the mouth has not been well cared for.
The odor of the breath is often significant; sweet in diabetes,
urinous in uraemia, fetid in disorders of the stomach, gangrene of
the lungs, bad teeth, etc.
The state of the appetite is of importance; it is usually lost in
acute diseases, but occasionally is excessive. Observe with care
how much food the patient actually takes. Nausea is often present
with or without vomiting. The frequency of the vomiting, whether
it is painful, and the character of the matter vomited should be noted.
Usually the vomitus consists of food at first, but this may be followed
by bile, mucus, or blood. When blood has been retained in the
stomach some time it becomes brownish in color, like coffee grounds ;
vomitus of this character is seen in yellow fever. Vomiting of fecal
matter is a sign of great importance and indicates obstruction of
the bowels. Great thirst is usually an indication of fever or
The number and character of the stools should be noted. Blood,
unless fresh, gives the stools a black, tarry appearance; in jaundice
they are generally clay-colored ; bismuth and iron color them black ;
they may be liquid or solid, and may contain mucus, pus, blood, or
Tenesmus, a constant desire to evacuate the bowels, is present
Belching of gas, rumblings in the bowels, and distention of the
abdomen are signs to be noted.
The urinary functions should be carefully noted, and in special
cases the amount passed carefully measured. In both suppression
and retention no urine is passed, but in the former, which is much
the more serious condition, no urine is secreted ; it may be distin-
guished from retention, which is caused by some obstacle to the
escape of urine from the bladder, by the fact that in suppression
the bladder may be shown to be empty by tapping with the finger
just above the pubis ; a hollow sound is produced if there is no urine
in the bladder.
Incontinence of urine, that is, the inability to hold it, may be
associated with retention, so that the mere fact of constant dribbling
does not preclude the possibility of the bladder being distended.
The quantity of urine should be measured and the frequency
with which it is passed noted. Useful information may also be
obtained from observation of its color and odor. Blood gives it a
smoky or red hue, pus a milky appearance, and mucus a stringy
condition. Bile imparts a greenish tinge, as does carbolic acid,
while santonin gives a bright-yellow color. Many drugs and vege-
tables impart a characteristic odor to urine.
Cough is an indication of some irritation of the air passages ; the
matters coughed up are called sputa. When there is no sputum
the cough is said to be dry. The cough may be tight, loose, or
painful; then there is the hoarse, crowing cough of croup or diph-
theria, the spasmodic whoop of whooping cough, the wheezing cough
of asthma, the painful cough of pleurisy, and the peculiar rasping
cough of aortic aneurism. The character of the sputum varies; in
bronchitis it is white or yellow and mucous; in pneumonia it is
reddish and very sticky; in tuberculosis it is at first mucous and
frothy, later it is purulent with cheesy nodules, and sometimes
stained with blood.
In gangrene of the lung the sputum is unbearably offensive.
Hiccough when it is persistent in the later stages of acute diseases
is often a very grave sign.
When a patient complains of feeling cold take his temperature;
a chill is nearly always accompanied by fever. Chills frequently
accompany the onset of acute disease ; when they occur in the course
of inflammation they often indicate suppuration ; in malaria, while
severe, they are not usually dangerous.
Hemorrhage from any part of the body is always significant;
nose-bleed is often one of the early signs of typhoid fever.
Pain is one of the most valuable signs which we possess, as it often
points toward the location of the disease. The kind of pain should
be described and whether it is constant or intermittent, severe or
slight. Exaggerated sensitiveness to touch is called hyperesthesia
and diminished sensibility anesthesia; the latter is often associated
with loss of muscular power or paralysis; paralysis of the lower
half of the body is called paraplegia; of a lateral half hemiplegia.
Disorders of motion include picking at the bedclothes, always
SYMPTOMS AND CLINICAL RECORD 183
a bad sign, twitching of the tendons (subsultus}, slight spasms, and
local or general convulsions. In convulsions always note the parts
affected and whether the attack is attended with loss of conscious-
Under disorders of consciousness are included delusions and hal-
lucinations, delirium, stupor, and coma.
The character of the delusions should be noted, whether occa-
sional or habitual, quiet or noisy ; in stupor note whether the patient
can be aroused; if he can not, it is coma, a very serious condition.
Coma vigil is a combination of sleeplessness with partial unconscious-
ness and is also a symptom of bad omen.
