the body through the invigorating outdoor exercise.
The patient in this instance was a delicate, nervous girl,
the more common type of patient with this deformity.
Dress is most important in young children. Straps hold-
ing up the clothing should always be made to bear on the
shoulders next the neck, as do men's suspenders, and not
be placed so that they pass over the outer part of the
shoulders. This position of the straps tends to cause the
shoulders to droop and induces round shoulders (Goldth-
wait).
Instruction in singing is much to be preferred to lessons
in instrumental mucic where the positions are bad (as in
playing the violin or piano). In singing the subject must
stand erect and learn how to breathe properly and lift and
fill the chest with air.
Round-back is part and parcel of general weakness, as
shown by weak ankles and turned out feet (see Figs. 17, 18),
and increasing the vigor of the body by exercises, alter-
nated with proper rest (the use of a low pillow at night or
none), is more important than braces or back supports,
324
THE PREVENTION OF DISEASE
although these have occasionally to be used. Considera-
tion of the actual treatment of the deformities resulting
from round-back or lateral curvature of the spine is out
of our province, but it consists chiefly in well-directed exer-
cises and occasionally (in lateral curvature) in the use of
special apparatus and even plaster casts. This treatment
may best be undertaken by the orthopedic surgeon.
KNOCK-KNEES AND BOW-LEGS
Both these conditions (Figs. 15, 16) are due to general
weakness or disease of the bones, particularly rickets.
Fig. 15. Bow-legs (after Taylor).
Fig. 16. Knock-knees (after
Taylor).
They are common deformities of young children. In
knock-knees there is weakness of the knees owing to the
stretching of the ligaments on the inside of the knees.
Carrying heavy weights and standing too much may bring
on knock-knee in older children. The feet are naturally
WEAK FOOT AND FLAT-FOOT 325
weak and turned out (see page 326) unless they are pur-
posely carried straight or turned in to counteract the
weakness in the knees. The gait is awkward and the knees
may knock together in walking. The deformity is due
either to a bending of the lower part of the thigh bone or the
upper end of the chief bone of the leg, or both. Only one
leg may be involved, but more often both legs. Occasion-
ally one limb may have the bow-leg and the other the
knock-knee deformity. In bow-legs the deformity com-
monly occurs below the knees in the chief leg bone (tibia),
although the thigh bones may also be bent out of line.
Prevention and Treatment. Children with rickets should
be under treatment for some months before they are per-
mitted to stand. When the condition of knock-knees is
not pronounced, so that the distance between the ankles
in standing is not greater than 2 inches, the deformity
may be corrected by making the inside of the sole of the
shoe \ inch thicker, so as to throw the weight on the outer
side of the foot and take the strain off the inner border of
the foot and the weak, inner side of the knees. In con-
spicuous cases of knock-knees or bow-legs braces should be
applied by an orthopedic surgeon in the case of children
under four who are walking. In severe cases operation
is necessary in either knock-knees or bow-legs affecting
children over four years of age. This consists in surgically
breaking the deformed bones under an anesthetic and then
setting the bones in proper position in a plaster-of-Paris
cast. The operation is practically without danger. If
the operation is done too early, as under four years, the
deformity may recur.
WEAK FOOT AND FLAT-FOOT
These conditions are often seen in young children, as
well as in adults who stand at their work, and should be
326
THE PREVENTION OF DISEASE
corrected in their earlier stages before actual deformity
occurs.
In weak ankles there is usually a tendency to flat-feet.
In standing, the characteristics of weak ankles are most
apparent. These consist in prominence of the bones on the
inside of the ankles, as seen in Fig. 17. Moreover, the sul>
ject stands with the feet hold apart and the toes well turned
out, as in Fig. 18. It was not so long ago that children
Fig. 17.
Fig. 18.
were taught to turn their toes out in walking, and they
were being continually corrected for failure to assume this
position.
The feet should be held in a straight line, neither
toeing out or in while walking, although the slightly toeing
in position is better than toeing out.
Both weak ankles and flat-foot are caused by weakness
of the ligaments and muscles of the foot. In weak ankles
WEAK FOOT AND FLAT-FOOT
327
the weight tends to fall on the inside of the foot, as in Fig.
19, so that the arch of the foot gives way on the inner side
and the entire sole of the foot rests on the floor. This is
called flat-foot. Ordinarily only the outer half of the foot
touches the floor in walking (Fig. 20) . To determine the
presence of flat-foot the soles of the feet may be smeared
with vaselin, and then the patient may stand upon blotting
paper to leave the impression of the feet; or, the soles of
Fig. 19. Foot seen
from behind.
