' suffering.
    Enlarged Tonsils are often found in young persons of delicate health, and give a peculiarly vacant appearance to the countenance by obliging the sufferer to keep the mouth constantly open, and to breathe heavily. A more serious consequence of enlarged tonsils is, however, the effect upon the chest produced by the imperfect admission of air to the lungs, the tendency to the deformity called "pigeon-chest" being common in these cases. The only effectual treatment is for the surgeon to remove a portion of each tonsil; and this can be safely done even in young children.

[-201-]

DOMESTIC SURGERY.-VIII.

BUNIONS, AND AFFECTIONS OF THE FEET AND LEGS.

    Bunion is a painful deformity of the joint of the great toe, due to the wearing of narrow and ill-made which the toes are crushed together, and the boots, by great toe bent out of its proper position. If the affection is quite recent, and no alteration has been caused in the joint by the pressure, it will be sufficient to wear wide boots, and, in addition, to place a small piece of cotton wool between the great toe and that one next, in order to restore the foot to its natural condition. Circular bunion-plaisters of either leather or felt are very serviceable in such cases, as also with corns, in taking off the pressure of the boot. If, however, the pressure upon the joint has been of long continuance, the joint will be found to have become more or less chronically inflamed and swollen, and if so, the application of the tincture of iodine to the skin for some time may be necessary in addition to the plaister, in order to restore the healthy state of the part. Occasionally acute inflammation of the part affected is set up, even running on to the formation of abscess, and as this may be serious as regards the whole foot, the advice of a surgeon should, without delay, be obtained. Of corns we have already spoken in our articles on the Management of the Skin, p. 124.

