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FIRST AID AT SEA

GENERAL DIRECTIONS FOR EMERGENCY CARE OF THE INJURED

1. Place the patient in a lying position whenever possible. This will prevent his fainting and falling.

2. If one or more of the following conditions are present, give treatment in the following order:

a. Severe bleeding
b. Stoppage of breath
c. Poisoning
d. Heatstroke
e. Shock and other conditions

Never release pressure on arteries unless other methods are ready to control hemorrhage. Be familiar with the main pressure points.

Always loosen a tourniquet every fifteen minutes for a period of from five to ten seconds until bleeding has stopped. Never completely remove a tourniquet. It should be left in place in case bleeding should re-occur.

3. Always examine patient carefully for injuries not clearly seen.

4. Never allow absorbent cotton, adhesive tape, wool, grease, oil or strong antiseptics to come in contact with wounds or burns.

5. When applying bandages avoid tying knots directly over a bony prominence or wound.

6. Always make sure that a bandage is neither too tight nor too loose.

7. Do not try to give an unconscious person anything to drink. He will be unable to swallow and will strangle.

8. Never give stimulants or morphine where a fractured skull or severe bleeding is present.

9. Make every effort to contact a doctor after your patient has been given emergency care. Be prepared to tell him how the accident occurred, all the symptoms of the patient (be sure to include his age, temperature, pulse and respiration), the treatment that has been given, and the materials available for further treatment.

10. Never attempt to move a patient without procuring proper transportation. It is always safe to assume that most patients should be moved only in a lying position. Never move a patient unless absolutely necessary.

11. Never begin traction if it cannot be maintained until proper splints are applied.

12. Never move a fracture case until proper splints have been applied.

13. Reassure the patient. Do not discuss his case or its severity in his presence. Do not allow him to see his own injuries.

14. Observe the patient closely for symptoms of delayed shock and be prepared to start treatment at once.

 

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POSTERIOR AND ANTERIOR VIEW OF SKELETON
POSTERIOR AND ANTERIOR VIEW OF SKELETON
 
 

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THE BODY
 
The human body is a complex and carefully balanced organism. It is a unit made up of numerous structures each of which is dependent upon the function of all the others. For the sake of simplification, the various parts of the body (such as bones, muscles, nerves, blood vessels, etc.) are considered separately, but it must be remembered that actually these are so closely interrelated that, at times, it is impossible to tell one part from another without the use of a microscope.

To render emergency treatment properly it is necessary to have a clear understanding of the structure of the body (anatomy) and the work of the various parts of the body (physiology).

A. THE SKELETON

The body is usually considered as being built over a framework of bones. Bone is one of the hardest structures of the body and possesses also a certain degree of toughness and elasticity. On examination of any section of fresh bone, it is seen to be composed of two kinds of tissue, one of which (the outer layer) is dense, as hard as ivory and pink in color while the other (the inner layer) is porous, lattice-like and deep red. This porous area not only makes the bones light but also affords space for the production of the blood cells.

The human body (male or female) ordinarily contains two hundred and six bones. This number varies in different individuals in some of whom additional vertebrae, etc., are found. Bones are classified according to their size and shape as long, short, flat and irregular.

1. The Bones of the Skull and Face-The bones of the skull and face are so closely joined together that for the purpose of this study they may be considered as a unit. The bones of the inner ear play an important part in the process of hearing. The nasal septum (that partition of bone which separates the nose into two nostrils) is easily fractured by a direct blow. The mandible (jawbone) may be either dislocated or fractured if sufficient force is applied. The vault (rounded portion) of the skull surrounds and protects the brain. The bones which form the vault are so closely situated to the brain that a blow can rock the brain to and fro, and the resulting jar can produce unconsciousness without the bones of the skull having been fractured; or the bones of the skull may be broken.

  In the latter instance death may occur unless proper emergency treatment is given. In the base of the skull are numerous openings through which pass blood vessels and nerves. The largest opening is in line with the canal through the spinal column and at this point the brain and spinal cord are continuous.