The amount and character of sleep should be recorded; patients'
statements on this point must be accepted with caution.
That nothing concerning the patient's condition may be forgotten,
clinical records are kept. The blank forms for this purpose are of
a uniform size, 3^" by 8", perforated at the top so that on the com-
pletion of the case the various sheets pertaining to it may be as-
sembled and filed together.
Collection of specimens. It is usually necessary to keep speci-
mens of urine, feces, sputum or vomitus, for the inspection of the
visiting physician. Ordinarily these are best kept in the vessel in
which they are received. It should be placed in a cool place and
protected from dust.
If sterile specimens are needed, the vessel in which they are
received to be kept, should be sterilized by boiling or otherwise.
If specimens of urine are to be kept for any length of time, it
may be necessary to add a few drops of formalin or chloroform to
them, to prevent decomposition.
FIG. 91. Reef Knot.
BANDAGING must be taught practically, one-half of the class prac-
ticing on the other half. Three general types of bandages are used
in the army ; triangular, roller, and tailed bandages.
The triangular bandage possesses special advantages for the mili-
tary service in that it is quickly
and easily applied and removed.
The triangles are made by tak-
ing a piece of cheese cloth 38 to
41 inches square and cutting it
diagonally into halves (Fig. 90).
The bandage is used in three general forms : as an open triangle,
folded twice from apex to base as a broad cravat, and folded three
times as a narrow cravat.
To fasten the ends together the reef knot (Fig. 91) is used,
which is much more secure than the
"granny" (Fig. 92).
Applications of the triangular
bandage. Head: Place the base
of the triangle just above the eyes
and let the apex hang down over
the occiput; cross the ends below
the occiput, bring them to the
front and tie (Fig. 93) ; bring
the apex up over the crossed ends
an( J p j n
FIG. 92. "Granny" Knot.
Eye: Use the narrow cravat, tying the ends behind (Fig. 95).
Chin or side of head or face: Use the narrow cravat, tying under
the chin or on top of the head. Or apply middle of handkerchief
over front of chin and tie back of neck (Fig. 96).
Neck: Use broad or narrow cravat. Place center of cravat over
dressing, cross on opposite side and tie in front (Fig. 97).
Chest: Apply the center of the open triangle over the dressing;
tie the ends on the opposite side, leaving one end long ; bring the
apex over the shoulder and fasten to the long end. If the end is
not long enough lengthen it by using a narrow cravat (Figs. 98 and
99). Pelvis: Apply the center of the base of the opened triangle
just below the navel; carry the ends around to the back and tie one
FIG. 93. Triangle of
the Head; front. -
FIG. 94. Triangle of the FIG. 95. Narrow Cravat of
Head; rear. One Eye.
end long; bring the apex over the perineum and between the legs to
the rear and fasten to the long end (Fig. 100).
Buttocks: Apply the base of the opened trangle to the lower part
of the back ; bring the ends around the sides, crossing them in front,
and pin; split the apex and fasten in front (Fig. 101).
Slings: The large arm sling is applied in three different ways.
FIG. 96. Narrow Cravat
of Chin and Face.
FIG. 97. Narrow Cravat
In the first method place one end of the triangle over the sound
shoulder; the base should be in front and the apex in rear; bring
up the front end over the shoulder of the injured side and tie oil the
side of the neck ; bring the apex forward and pin (Fig. 102). When
the collar bone is injured the second form is used ; it is applied in
the same manner as the first except that the front end is carried
under the arm pit instead of over the shoulder of the injured side
(Fig. 103). In the third form the rear end is carried over the
shoulder of the injured side ; otherwise it is the same as the second
(Fig. 104). For the small
sling the narrow cravat is
used, carried over the
shoulders and fastened be-
hind (Fig. 105).
Shoulder: Place the apex
of the triangle on the
shoulder; carry the ends
around the arm, crossing
them and tying at the out-
side; fold the apex over a
sling or neck cravat and
pin (Fig. 105).
Elbow: Use a broad
Cravat as Shown in Fig. FlG - 98- Triangle of the Chest; front view.
105, or a large arm sling (Fig. 102).
Hand: Place the hand, palm up, on the triangle, ends of the
fingers toward the apex ; bring the apex up over the palm ; pass the
ends around the wrist
over the apex, which is
then folded toward the
fingers and covered by
another turn of the
ends; tie the ends be-
hind (Fig. 105).