    Ingrowing Toe-nail is another result of sacrificing health and comfort to fashion, in the form of tight boots. The great toe-nail, when healthy, is very slightly curved, and is broad and thin, and this condition may be maintained by carefully cutting the nail from time to time straight across, provided sufficiently wide boots are habitually worn. When, however, the toes are crushed together, the nail of the great toe becomes more curved than natural, and presses into the tender skin on each side, and if the slight inconvenience at first experienced does not warn the sufferer to seek relief he will find matters rapidly going from bad to worse, inflammation being set up on each side, and exuberant painful granulations springing up and overlapping the edges of the nail, as seen in Fig. 26. In the early stage of this disorder, when the nail first begins to excite irritation, the immediate abandonment of narrow boots and the careful insertion of a small pledget of cotton wool in the groove on each side of the nail will generally effect a cure but if this is not enough, with a sharp pair of nail-scissors a small slip of the nail on each side should be removed, without going down to the matrix, or "quick." In many persons this occasional removal of a slip of nail is a necessary and painless operation, though some prefer to scrape away the centre of the nail, so as to thin it until it bends readily, which in our experience is both a painful and useless operation. A better plan is to let the nail grow long and to cut a notch in the centre of it - as shown in the illustration, Fig. 26 - when the growth takes place chiefly at this spot, and the edges do not appear to encroach so rapidly upon the soft tissues. When the irritation has been allowed to go to the extent which we have shown in the illustration, the advice of a surgeon should be immediately sought, as it may possibly be necessary to remove part of the nail in its whole length - an excessively painful operation, for which the administration of chloroform, or some other anaesthetic, will be found necessary.
    Flat Foot occurs very generally in young persons who have had their strength overtaxed in carrying weights - for example, among nursemaids and errand-boys - though it may occur later in life, as is seen in the case of soldiers and policemen, and others who are on their feet during many consecutive hours. The sufferer finds the feet remarkably tender and painful after walking, and if it be neglected the distortion becomes so confirmed as to render him quite lame. In a flat-footed person, if he be made to stand up with bare feet, it will be seen that the arch of the foot has been more or less broken down, as shown in Fig. 27, so that instead of the weight of the body coming upon the extremities of the arch-the heel and the ball of the great toe-the centre bones have fallen dawn and touch the ground, and hence the pain. 
    The great object of treatment is to support the bones of the foot until the ligaments which have become relaxed shall have again become braced up. With this object in view, the sufferer should avoid much walking, and especially the carrying of heavy weights, and should have his foot carefully bandaged, as shown in a preceding paper. In order to restore the arch of the foot, the best plan is to have a piece of cork fitted to the inside of the boot so as to press up the fallen bones as much as the patient can bear without pain. After a time, as the foot improves, this can be increased in thickness, and so eventually the arch of the foot will be restored. When this has been done, a metal spring in the "waist" of the boot is useful in preventing a return of the complaint.
    [-202-] Weak Ankles are common accompaniments of "flat foot," or may exist alone. The sufferer is found to "tread over" considerably in walking, and is often conscious that the ankles yield during walking, the foot having a tendency to turn on its side. The best remedy is well-made lace-up boots, with the sides made stiffer than usual, those with elastic sides giving no efficient support. In children where there is often enlargement of the ankle-bones, bathing  with Tidman's sea-salt and water, or sea-water, and the administration of cod-liver oil are very useful remedies.