2. The Vertebrae-The spinal column is made up of thirty-three separate bones which are known as vertebrae. These are joined together by disks of cartilage and the manner in which they are joined allows the spine a certain amount of flexibility. The first twenty-four and the last four of these vertebrae are movable, but the five which are fused together to form the sacrum are immovable. The last four are small and form the terminal bone (coccyx) of the spine. Through the vertebrae passes the spinal cord which communicates with nerves going to and from all parts of the body.

These nerves are attached to the spinal cord at a point higher than the area of the body which they serve. Hence, in a fracture of the vertebrae of the neck, the arms and hands may be paralyzed; and in a fracture of the back, the legs and feet may be paralyzed.

3. The Breast Bone (Sternum)-The sternum is a long, flat bone which is situated in the center of the front wall of the chest. Its upper portion supports the clavicles (collar bones) and the ribs are attached to it on each side by cartilage.

4. The Ribs (Costae)-The ribs are elastic arches of bone which form the greater part of the framework of the chest. They are usually twelve in number on either side but, like the vertebrae, in some individuals this number may be increased or decreased by one or two. The first seven are connected behind with the spine and in front, by the help of the costal cartilages, with the sternum. These are called the "true ribs." The remaining five are called "false" ribs because they are attached to the vertebrae behind but in the front they are either connected with the rib above by cartilage or not connected at all. Usually the last two are not connected and these are termed the "floating" ribs. The ribs are situated one below the other in such a way that spaces (intercostal spaces) are left between them.

5. The Pelvis-The pelvis is a ring of bones (fitted together in a "basin shape") which is

 

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situated between the movable vertebrae and the lower limbs. It is composed of the hip bones, one on either side, and the sacrum in the rear. It is stronger and more massively constructed than the skull or the ribs. In proper posture it serves as a support for the abdominal contents. It also helps form the floor of the abdominal cavity and provides a deep socket on either side into which the heads of the thigh bones fit.

6. The Thigh Bone (Femur)-The femur is the longest and strongest bone in the body. Its upper, rounded end fits into sockets in the pelvis, and its lower end is broader and forms a part of the knee joint.

7. The Kneecap (Patella)-The patella is an almost triangular flat bone. It forms the front of the knee joint and can easily be felt beneath the skin.

8. The Leg Bones (Tibia and Fibula)-These bones form the lower leg between the knee and ankle. They are very unequal in shape. The tibia (shin bone) is the larger of the two and, after the femur, is the longest bone in the body. It forms most of the ankle joint and all of the knee joint and is located toward the middle of the leg. The fibula is the smaller of the pair. It is narrower than the femur but almost as long. It forms none of the knee joint, part of the ankle joint, and is located toward the outside of the leg.

9. The Bones of the Ankle and Foot (Tarsus, Metatarsus, and Phalanges)-The bones of the ankle and foot are divided into three groups. The first of these are the seven tarsal bones which form the back part of the foot. These are irregular in shape and so fitted into each other as to form a strong and slightly flexible unit. Adjoining these and in front of them are the five, long metatarsal bones. These correspond to the bones of the hand and, in a similar way, form a strong supporting arch. Fourteen smaller bones shaped somewhat like the metatarsals form the end of the foot. These are called phalanges and correspond to the bones of the fingers and thumbs.

10. The Collar Bone (Clavicle)-The collar bone is a long bone shaped like a straightened letter S. It lies just in front of the first rib between the sternum and the shoulder joint. Together with the scapula it forms the concavity in which the head of the humerus moves. The collar bones hold the shoulders apart.

11. The Shoulder Blade (Scapula)-The scapula is a flat bone which is generally considered to be of triangular shape. It lies toward

  the upper and outer part of the back of the chest. At the shoulder (together with the clavicle) it forms a portion of the shoulder joint. The scapula is held in place with muscular and tendonous attachments.