Hip: Apply a narrow
cravat around the waist.
Carry the ends of the
triangle, base down,
around the thigh and
fasten. Pass the apex
under the cravat, fold
over and tie (Fig. 106).
Knee: Use the broad
F.o. 99 - Triangle of the Chest; rear view. ^^ . ^^ ^.^
and knot in front below the knee-cap; or vice versa (Fig. 107).
Foot : Place the foot on the triangle, toes toward the apex ; bring
the apex up over the toes toward the ankle ; cross the ends over the
front of the ankle and over the apex of the bandage, then carry
them back around the ankle, crossing them behind in such a manner
as to catch the base of the triangle ;
next draw up the apex so as to
tighten the bandage and fold it
over toward the toes. Bring the
ends forward and, crossing over
the ankle and apex, carry them
beneath the foot and tie on the in-
side (Fig. 1 08).
To fasten splints: Take a narrow
cravat, double it upon itself; place
the loop on the outside of the limb ;
carry the free ends around the
limb and one of them through the
loop ; then tighten as much as neces-
FIG. ioo. Triangle of the Pelvis. sary and tie (Fig. 64).
Roller bandages consist of strips of cloth of variable length and
width. To apply them properly requires care, time, and constant
practice; hence they have con-
siderable less value for first-aid
purposes than has the triangular
The chief materials from
which rollers are made are mus-
lin, cheese cloth, gauze, flannel,
and rubber; each has its own
The most general and useful
sizes are as follows :
For the head, 2 inches wide
and 5 yards long.
For the upper limb, 2 l /2 inches
wide and 5 to 10 yards long.
For the trunk, 4 inches wide and 5 to 10 yards long.
For the lower limb, 3 inches wide and 5 to 10 yards long.
For the fingers, 1/4 of an inch wide and i to 2 yards long.
FIG. 101. Triangle of the Buttocks.
FIG. 102. Large Sling No. i.
Roller bandages should be torn, not cut. To prepare a number at
one time take a piece of muslin of the required length, tear off the
selvage, with the scissors split one end into the required widths, tear
down for a couple of feet,
separate the alternate strips,
hand one set to one person
and the other to another.
Each now pulls firmly until
the piece of cloth is torn
through the entire length.
Besides a machine for roll-
ing bandages there are two
methods of rolling by hand.
Take a couple of feet of the
end of the bandage and fold
repeatedly upon itself until a
firm mass is formed; then
sitting in a chair cover the
right leg, foot, and adjacent
floor with a clean towel or sheet, place the small roll on the thigh,
the loose part of the bandage extending down over the knee to the
floor, and roll toward the
knee; when the roll reaches
the knee draw it up to the
groin and then repeat the
motions (Fig. 109).
After a firm roll is made in
this manner it may be finished
by hand if desired ; in this
method the bandage is grasped
as shown in Fig. no and
rolled by alternate movements
of pronation and supination
of each hand.
Rules for bandaging: I.
FIG. 103. Large Sling NO. 2. Place the limb in the position
it is to occupy. If the arm is bandaged in the straight position and
then bent, the bandage will cut in at the bend of the elbow and stop
2. Begirt at the extremity of the limb, the ends of the fingers for
the upper extremity, the tips
of the toes for the lower; if
this rule is not followed, the
parts below the bandage will
3. Place a layer of cotton
between opposed skin sur-
faces, such as the fingers and
4. Hold the roller in the
right hand when bandaging
the left limb, and vice versa.
5. Place the outer surface
of the bandage on the in-
. Jfj _, ., , FIG. 104. Large Sling No. 3.
ner side of the extremity and
secure by making a couple of circular turns.
6. Bandage evenly and
neither too tight nor too
loose. Leave the tip of the
extremities exposed to ob-
serve the state of the circula-
tion in the part. If the blood
when pressed out of the nails
does not promptly return, the
bandage is too tight and may
Roller bandages may be ap-
plied by circular turns, simple
spirals, reversed spirals,
fignre-of-S, spica, and knotted
Circular turns and rapid
spirals are used chiefly to hold
dressings in place ; the method
of using them is clearly shown
^ I in Fig. in. The slow spiral
(Fig Iia) is used where a
FIG. 105. Small Sling, Triangles of the '
Hand, Elbow, a n4 Shoulder. Hmb is nearly cylindrical in
shape ; each turn is parallel with the turn below, which it envelops
for about one-third of its width. For a limb increasing in size like
the leg or forearm this bandage would not lie evenly, and it becomes
necessary to resort to reverses.