    Bow Legs are common in "ricketty" children who have been put upon their feet too soon, and are, therefore, more common among the poorer classes than among those who have attendants to carry them when young. The earthy material of the bones of these children being deficient in quantity, their legs bend with the weight of the body, and if not attended to the deformity will be permanent. The great point is to improve the little patient's health by sufficient and proper food, and particularly by supplying it with genuine and unadulterated milk and wheaten bread, both of which articles of diet contain the earthy salts necessary for the formation of bone. Fresh air and, if possible, the sea-side, are very advisable if they can be procured, and the medical treatment must be carefully carried out under the direction of a competent adviser. As regards the use of apparatus for the treatment of this and every other form of deformity, the parent should be guided by the advice of a surgeon, and not by that of a self-interested instrument-maker. Many slight cases of bow-legs do perfectly well without any apparatus at all, and in most cases a simple lath on the inside of the leg, with broad webbing straps and buckles, is as efficacious for the treatment, and better, because lighter, for the child, than complicated and expensive steel and leather supports.
    Knock Knees occur generally in youths who have somewhat overgrown their strength, and particularly in those who have been in the habit of walking or running a good deal. The ligaments of the knee-joints become weakened and gradually yield, and the lad finds that his knees are apt to touch in walking, causing the trousers to wear out on the insides of the legs, and giving to the individual a very ungainly appearance, with more or less pain in the knees themselves. The patient's health should be improved, and he should avoid walking; but if able to obtain horse exercise may avail himself of it with advantage, as it will tend to bow the knees out, as is seen in an exaggerated form in grooms and jockeys. With the same object in view, he may sleep with a pillow between his knees, and with the ankles fastened together by a silk handkerchief. A simple alteration in the sole of the boot is very useful in slight cases of this kind. It consists in having the heels of the boots prolonged on the inner side along the "waist" of the boot, the effect of which is to throw the foot slightly on one side, and thus counteract the in-bowing of the knees; the boots should be strong lace-up ones, so as to well support the ankles, which might otherwise yield. In severe cases of knock knee, it will be necessary for the patient to be confined to the sofa, and wear proper apparatus under the direction of a surgeon.
    Housemaid's Knee is, as its name implies, an affection common among domestic servants who kneel to scrub floors, &c. The little bag, or "bursa", beneath the skin of the knee and in front of the knee-cap is apt to get inflamed and swollen from the pressure it sustains, and is then often very painful, and the part looks red and swollen. Hot fomentations and poulticing, with rest for a day or two, will generally effect a cure; but if not, and the part throbs, the advice of a surgeon should be at once obtained, as possibly an abscess may have formed. In some cases there is no pain or heat, but a swelling is formed in front of the knee (as seen in Fig. 28), which gives inconvenience in kneeling. This will often subside by avoiding the practice which has given rise to it, and by painting the skin over it daily with tincture of iodine ; but if it does not disappear it should be shown to a medical man. In all cases in which it may be a matter of necessity that. work should be continued as usual, the sufferer should be very careful to provide herself with a soft pad of carpet, or matting, to kneel upon, to prevent, if possible, any increase of the inflammation.
    Hip Disease is only mentioned here because its onset is so insidious as often to be overlooked until the disease has made considerable progress; and as treatment, to be efficacious, must be early, it is important that parents should have their attention called to the first symptoms of the disorder. The disease generally occurs in weakly children, and may date from a fall which gave rise to no special symptoms at the time. The child is noticed to have a slight limp, and complains very probably of pain in the knee and not in the hip itself, unless that part is touched. These symptoms are quite sufficient to justify. recourse to the surgeon, whose directions should be strictly carried out for many weeks, or even months, if necessary to effect a cure.