12. The Arm Bone (Humerus)-The humerus is the longest and largest bone of the upper extremity. It extends from the shoulder to the elbow. The upper portion of the humerus is rounded and fits into the cavity formed for it by the union of the clavicle and scapula. This comprises a ball and socket joint which permits the upper arm to be moved in a rotary fashion from the shoulder.

13. The Bones of the Forearm (Radius and Ulna)-The two bones of the forearm extend from the elbow to the wrist. The radius is on the outer or thumb side of the hand and forms the major part of the wrist joint. The ulna is on the inner or little finger side of the hand and forms the greater part of the elbow joint.

14. The Bones of the Wrist and Hand (Carpus, Metacarpus, and Phalanges)-The bones of the wrist and hand are divided into three groups. The first of these are the eight carpus bones which form the so-called "heel" of the hand. They are irregular in shape and are fitted into each other as to form a strong and slightly flexible unit. Adjoining these are the five, long metacarpus bones. The shape of these bones and their arrangement in the palm of the hand forms a shallow arch. The fourteen bones of the fingers are called phalanges. They are classified as long bones and are similar in shape to the metacarpals. Two of these bones form the thumb and three form each finger.

B. JOINTS AND LIGAMENTS

A joint is formed by the connection of bones at different parts of their surfaces. They may be generally classified as movable and immovable joints. (The bones of the cranium, for example, are immovable joints.) To increase the ease with which a joint may function, the ends of the bones are covered with cartilage and the interior of the capsule (sac) which encloses the joint is lined with a membrane which secretes a fluid. This joint fluid is normally a thick, viscid substance (not unlike the white of an egg) without which the joint would become dry and stiff. The outer portion of the joint is a strong, white fibrous tissue which completely envelops the joint. This, together with the joint ligaments, holds the bones together and limits their motion. In sprains or dislocations the ligaments and cartilage may be torn or broken.

 

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IMPORTANT ARTERIES OF THE BODY
IMPORTANT ARTERIES OF THE BODY
 
 

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DIAGRAM OF THE HEAD AND TORSO SHOWING RELATIONSHIP OF THE ORGANS
DIAGRAM OF THE HEAD AND TORSO SHOWING RELATIONSHIP OF THE ORGANS
 
 

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C. MUSCLES AND TENDONS

Motion in the body is executed by a system of structures called muscles. These are of two general types: (1) the voluntary muscles (such as the biceps muscles) and (2) the involuntary muscles. The voluntary muscles are controlled by will but the involuntary muscles function without direct order of the conscious mind. (An example of involuntary muscle would be the muscles of the heart.) Muscles have the ability to contract or shorten themselves when they receive a nerve impulse from the brain.

For the consideration of the seaman rendering emergency treatment, the greatest attention will be paid the voluntary muscles. Most of these are attached to bones at either end. They may be attached directly or through strong, white fibrous bands called tendons. Since these muscles are attached to two bones and occasionally to the skin, the contracting of the muscles will cause motion.

In most fractures, dislocations and cramps, an involuntary contraction (spasm) occurs in the muscles, especially in the injured part. This spasm usually causes further displacement of a fractured or dislocated bone and can seriously interfere with setting of the bone or the reduction of the dislocation.

D. CONNECTIVE TISSUE

Throughout the body, binding together even the smallest portions of the soft tissues, is a filmy, fibrous material known as connective tissue. This tissue, like mortar between bricks, serves the double purpose of binding together various portions of the body while keeping them apart.

E. THE SKIN

The skin (the common integument) serves as the protective covering of the body but it also has many other functions. It is the organ of the sense of touch. It contains numerous sweat glands which not only possess certain excretory functions but, through the process of sweating, manage the control of body temperature.

The openings to or from the interior of the body are lined with mucous membrane which is a structure somewhat similar to skin except that it is more delicate, more subject to certain infections and has greater recuperative powers.