The method of making the
reverse is shown in Fig. 113;
the bandage should be held
loosely to give slack; the re-
verses should be in line and
on the outside of the limb.
For covering the joints the
figure-of-S bandage becomes
necessary ; as the name im-
plies, figures-of-8 are made
in alternate loops above and
below the joint; each loop
covering in one-third of that
immediately below (Fig. 114).
The spica is really a figure-
of-8 with one loop much
larger than the other, and is
used especially at the hip and
shoulder (Fig. 114).
The knotted turn is used
where it is desired to make
pressure, especially on the temple. Unroll about a foot of the band-
age and hold it against the temple; then
carry the roll around the forehead and
occiput; on reaching the starting point,
twist the roller around to a right angle and
carry it down under the chin and over the
vertex; then fasten the ends (Fig. 53).
Special applications of the roller bandage:
Recurrent of the head: Make a couple of
circular turns about the forehead and
occiput; reverse in front and carry the
roller back to the occiput over the middle
FIG. 107. Broad "Cravat of o f the vertex ; reverse again and bring for-
FIG. 1 06. Triangle of the Hip.
ward, covering in one-third of the preceding turn, continuing to carry
the roller backward and forward until the head is well covered, when
all the reverses are held in place by circular turns and pins or
sewing. Until the circular turns are
made all the reverses must be held in
place by an assistant (Fig. 115).
Recurrent of a stump: Made in the
same manner as the recurrent of the head
Figure-of-S of the eye: Place the end
of the roller on the temple and make a
FIG. 108. Triangle of the Foot, couple of circular turns around the fore-
head and occiput, from right to left for the right eye, and vice versa
for the left. Reaching the occiput, pass from under the right ear
up over the right eye, across the
opposite temple and down again to
the occiput; make as many of
these turns as necessary, and finally
fix by circular turns (Fig. 117)-
Figure-of-S of the jaw (Barton's
bandage} : Place the end of the
roller below the occiput; pass ob-
liquely up over the right parietal
bone, across the vertex, down over
the left temple in front of the ear,
under the chin, up over the right
temple in front of the ear, across
the vertex, and back to the starting
point. Then pass forward along
the right side of the jaw in front
of the chin and back along the left
side of the jaw to the starting point.
These turns may be repeated as
Often as necessary (Fig. Il8). FlG - J 9- Rolling Bandage on the Knee.
Spiral of the chest: Unroll about five feet of the bandage; let the
free end drop down over the front of the chest to about the knees of
the patient, carry the roller over the opposite shoulder to the base of
the chest, then around the chest over the loose end, ascending by a
slow spiral. When the chest
is bandaged as high as neces-
sary fasten the last turn by a
pin. Then bring up the loose
end of the bandage over the
other shoulder and down the
back to the base of the chest
and fasten to the lower and
upper turns ; this prevents the
bandage from slipping down.
Velpeau (for fractured
clavicle): Place the palm of
the hand of the injured side FlG - "o. Roiling Bandage by Hand.
on the sound shoulder, with padding between the arm and chest
wall. Place the initial end of a. roller in the axilla of the sound
FIG. in. Rapid Spiral.
FIG. 112. Slow Spiral.
FIG. 113. Steps in Making Spiral Reverses.
side, carry the bandage
up across the back, over
the shoulder of the in-
jured side, down the out-
side of the arm, under
the outside of the elbow,
and across the front of
the chest to the starting
point; repeat this turn,
but when the sound
axilla is reached the
second time make a cir-
cular turn around the
chest and over the arm ;
then repeat the first and
third turns alternately,
each layer of bandage
covering in about two-
thirds of its predecessor.
Stitch or pin the points
of intersection of the
turns (Fig. 119).
of Velpeau: Commence
in the axilla of the sound
side as in the ordinary
Velpeau, but carry the
first and second turns
horizontally around the
front of the chest, the
first under and the
second over the elbow.
The third turn ascends
over the front of the
chest to and over the
injured shoulder, down
the back of the arm, un-
der the elbow and up
again over the same
FIG. 114. Figure-of-8, or Spica of the Shoulder. FIG. 1 13. Recurrent
of the Head.