Fig. 20.
Fig. 21.
the feet may be brushed over with charcoal and the sub-
ject may stand upon white paper. In Fig. 20 is seen the
impression of a normal foot, while in Fig. 21 is shown an
impression of a very marked case of flat-foot. In adults
who develop flat-feet because their occupation requires
them to be on their feet continually, as in the case of nurses,
policemen, etc., there is often great discomfort or pain.
This condition is commonly thought to be rheumatism.
328
THE PREVENTION OF DISEASE
There may be pain and tenderness under the sole of the
feet, about the ankles, under the heel, or under the outer
ankle bone, and even in the calves of the legs, knees,
thighs, hips, or back. Persons who stand much and have
flat-feet and pain in the knees, hips, or back are often
treated for rheumatism, or, if women, for womb trouble.
On looking at the shoes of persons
with weak ankles and flat-feet it will
be seen that there is unusual wear on
the inner edge of the soles, owing to the
weight bearing chiefly on the inside of
the feet (see Fig. 19). As we are dealing
in prevention, it is not within our pro-
vince to consider treatment of chronic
and bad cases of flat-feet which often
need forcible correction of the deformity
by a surgeon and rest in bed with the
feet in a plaster cast. Even marked
cases of flat-feet, which require plates to
hold up the inner side of the soles of the
feet, should go to the orthopedic surgeon
for the fitting of plates rather than con-
sult the shoe man, who will supply the
ready-made articles so commonly worn.
To prevent flat-foot in the case of weak ankles and feet in
children and adults who stand at their work the following
advice may be given:
In the first place the proper shoe should be worn.
Such a shoe as is shown in Fig. 22 is of service and is often
sold under the name of anatomic or orthopedic shoe. The
sole forms a straight line on the inside of the shoe, so that
the patient may have more bearing on the part where the
greater weight comes, and the heel of the shoe is extended
forward and inward for the same reason. This feature in
Fig. 22.
WEAK FOOT AND FLAT-FOOT 329
the heel is a counterpart of the great toe in the barefoot
savage which spreads out, or really in that is, away from
the outside of the foot and prevents the foot and ankle
from giving away as in weak ankle. Straight-foot walk-
ing and standing should then be practised. The raising
of the inner side of the sole of the shoe throws the weight
of the body more on the outer side of the foot, and this is
sometimes accomplished by an added sole piece about YS
inch thick (see Fig. 22), or by making the whole sole
this much thicker along its inner border.
Exercises in bare or stockinged feet are also essential.
The following are recommended:
(1) Walk about the room three to five minutes with the
toes pointing inward and the heels slightly raised from the
ground (on tiptoes).
(2) With the toes turned in walk on the outer border of
the feet three to five minutes.
(3) Stand with the toes turned in, quickly raise the heels,
and slowly come down on the outer borders of the feet
(three to five minutes).
(4) While standing, rise on the toes, turn the heels out-
ward; lower the heels slowly to the floor.
The trained masseuse will also be of much service to
children in manipulating the feet. Children should have
times for rest and should practice walking straight-footed
and on the borders of their feet with their shoes on. Bath-
ing the feet with hot and cold water alternately for five
minutes, followed by vigorous rubbing, will strengthen the
muscles.
If the general tone is low the improvement in the gen-
eral condition will have a correspondingly beneficial effect
upon the condition of the feet.
CHAPTER XVIII
PREVENTION OF INFECTION AND BLEEDING IN
WOUNDS
Sterilization with lodin, Inflammation, Sterilization by Washing.
To Prevent Lockjaw. Special Wounds. Bullet Wounds. To Stop
Bleeding.
THERE arc two methods in vogue to prevent the occur-
rence of inflammation or infection in wounds. The first
is most recent and simple.
Sterilization of Wounds with lodin. This is applic-
able in wounds and cuts of all kinds where there is not so
much bleeding as to demand its immediate arrest.
Apply to the wound itself and to the skin immediately
surrounding it the pure tincture of iodin by means of a
small piece of absorbent cotton wound about the end of a
stick, match, or toothpick. The iodin should be freely
applied so as to cover every part of the raw tissue. Wait a
few minutes until the iodin is dry on the skin and then
apply an absolutely clean or sterile dressing and bandage.
If sterile gauze is not at hand, one may use cotton cloth
which has first been boiled in water for five minutes. A
dry dressing is better, however. In placing the sterile
gauze or cotton over the wound one should not allow one's
fingers to touch the part of the dressing that will come in
contact with the wound. In small cuts which require no
covering iodin is ideal for treatment.