[-252-]

DOMESTIC SURGERY.?IX

VARIOUS LOCAL AILMENTS.

    A Cold in the Eye.?This is a very common affection, and consists in an inflamed condition of the membrane covering the eye-ball and lining the eye-lids, and is often due, as the name implies, to exposure to a draught. The patient feels as if some dust had got into the eye, and can sometimes be hardly persuaded to the contrary; the white of the eye itself is seen to be reddened, and there is a constant flow of blinding scalding tears. The best treatment is to foment the eyes with pure warm water, or better, with water in which two or three crushed poppy-heads have been boiled for half an hour, to extract their sedative qualities. A shade should be worn over the eyes in the intervals of fomenting, and a dose of rhubarb and magnesia should be administered. If the inflammation does not subside in a day or two, a doctor should be consulted, if possible ; but, if this is not possible, good will probably be done by dropping into the eyes, two or three times a day, some solution of sulphate of zinc or white vitriol, in the proportion of one grain to two table-spoonfuls of water.
    Strumous children, especially when improperly fed, often suffer from another form of inflammation of the eye, in which the chief symptom is intolerance of light, the child using its hands to exclude the light as much as possible, or, if in bed, burying its head beneath the clothes. These cases require careful local and constitutional treatment, for which medical advice should be sought; but, wanting this, the little patient will be much relieved by having its eyes frequently bathed with cold water, and wearing a green shade over them.
    New-born children occasionally suffer from another disease of the eye, of which the chief symptom is a discharge of yellow fluid or pus from beneath the lids, which are apt to be glued together by the discharge drying on them. This is a very serious affection, since the sight of the eye may be utterly lost if it is neglected, and medical advice should, therefore, be obtained. In its absence, the eye should be carefully washed out several times a day with warm water, and a lotion of alum, in the proportion of ten grains to an ounce of water, be thoroughly applied. In doing this, the greatest care must be taken not to convey any of the yellow fluid into the eye of another person, since it is highly contagious, and will certainly lead to violent inflammation of any eye it may happen to touch.
    In washing a child's eye, the best plan is for one person to hold it firmly on its back with its head secured between the knees of the nurse who is to wash it, and its body resting on the knees of the assistant. Gently separating the eye-lids with the fore-finger and thumb, the nurse then lets the water or lotion trickle in between them from a small, clean, and soft sponge, then wipes the lids gently with the sponge, and repeats the operation on the opposite eye. When eye-drops have to be applied, the same position should be adopted, and the drops may be conveniently extracted from the phial and inserted between the lids with an ordinary quill-pen, the nib of which has been rounded off. In making a shade for the eye, a piece of card-board large enough to cover both eyes, and shaped out so as to fit the forehead, should be covered with green silk, and attached by a ribbon round the forehead.
    A Stye in the Eye is a little abscess formed at the edge of the eye-lid by the inflammation of one of the little follicles which lubricate its edge. It generally occurs in persons out of health, or in strumous children, and is apt to occur again and again until the health is improved. At the commencement of the disorder, the part is sure to be swollen and red, and feels hot and uncomfortable to the patient ; then it begins to throb, and matter forms, as is shown by the yellow point in the centre of the "stye." When this is let out, or discharges itself, the inflammation subsides, and the lid gets well rapidly. In the early stage, the only treatment is to bathe the eye frequently with hot water, and at night to put a bread and water poultice over it. When the matter forms, it may be pricked and let out with a needle, if the patient will be steady enough to allow this to be done without danger to the eye, though there is a popular but unfounded prejudice that any interference with a stye leads to the formation of others.
    The formation of an abscess on the inner side of the eye, close to the nose, is a much more serious thing, as it involves the passage by which the tears reach the nose, and will require early and careful surgical treatment, or a very disfiguring scar may result.
    Whitlow is a very common affection, and one which, in its simpler forms, may be treated domestically without danger. The simplest kind of whitlow is that which forms about the root of the nail, and which may or may not depend upon some trifling injury, or upon the introduction of some irritating substance beneath the skin. At first the finger is found to be tender and hot, and soon a sense of throbbing is experienced in it. This is relieved by holding the inflamed part in hot water, and by poulticing ; but, in all probability, matter will form, and will be seen as a white fluid, either beneath the nail itself, or raising the skin around its root. The pain is now severe, owing to the matter being pent up, and immediate relief will be obtained as soon as it is evacuated. If beneath the nail, the best plan is to remove a small wedge-shaped piece of the nail with sharp pointed scissors, so as to reach the point where the matter lies, and this can be generally effected without pain to the patient. If the skin around the nail is distended with the matter, it should be freely incised with a lancet or sharp and clean penknife, and this operation, though much dreaded by the patient, is absolutely painless, the skin having already lost its sensibility.
    The more severe forms of whitlow require prompt surgical attendance. In one, the end of the finger becomes violently inflamed and swollen, the mischief beginning in the membrane covering the bone. Then an early and free incision down to the bone is absolutely necessary, in order to save it from destruction ; but fortunately, even in neglected cases, it is seldom, if ever, necessary to perform amputation for this complaint, the surgeon being able to extract the piece of dead bone, and leave a very useful though somewhat shortened finger. In another and more severe form of whitlow, the matter forms in the finger and palm of the hand, both of which become immensely swollen ; and here a skilful incision is necessary, in order to evacuate the matter without damaging the important structures of the palm of the hand, or leading to stiffness of one or more of the fingers. In case the assistance of a surgeon cannot be obtained, it may be mentioned that the proper place to incise this form d whitlow is in the central line of a finger, and just at the point where it joins the hand. The incision should be not more than half an inch long, and should always be co the palmar surface, or under side of the finger.