F. THE BLOOD

The blood is a living, opaque, rather viscid fluid, the purpose of which is to maintain life in the body by the collection and dispersion of

  various substances (some beneficial, some dangerous), through the medium of the blood cells. Blood is faintly salty to the taste, has an alkaline reaction and a peculiar, distinctive odor. Its temperature is generally about 37 degrees Centigrade or 98.6 degrees Fahrenheit but this varies slightly in different parts of the body.

The fluid of the blood is known as blood plasma or blood serum. This is a slightly yellowish fluid in which are suspended the blood cells or corpuscles. Most of these blood corpuscles are colored and impart to the blood its red color.

The colored or red corpuscles can only be seen as individual flat cells with the aid of a microscope. In the smaller capillaries these cells pass one by one and give the appearance of a row of coins. The red corpuscles are the carriers of oxygen.

The white corpuscles are of several different sorts and sizes and possess individual functions. Some destroy infection and through this ability act as the body's chief defense and protection from this danger.

The formation of a blood clot in the severed ends of the blood vessels will cause bleeding to stop. Normally, blood is in constant motion but when blood escapes from a damaged vessel certain blood cells undergo a rapid change, disintegrate into granular masses, and coagulate. This forms the blood clot without which the blood would continue to flow and the patient would die. The normal clotting time is generally considered to be from three to six minutes.

The body contains from five to six quarts of blood. The loss of two pints of blood may be serious and the loss of three pints may prove fatal.

The arterial blood is a bright-red color (due, partially, to the presence of oxygen) and the venous blood is a slightly darker hue of reddish-purple.

G. THE HEART

The heart is a hollow, muscular organ, the chief purpose of which is to pump blood through the body. It is divided into two general parts or halves. These two halves are entirely separated by a muscular partition; but always work in unison. The right half of the heart pumps blood from the rest of the body into the lungs, from which it is returned to the left half. From there it is pumped throughout the body again.

While in the lungs the blood is cleansed of certain waste materials (such as carbon dioxide) and receives oxygen. While in the body the blood acquires and distributes food particles

 

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and transports internal secretions which enable the body to maintain a state of health. At the same time the blood circulating through the body is able to carry various waste materials to the kidneys, sweat glands, etc., and thus undergo a purification process before returning to the right half of the heart.

From the heart, the blood is pumped through arteries to smaller arteries called arterioles. From these arterioles it passes to the capillaries where it is able to make its various exchanges of food and poisons. From the capillaries it flows into small venules, thence into veins and back to the heart.

The heart lies between the lungs, behind the sternum and ribs and slightly to the left of body-center. The average heartbeat for men is seventy-two times per minute.

H. THE ARTERIES, CAPILLARIES AND VEINS

Blood vessels that carry blood away from the heart are called arteries. These are thick-walled vessels constructed to bear a fifty-pound pressure with each heartbeat. Blood coming from an artery comes in spurts due to the pumping action of the heart.

Most arteries are protected by being situated below the veins where they would be least likely to be injured. In cases where a deep artery is injured the blood from it will not flow in the characteristic spurts but will seem to well up intermittently.

Capillaries form a dense meshwork throughout the body. These vessels are so fine that they can only be seen microscopically. They constitute the connecting link between the arteries and the veins. The blood from these capillaries oozes slowly and presents no problem of control. Capillary bleeding is usually considered advantageous as it tends to wash the germs and foreign particles from abrasions. Pressure over an area in which capillary bleeding is occurring will hasten coagulation.

Veins carry blood back to the heart from the capillaries. They leave the capillaries in the form of venules which join together to form the larger and more commodious veins. The number of veins carrying blood back to the heart is much greater than the number of arteries carrying blood from the heart. Large veins are not as well protected as arteries and are much more liable to be cut. Blood from veins is of slightly darker color than blood from arteries, but its most distinguishing characteristic is the

  slow, even manner, in which it flows. Since the flow of venous blood can be inhibited by gravity, elevation of the affected part frequently results in the cessation of hemorrhage.