No water should be applied to a wound before using
iodin, because then the iodin will not penetrate into the
tissues and kill germs. When the skin is very dirty or
330
STERILIZATION OF WOUNDS WITH IODIN 331
greasy about the wound it is well to wipe it off with alcohol
or benzin, while protecting the wound by covering it with
a bit of sterile absorbent cotton or sterile gauze before
applying the iodin. Then when the skin is dry apply the
iodin to the wound and surrounding skin. If there are
pieces of clothing, hair, splinters, or glass, etc., in the wound,
these should first be picked out with forceps or hatpin
before applying the iodin.
Tincture of iodin is the most valuable first-aid treatment
for all wounds, and should be kept on hand wherever sur-
gical accidents are likely to occur. Some smarting is
produced by the application of iodin to fresh wounds, but
this is temporary and not severe. In a recent book by the
present Medical Inspector General, Delorme, of the French
Army (1915), the author states in italics, "Tincture of io-
din is at present the best and safest disinfectant to make
use of in the practice of war surgery, both in the fighting
line and in the rear." It is sometimes inconvenient for
individuals to carry about on their persons a liquid like
the tincture of iodin, so that ointments and powders may
be substituted for the prevention and treatment of wound
infections.
Recent experiments in this country indicate that an
ointment containing 10 per cent, each of tricresol and
thymol may be safely used to the extent of a dram (or
teaspoonful) on a wound, and will prove as effective as
tincture of iodin in preventing infection. The bulk or base
of the ointment consists of castor oil, 70 per cent.; white
wax, 20 per cent.; and spermaceti, 10 per cent.
Clean wounds, like cuts made by a surgeon, will heal at
once without the formation of pus or inflammation, pro-
viding cut surfaces are brought together and the wound is
not too much torn or bruised. A single dressing is all
that is required in such cases, and it is always advisable
332 THE PREVENTION OF DISEASE
for the layman to leave the first dressing untouched until
the wound may be seen by a surgeon, even if a week or more
elapse, if there is no fever, great pain, or certain signs of
inflammation.
In place of stitches the layman can more readily use
surgeon's adhesive plaster to close wounds. Strips of
plaster 3 inch wide and long enough to obtain a good
hold on the skin (perhaps 2 inches on each side of the
wound) should be laid at intervals of \ inch across the
wound. The ends are firmly pressed down on one side of
the wound, and while the edges of the wound are pinched
together the free ends of the plaster are drawn tightly
across the wound and pressed firmly down on the skin
beyond. Strips of plaster should never completely encircle
a limb or the circulation will be impeded. Large wounds
should only be closed in part, leaving an inch or so for
drainage. Small punctured wounds should not be closed
at all, but after swabbing them deeply with iodin, a strip
of sterile gauze or boiled cotton coth should be pushed to
the very bottom (by a boiled hairpin) to secure drainage
before covering the wound with dressing.
Inflammation. When there is much redness, swelling,
pain, and heat about a wound it is best to apply a moist
dressing until inflammation subsides. Soak sterile gauze
(or boiled cheese-cloth) in boiling water containing as much
boric acid as will dissolve. When sufficiently cool wring
the water out of the gauze slightly with the clean hands,
being careful not to touch the part of the gauze which will
come in contact with the wound. Cover the wound over a
large area with the dressing an inch thick, and then on this
lay a piece of oiled silk or rubber cloth and enclose the
whole with a bandage. Such a dressing is an absolutely
harmless antiseptic poultice and will remain moist for
twenty-four hours, when it may be replaced.
TO PREVENT LOCKJAW 333
Sterilization of Wounds by Washing. The older method
consists in washing wounds for fifteen minutes or so until
all dirt and germs are removed. This is an efficient treat-
ment, but requires some knowledge and skill to perform
properly. Antiseptic solutions are often used, but water
to which salt is added (1 level teaspoonful to the pint) and
that has been boiled five minutes and allowed to cool suffi-
ciently, is just about as efficacious. Pouring the water
warm from a clean pitcher in a small stream upon the
wound is one of the best methods, as one does not convey
any germs to the wound with the hands.