    Abscesses may form in any part of the body, and are' often only evidences of deeper-seated mischief, for which medical advice should be at once procured. In cases at disease of the spine, leading to projection of the bone, and what is commonly called " broken back," an abscess very commonly forms, without any special pain, in the upper part of the thigh, and the same kind of thing may be witnessed in other parts, the patient experiencing no pain, but having an elastic swelling, in which the peculiar and characteristic sensation due to the fluctuation of the contained fluid, may be readily felt with the fingers. These chronic or cold abscesses should always be submitted to a medical man, as they may be of great importance, and their treatment requires skill and attention. The more acute abscesses have much the same symptoms as whitlows, there being heat, redness, and tenderness of the part, followed by a throbbing pain, and tension of the skin from the presence of matter within. Poulticing and fomentations form the appropriate treatment, and, if pursued long enough, will no doubt lead to the breaking of the abscess and the relief of the patient. Many days will, however, be consumed in the process, during all which the patient will be worn out with pain and want of rest, whilst a momentary incision by a surgeon's skilful hand will give immediate and permanent relief. It is very mistaken kindness for the friends to abet a patient in refusing to submit to a moment's pain in order to obtain a cure; and the patient is usually ready enough to express gratitude to those who have been " cruel only to be kind," the moment the relief is experienced.
    Milk Abscess is one of the most common forms of abscess, and is met with in mothers who either have been obliged to wean their child suddenly, or who suffer from "sore nipples," which incapacitate them from nursing. Sore or chapped nipples are more apt to arise after a first than after a subsequent confinement, and may be generally avoided by taking the precaution to harden the nipple by bathing it with weak brandy and water for a few days before the birth of the child. If the nipple is very much flattened, it should be drawn out with a breast-pump or glass, or a healthy child of a few months old may be put to the breast as soon as there is any milk. When the nipple has unfortunately become sore, the best plan is to protect it with a nipple-shield of glass, and to dry it thoroughly after being used. Almost any stimulating lotion will then effect a cure: borax, alum, or white vitriol, in solution, are all favourite remedies ; but perhaps the most successful is the application of a solution of nitrate of silver (two grains to the ounce of water) with a camel's-hair brush, three or four times during the day.
    When from any cause a mother is unable to nurse her child, the breast is apt to become gorged with milk, and unless this is got rid of, inflammation and abscess are pretty sure to follow. By the use of the breast-pump, or gentle and equable pressure with the hands, much relief can be afforded, and attention must then be directed to diminishing the flow of milk to the breast by rubbing it with warm sweet oil, or better, by smearing it with extract of belladonna mixed with equal parts of glycerine. At the same time the diet of the patient should be reduced, and a dose of Epsom salts given every morning. By these means a milk-abscess may often be averted, particularly if the breast is well supported in a sling, arranged as follows:- A large handkerchief being folded so as to form a triangle, should be applied obliquely across the chest, with the straight part immediately below the breast, one end passing over the opposite shoulder, and the other through the armpit of the same side, and the two being tied behind the back. The handkerchief being now slightly unfolded, can be made to support the breast comfortably at any height desired, and the top corner can be brought up over the shoulder, and fastened round the neck, as shown in the illustration. But if an abscess unfortunately forms, as will be known by the occurrence of a shivering fit and the throbbing pain in the breast, the advice of a surgeon should be immediately sought, if it has not been before, in order that he may give relief by an early incision. The patient is often so much reduced by the pain she has undergone as to be unable to nerve herself to sustain this necessary operation, unless her friends are very firm in supporting the surgeon in doing his duty. A milk-abscess, like any other, may, as already mentioned, break under prolonged poulticing, but only at the expense of great suffering and very considerable permanent damage to the breast, owing to the matter burrowing in several directions. In some cases it may be advisable to administer chloroform to the patient before interfering surgically, but the necessity and advisability of this must be left entirely to the medical man.
    Boils are very common, and very painful affections, and are usually found in persons who have got into a low state of health. A boil very generally begins in a little pimple, and if this is protected from irritation by being covered with a piece of soap-plaister, whilst the general health is improved by change of air and altered diet, very probably there will be no further trouble. If, however, a regular boil forms with a red surface and great tenderness, it had better be poulticed, and either allowed to break, or?a great saving of time and pain?a narrow knife or a sharp blade of a pair of slender scissors being pushed into the centre of it, and to the depth of half an inch, will allow the matter to escape with immediate relief. Prolonged poulticing of a boil is apt to bring out a crop of troublesome pimples around it, and it is well, therefore, to protect the surrounding parts with a piece of linen in which a hole is cut to fit the inflamed surface and allow of the poultice reaching it. When a boil has broken, it heals up readily enough under any simple dressing?either a little spermaceti ointment or a piece of wet lint under oil-silk. The nostrums vulgarly employed to "bring to a head"?such as soap and sugar, or the yellow basilicon ointment?are useless, and much better avoided, as they only serve to irritate the skin.
    Carbuncles are much more serious affections than boils, which, however, they much resemble, except in being larger, and therefore more dangerous to the patient. Carbuncles usually attack the nape of the neck, the back, &c., in old people, and as the most careful treatment of these affections is required from their very commencement, no time should be lost in consulting a medical man.