I. THE RESPIRATORY SYSTEM

The process of breathing is called respiration and is divided into inspiration (the act of drawing air into the lungs) and expiration (the act of expelling air from the lungs). During inspiration oxygen is brought into contact with the blood stream and during expiration carbon dioxide and other waste materials are discharged from the blood stream into the air in the lungs.

Respiration occurs on an average of seventeen to twenty times per minute, but this number may vary in healthy individuals from thirteen to twenty-five times per minute depending on their age, activity, etc. The quantity of air drawn into the lungs during each average inspiration is about one pint, but, by taking a deep breath, about four times this amount may be inhaled.

Ordinarily not all the air is expelled from the lungs during a normal expiration. From four to six times the amount of air expelled remains in the lungs when the expiration is completed.

Normal breathing is through the nose rather than through the mouth. By passing through the nose the air is warmed, filtered and moistened. It then passes to the throat and thence to the windpipe. The windpipe (trachea) is protected at the top by a cartilaginous flap which closes automatically when the process of swallowing is begun. This prevents liquids or solids from entering the windpipe. However, if the patient is unconscious, this arrangement may fail to function properly and substances given by mouth will be able to enter the windpipe and choke the patient. At about the center of the sternum the windpipe divides into two portions called the bronchial tubes or bronchi. These bronchi enable air to enter and leave the lungs. Like the arteries, they divide and subdivide, until they end in small, grape-shaped spaces known as the air cells, the walls of which are covered with a network of capillaries so fine and thin-walled that the oxygen in the air can pass readily into the blood stream and carbon dioxide and various waste products can pass in the reverse direction to be excreted. The lungs are two pliable, spongy organs, which are made up of the bronchial tubes and air cells in which they end. These various structures are

 

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held together by a special connective tissue and are covered with a double-walled membrane called pleural sac. The lungs entirely fill the thoracic cavity (chest) except for the space occupied by the heart, blood vessels, and esophagus. The thoracic cavity is tightly sealed so that air cannot enter except by way of the lungs.

J. THE DIGESTIVE SYSTEM

The digestive system may be considered as a single muscular membranous tube (with many side branches) around which the body is built. Food travels through this tube and undergoes several processes by which it becomes assimilable. The first of these processes is mastication and chewing. During this mastication the food is broken into many small particles and mixed with saliva (the first of the digestive juices with which it comes in contact). The saliva makes the food easier to swallow and aids in the digestion of several types of food. The food is then swallowed and passes from the mouth through the esophagus to the stomach. The stomach is a muscular, membrane-lined sack which will ordinarily contain about three pints. The muscles in the wall of the stomach produce a churning motion which mixes the food with the secretions from the membrane of the stomach. At the lower end of the stomach, where the stomach and the small intestines connect, there is a valve which opens and closes intermittently, each time allowing a small amount of food to pass into the small intestine to be further digested. Not only is the small intestine itself lined with a membrane which secretes a digestive juice, but several additional glands pour their products over the food and the constant motion of the small intestine further digests its contents. All of these various digestive juices are necessary to make the food absorbable. This digested material passes through the twenty-one feet of small intestine and then enters the large intestine where it

  passes through an additional five feet. There is always a considerable amount which cannot be absorbed through the walls of the intestine; this passes out from the body at the lower end of the large intestine (the rectum) in the form of stool, or, excreta.

While in the large intestine the greater amount of water remaining in the food is absorbed into the blood stream. In cases where food is allowed to remain in the large intestine for an excessive period so much of the water content is absorbed that the remaining waste matter becomes dehydrated or dry. This produces the condition known as constipation.

Digested food products are absorbed from the walls of the intestines and enter the blood, transporting to all parts of the body where it is "burned" by being united with oxygen, and used for growth and repair of tissues. This latter union produces heat, energy, etc. The lungs, kidneys, and skin assist in removing additional waste matter from the blood.