If there is much bleeding, water should be used as hot
as can be borne. If the skin is very dirty surrounding the
wound cover the wound first with a piece of sterile gauze
or boiled cotton cloth to protect it, and then wash the
skin thoroughly with soap and water, and finally with alco-
hol diluted one-third with water. If there is much hair
about the wound, as on the head, this must also be cut or
shaved off for about an inch around the wound. The
more thorough or, in other words, the longer the washing is
conducted (from ten to twenty minutes), the better will be
the result. In case it is necessary to remove some dirt or
clots that cannot be washed off, one may boil some pieces
of absorbent cotton or old cotton cloth for five minutes,
and after washing one's hands for the same length of time
may bathe the wound and rub off the dirt or clots with these
as sponges. Then the wound should be covered with dry
sterile gauze or, lacking this, wet cotton cloth after boiling
it for five minutes. The part of the sterile gauze, or boiled
cotton cloth, which will touch the wound should not first
come in contact with the fingers.
To Prevent Lockjaw. Punctured wounds of the hands
or feet soiled with street or stable dirt are especially liable
to lockjaw unless properly handled. Any wounds much
334 THE PREVENTION OF DISEASE
bruised or torn are also more subject to this infection.
The reader is referred to page 96 for means of absolutely
preventing this fearful complication.
Special Wounds. In deeply cut wounds of the hands it
is not sufficient that the wound be closed by stitches, but
nerves and tendons must be properly united or some of the
fingers may be useless. This is work for an able surgeon
and the general practitioner not infrequently fails to
secure good results in these cases. Ragged, bruised wounds
should be swabbed with iodin and left open to a con-
siderable extent for drainage.
Punctured wounds made by nails, splinters, knives,
and teeth of animals are" among the most difficult for the
layman to treat properly, even in the way of a first dressing.
Unless made by a small, very clean body, as a needle, such
wounds must be swabbed to the bottom with iodin and
kept open by stuffing in strands of string or cotton cloth
which have been boiled five minutes. Iodin may be ap-
plied by means of a little absorbent cotton wound on a
toothpick. The toothpick should be wet before twisting
the cotton about it to keep the cotton from coming off in
the wound.
Punctured wounds so small that one cannot swab them
out with iodin, as from nails or bullets, are those which
especially demand immediate surgical attention because
germs become sealed in the wound and inflammation and
lockjaw may result (see page 96). The moist, antisep-
tic dressing, described under Inflammation, is often best
for punctured wounds. Scalp wounds frequently bleed
freely. The bleeding may be stopped by pouring water
as hot as. can be borne over the wound and by covering
the wound with a pad of sterile gauze or boiled cotton
cloth and holding it very tightly by a bandage about the
head. Iodin is the best agent to apply when bleeding has
BULLET WOUNDS 335
stopped. The hair should be cut off for 2 inches about the
wound, which maybe closed by adhesive plaster (see above)
and covered with dry sterile gauze and bandage.
Bullet Wounds. Clothing should be cut away about
the wound and the wound and skin (for 2 inches around
the wound) should be painted with tincture of iodin. As
soon as the iodin is dry a pad of at least an inch in thick-
ness should be bandaged snugly over the wound. The
pad had best consist of sterile gauze, but in its absence,
old cotton cloth which has been boiled five minutes or
sterile absorbent cotton may be used. The patient should
be kept absolutely quiet in bed, as shock is common.
If a limb is wounded it is well to apply some sort of a
splint made of thin board, padded with folded sheets, to
keep the wound at absolute rest.
Shock is shown by pallor, cold hands and feet, and
weak, rapid pulse. The patient should be given 4 table-
spoonfuls of whisky in an equal amount of hot water
and be surrounded by hot-water bags.
Probing for bullets should never be undertaken by the
layman and is usually undesirable on account of the danger
of pushing germs into the wound. The axray is employed
to locate bullets. Bullets are sterilized to some extent by
the scraping they get and the heat generated in the
weapon, but if they carry any clothing into the wound
inflammation is almost sure to result.
Where a bullet passes through the body the wound of
exit is usually larger and more ragged than the wound of
entrance. If a person is hit by a charge of shot from a
shot-gun at close range a dreadful wound is produced.
Bleeding must be stopped (see below), the cavity thor-
oughly swabbed with iodin, and packed loosely with sterile
gauze or boiled cotton cloth, and covered with a thick
pad of the same and bandage. Bullet wounds of the head,
336 THE PREVENTION OF DISEASE
chest, and abdomen are naturally the most serious and
demand instant surgical attendance.
To Stop Bleeding. Keep cool. An adult may lose 1 to
2 pints of blood without danger.