FIG. 1 1 6. Recurrent of a Stump.
FIG. 117. Figure-of-8 of One Eye. FIG. 118. Figure-of-8 of the Jaw (Barton's I5andaK<->.
shoulder, thence across the back to the opposite axilla, and again
horizontally around the chest, covering in one-third of the previous
horizontal turn. These movements are repeated until the shoulder
is reached (Fig. 120).
Finger bandage: Make two turns about the wrist, pass diagonally
over the back of the hand to the root of the finger, descend by spiral
turns to the tip, make a circular turn, then ascend by slow spirals
FIG. 119. Velpeau of the Shoulder.
or reverses ; on again reaching the base of the finger cross the back
of the hand to the wrist and finish with a circular turn about the
latter (Fig. 121).
Foot bandage: Make a couple of circular turns around the ankle ;
descend obliquely over the dorsum, under the sole, and back to the
dorsum of the foot, up which the bandage must pass by several
spiral turns, covering the instep ; when this is reached, pass the
bandage under the point of the heel, thence to the dorsum, then
down beneath the sole, then along the outer surface of the heel,
next around the heel above its point to reach the instep, whence',
FIG. 1 20. Modified Velpeau.
passing to the sole, a turn is made around and above the point of
the heel on the inner side, again to pass the instep, when the roller
must be carried by spiral and reversed turns up to the knee (Fig.
FIG. 121. Finger Bandage.
Tailed bandages: Bandages of various widths split at each end
are called 4-tailed and are very useful about the head. The methods
of their application are shown in Figs. 123 and 124.
The T-bandage is especially useful in confining dressings to the
perineum and pubic region ; it is made by sewing a strip of bandage
to the middle of another strip, the two forming a right angle.
Cause bandages, sterilized, are usually employed in aseptic
FIG. 122. Foot Bandage.
Flannel bandages are used when it is desired to produce a moderate
degree of elastic pressure, or^ where warmth is necessary. They
lie more smoothly than non-elastic materials.
Rubber bandages are of special value when considerable pressure
and support are necessary. They must be used with care and fre-
quently adjusted and washed with soap and water. They are also
FIG. 123. Four-Tail Bandage for the Vortex. FIG. 124. Four-Tail Bandage for the Occiput.
employed like a tourniquet to control bleeding and may be very
quickly and effectually applied as follows: Make several circular
turns about the limb above the bleeding artery, then lift up one of
the turns and pass the unrolled part of the bandage under the turn
and over the artery (Fig. 44).
Crinoline is used for fixed bandages, especially the plaster-of-
paris bandage; gauze may also be used for this purpose, but a stiffer
material is better. The bandages are prepared by placing on a
paper a lot of freshly opened plaster and rubbing it into the meshes
of the material with the hand while the bandage is being loosely
rolled. When the bandages are not required for immediate use
they should be wrapped separately in waxed paper and kept in a
warm, dry place, preferably in tins. To apply, first cover the part
with a flannel bandage or other protective, then place a plaster
bandage, end down, in water sufficient to cover it; when bubbles
cease to escape, squeeze, the bandage gently and apply like any
other bandage. Each time a bandage is taken out of the water
place another in so as to have one always ready. Usually several
thicknesses of bandage are required, especially over the joints; when
necessary -the dressing may also be stiffened by strips of tin incor-
porated in the bandage.
The floor should be protected by sheets or newspapers and the
clothing of the patient and operator by the use of sheets.
The limb must be shaved, washed, dried, and powdered before the
application of the bandage.
To remove plaster from the hands after completion of the oper-
ation, sugar or carbonate of soda should be added to the water, or, .
better, rubbed on the hands.
To remove plaster dressings when they are no longer necessary
is an operation requiring patience and care. If the dressing is thin
plaster shears can be used, but if it is thick a strong knife or saw is
necessary. The track of the knife or saw may be softened somewhat
by dropping into it a little strong acetic acid or hydrochloric acid.
The operation of removal is much facilitated if a strip of tin has
been placed under the plaster, in the line of incision, while it was
being applied ; the strip may be cut down upon without fear of
wounding the patient.
INFECTION AND DISINFECTION
Bacteria are the minute vegetable organisms, so small that they
can not be seen except with a microscope, many of which grow on
or in the human body and cause disease. The terms microbes and
germs are ordinarily used in the same sense as bacteria.