K. THE NERVOUS SYSTEM

The nervous system is composed of the brain, the spinal cord and the afferent (to) and efferent (from) nerves. The brain and spinal cord may be considered as a clearing house for information and formation of thought and action. The afferent (to) nerves and efferent (from) nerves as the carriers of information. The structure is, of course, far more complicated than this but it will be sufficient to remember that a single nerve carries two main types of fibers one of which transmits sensation of pain, heat, cold, etc., and the other causes movements of the body. If a nerve is cut the part supplied by that nerve is devoid of sensation and movement. Thus, in a fracture of the arm, a crushed bone may allow pressure to so damage the nerves that they will be unable to transmit sensation of pain, heat or cold or to carry the impulses that should result in motion of the affected part.

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WOUNDS AND HEMORRHAGE
 
Cardinal Points: I. Stop Severe Bleeding
II. Treat Shock
III. Prevent Infection

BLEEDING

A. Types of Bleeding and How Controlled-

1. Capillary: (the small vessels that connect arteries and veins) from which the blood oozes slowly. Direct pressure and sterile dressing.

2. Vein: (the thin-walled vessels which carry blood from capillaries to the heart) flows in an even, steady stream. This blood is slightly darker than arterial blood.

To stop the flow:

a. Elevate part which is bleeding.

b. Apply a sterile pressure dressing to wound.

c. Apply pressure on side of wound away from heart.

d. Last resort, use tourniquet.

3. Artery: (the thick-walled vessels which carry blood from the heart to the capillaries) flows in jets or spurts or, in a deep wound, may well up rapidly like a spring. This blood is bright-red.

To stop the flow, apply direct pressure on artery at pressure-point. Apply tourniquet at the proper tourniquet point. The six pressure points for arterial bleeding are:

1. In front of ear stops blood flowing to temple and scalp.

2. Along jawbone stops blood flowing to face and lips.

3. On neck beside windpipe stops blood flowing to throat and head above that point.

4. On first rib, in hollow above collar bone, stops blood flowing to shoulder and armpit. (When using this pressure-point always tilt head toward shoulder in which bleeding is occurring.)

5. Inside upper arm stops blood flowing to arm and hand.

6. On groin (use heel of hand) stops blood flowing to leg and foot.

The two points at which a tourniquet is most effective are:

1. The upper arm a hand's width below the armpit.

2. The thigh a hand's width from the groin.

Remember that a tourniquet is dangerous and should be used only when absolutely necessary.

  A tourniquet may be made from any soft material such as neckerchiefs, towels, handkerchiefs, neckties, or rubber-tubing.

1. Place a pad on the inside of the extremity on the proper pressure-point. Wrap a tourniquet twice around the arm if possible. This will prevent bruising the tissues. Apply the tourniquet over this with a stick on the outside of the limb. Tighten only enough to stop the flow of blood. It should not be tight enough to cut or damage the skin. When applied the pulse can no longer be felt. Apply a compress on the side of the wound away from the heart to stop simultaneous venous flow. The tourniquet must be loosened every fifteen minutes for a period of one minute.

Do not remove the tourniquet completely until certain that the bleeding will not begin again. Loosen it and allow it to remain in place.. Be prepared to apply direct pressure over the proper pressure-point if bleeding is renewed. Always mark the tourniquet-patient with "TK'' on his forehead and tag him with a note telling when the tourniquet was applied. Never cover a tourniquet with a bandage.

Care must be taken to remove all foreign bodies from the wound. This must be done with sterilized instruments. Instruments may be sterilized by flame, alcohol, or by being placed in boiling water for fifteen minutes. After an instrument has been sterilized the portion to, be brought in contact with the wound must not be touched. If it is touched it must be resterilized. Hair, sand, etc., must be removed carefully to prevent renewed bleeding. Grease and oil must be removed by a special detergent such as turpentine or ether. When cleaning a wounded area begin by cleaning the wound first and then washing away from the wound; otherwise dirt and foreign particles will be washed into the area. Examine these wounds for foreign materials. In a puncture wound where the weapon or object causing the puncture first goes through a cloth garment, cloth is usually found at the bottom of the wound. After cleaning these wounds swab thoroughly with an antiseptic.