When Bright Red Blood is Flowing in Spurts. Place
the patient on his back and make firm pressure with both
thumbs into the flesh just above the wound, that is, nearest
the body. An assistant should then tie a tight bandage
about the limb between the wound and the body an
elastic pair of suspenders or (best) a piece of rubber tubing.
Or a rope or strap may be fastened tightly over a folded
towel, to prevent injury of the" skin. A folded towel or
handkerchief may be twisted tightly about the limb with
a stick. A pad of sterile gauze, rounded stone, or cork,
under the bandage and over the wound, may help to plug
the opening. A tight bandage (or tourniquet) may be
kept on a limb for an hour without doing serious damage
to the tissues. A bleeding arm or leg should always be
held well up in the air resting upon some extemporized
support. Spurting blood comes from an artery.
To Stop Steady Flow of Dark Blood. Make firm press-
ure with a pad of sterile gauze, or absorbent cotton, or
clean handkerchief wet with alcohol, directly over the
wound. This may be held in place with a tight bandage.
Raise the limb on a support. If the flow of blood is large
tie a tight bandage about the limb below the wound, that
is, farthest from the body. This may be removed in half
an hour. Steady flow of dark blood comes from a vein
bringing blood toward the body and heart. Spurts of
bright red blood come from an artery bringing blood away
from the body and heart.
To Stop Constant Oozing of Blood. This means that
small vessels are cut, and bleeding may be expected to
stop through clotting of blood and contraction of the cut
TO STOP BLEEDING 337
ends of the ^vessels. If it persists, pouring water as hot as
can be borne upon the wound may stop the bleeding, or
constant pressure made on a pad of sterile gauze, absorb-
ent cotton, or folded handkerchief wet in alcohol will ar-
rest it.
Ice-water at hand may be used in place of hot water,
although the latter is preferable. The bleeding limb
should be elevated.
22
INDEX
ABSCESS of teeth, 147, 159
Adenoids and tonsils, diseased,
cause of, 154
how to detect, 154
remote effects of, 121, 130,
131, 146, 147, 152, 153,
155, 158, 205, 224
removal of, 155
Alcohol, action of, 7
on circulation, 9, 10
on mental efficiency, 8
on muscular system, 9
on nervous system, 8
on stomach, 11
on temperature of body, 10
as a food, 1 1
as a poison, 11
as a stimulant, 9
bad effects of, 11
composition of various drinks,
5, 6, 7
summary of action, 12
Amebic dysentery, 85
Ankles, rheumatism of, 327
weak, 325. See also Weak
ankles.
Appendicitis, cause of, 152, 272
Armpits, perspiring, 57
Arteriosclerosis, 228
blood-pressure in, 234
estimation of, 235
high, 234
Arteriosclerosis, causes of, 228-
232, 244
constipation in, 260
diet in, 240
drinking in, 242
examination for, annual, 238
exercise in, 239
prevention of, 238
work in, 243
Asiatic cholera, 82
carriers of, 82
how communicated, 82
means of preventing, 82, 83
vaccination against, 83
Asthma, cause of, 153
BACILLARY dysentery, 85
Baldness, 69
Barber, diseases acquired from,
69
Baths, 58
cabinet, 58
cold, 59
hot, 63
hot-air, 63
lukewarm, 62
outdoor, 59
dangers of, 61
sea, 59
Turkish, 63
warm, 62
Beriberi, 297
339
340
INDEX
Beriberi, cause of, 297
symptoms of, 300
vitamins in, 297
Bleeding, to stop, 336
Blood-pressure, 234
estimation of, 235
high, 234
significance of, 234
Bow-legs, 324
causes of, 324
prevention of, 325
treatment of, 325
Breakbone fever, 115
Bright's disease of kidney, 230,
237
causes of, 237
prevention of, 238
Bubonic plague, 104. See also
Plague.
Bullet wounds, 335
CAFFEIN, 1, 5
Cancer, classes of, 163
cures possible, 164, 167, 169
early signs in, 163
frequency of, 165
heredity in, 177
immunity in, 176
injury as cause of, 168, 169
mortality in, 165, 178
of appendix, 174
of breast, 160, 169
of colon, 162
of face, 175
of gall-bladder, 174
of lip, 160, 174
of mouth, 160, 169
of rectum, 162
of skin, 160, 169, 174
of stomach, 162, 171, 271
of thyroid, 161
Cancer of tongue, 160, 175
of womb, 161, 173
precancerous stage of, 163
Canned food, poisoning from,
292, 293
Cerebrospinal meningitis, 137
curriers in, 139
prevention of, 139
serum cure of, 138
symptoms of, 137
vaccination in, 141