[-286-]

DOMESTIC SURGERY.?X.

VARIOUS LOCAL AILMENTS.

    Rupture or Hernia means the protrusion of a small portion of the bowels through an opening in the groin or at the navel. It occurs in children from violent efforts in crying, and in older persons from lifting heavy weights, coughing, &c. If a mother notices any swelling in the neighbourhood of the groin in her child (boys being much more liable than girls to this affection), she should lose no time in consulting a medical man, and ascertaining whether this is due to a rupture or to some other disease. In order to effect a cure of a rupture, it will be necessary for the child to wear a properly-fitted truss for some months, and it will be well worth a mother's while to pay every attention to this matter, so as to bring about a cure as soon as possible. It is not necessary that a truss should be worn at night, except in the case of an infant who cries as much at night as in the day, but the mother should see that the child never runs about before the truss is put on in the morning, and must be particularly careful to see that the rupture is pushed back thoroughly before the truss is applied, which is most readily accomplished when the child is lying down. It is convenient in children to cover the truss with a linen cover, which can be changed when soiled, and the greatest care must be taken to prevent the instrument chafing the skin by powdering it thoroughly. In grown-up persons the occurrence of a hernia is of even more importance than in children, since it is more likely in them to become "strangulated," i.e., it cannot be pushed back by the patient himself, obstruction of the bowels results, and this is followed by vomiting, and even by death, unless promptly relieved by the surgeon. In any case, therefore, where a rupture cannot be returned, or when after any exertion a lump has appeared in the groin, the advice of a surgeon should be sought. It unfortunately happens every now and then that a patient suffering from the bilious vomiting caused by a strangulated hernia conceals the real cause of the disease, either from ignorance of the connection between the two affections, or from a feeling of false delicacy. No one is justified in trifling with his or her own life in such a matter, and a medical man will rightly insist upon making the necessary examination if his suspicions are aroused by the symptoms, as they probably will be. When a surgeon finds that he is unable to return a rupture, it will be necessary for him to perform a slight operation in order to save the patient's life, and neither patient nor friends should have any scruple in consenting to this being done at once. Every minute is of importance in these cases, and though it is perfectly true that patients die after the operation for strangulated hernia, it is equally certain that they die in consequence of the operation having been delayed too long, rather than from the proceeding itself.
    Started Navel.?This is a not uncommon affection in young children, and if not properly attended to will lead to the formation of a rupture. The treatment consists in preventing the protrusion from taking place until the parts are in process of time restored to their natural condition, and this can only be effected by care and attention on the part of the nurse and mother. The child being laid on its back, and the protrusion carefully returned with the finger, a pad made of a slice of a wine-cork half-an-inch thick, or a farthing, should be wrapped in a piece of soft [-287-] linen and applied over the spot, and bound on firmly with strips of plaister half-an-inch wide. The strips of plaister (the common white strapping) should be about twelve inches long, and should be arranged star fashion ; they should be dipped in hot water in order to warm them, as they then stick much more firmly than if held to the fire. A roller of linen or fine flannel should be applied round the infant's navel over this. In cases of larger protrusion either in children or grown-up persons, a suitable abdominal support should be procured from an instrument maker, and should be worn with the same precautions as have been given for the use of a truss.
    Piles are often a very troublesome and painful affection, and are of various kinds, each of which requires a different treatment, for which a surgeon should be consulted. They are mentioned here principally in order to impress upon those who suffer from them and go on for years bearing pain, or even having their health undermined by constant loss of blood, that their disease is curable, and that they should not allow feelings of false delicacy to prevent their applying for relief. As a temporary means of relief, a sufferer may regulate the bowels with occasional doses of "lenitive electuary," and may employ an enema of cold water. Habitual sufferers from affections of the bowels frequently derive very great comfort from relieving the bowels at night rather than in the morning, so as to obtain some hours' rest in the horizontal position after an evacuation.
    Prolapse of the bowel in children should be gently returned after sponging with cold water. It may be simply the result of debility, or may be a symptom, in boys especially, of a much more serious affection?stone in the bladder? and the advice of a surgeon should therefore be obtained.
    Incontinence of Urine in Sleep is very common among weakly children, and is often the cause of great suffering to a child at school, when he is punished for what he is quite unable to help. Careful supervision will often effect a cure by avoiding too long intervals of unbroken sleep, and the use of a night-light will obviate the fear of rising in the night or early morning, which is often a cause of the disaster. As this affection may be only the evidence of more important diseases, it will be well to have medical advice if the occurrence appears to be becoming habitual. The opposite condition of things ? retention of urine ? is much too serious an affection to be treated domestically, and immediate surgical attendance should be obtained for it, at whatever age it may occur.