A compress is usually made of a square of several layers of sterile gauze. This gauze has been specially sterilized to kill any germs that may have been on it. If the portion to be placed next to the wound is touched or contaminated in any way it then becomes unsterile. If sterile

 

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gauze is not available, and the case requires emergency care, pressure may be applied with a clean pocket handkerchief. Open it carefully but do not unfold it completely. Set fire to a small twist of paper and flame the untouched inner portion of the compress. (A slight scorching of the cloth will not be injurious to the wound.) Place the inside of the handkerchief against the wound and apply pressure.

When applying a dressing, care must be taken that the sterile portion is placed exactly on top of the wound and does not first come in contact with the surrounding skin. If the sterile compress is first placed on the skin and then dragged over the injury it may carry with it bacteria and foreign matter. When a compress has been correctly secured by a bandage it will not slip. However, the bandage must be loose enough to permit proper circulation in the affected part. The bandage should be tied with a square knot so that it will hold fast and allow it to be easily untied.

When no clean material is available, with the patient losing a very large amount of blood, and when unable to locate the pressure-point; or when the bleeding is venous, pressure with the bare hand may be applied directly over the wound. Remember that this last resort should be used when all other methods fail. It will produce a dirty wound but it is better to have an infected wound and a living patient than a clean wound and a departed patient.

  Beware of strong disinfectants. Powerful solutions of phenol (carbolic acid) or bichloride of mercury and similar disinfectants, though valuable for some purposes, have no place in treating a wound as they destroy body tissues. Absorbent cotton, adhesive tape, or collodion should never be applied directly over a wound. If the edges of a wound do not touch or cannot be made to touch by a bandage, sterile clips or sutures necessary to keep the edges in contact must be applied by a medical officer. However, if one is not available and it seems essential to bring the edges of the antisepticised incision together before applying a dressing, the following procedure may be used: Take one or more strips of one-half inch adhesive tape (from two to four inches in length, depending on the size of the area to be treated); cut a wedge-shaped section from each at either side of the center so as to leave about one-eighth inch. Sterilize this narrow, middle portion, with flame. Draw the edges of the incision together by pressing on the surrounding flesh. This closed position of the wound may be maintained by applying the "dumbbell" tape with its narrowest portion directly over the cut. The purpose of this method of taping is to facilitate removal of the adhesive tape without reopening the wound. For emergency treatment careful, firm, sterile pressure dressings will usually be sufficient.
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SHOCK
 
Treat for shock after bleeding has stopped. Remember that bleeding always increases the severity of shock. (See Section on Shock.)

TREATMENT OF WOUNDS

A. Types of Wounds-

1. Incised; a cut made by a sharp instrument (bleeds freely).

2. Lacerated; a wound made by a blunt object or explosion (bleeds profusely).

3. Puncture; a stab or perforation made by a round or narrow instrument (shows little surface bleeding but may bleed internally).

4. Brush or mat "burn;" made by skin scraping against rope, wood, etc. (shows capillary bleeding). Known as an abrasion.

B. Treatment of Wounds (After Bleeding Has Stopped)-

1. Prevent adding new infectious material by scrubbing hands, wrists and arms to the elbow with brush and soap for at least five minutes.

2. Then follow one of the procedures given below:

Treatment A-if a large amount of septic (infected) material is present in the wound and bleeding has not been excessive, wash the wound carefully with large quantities of soap and sterile water. (Water is sterilized by boiling for fifteen minutes. Allow to cool.) Take care not to disturb large blood clots as this may renew bleeding. Dust sterile sulfa powder into the wound and bandage with sterile dressing or:

Treatment B-if bleeding has been excessive, do not attempt to wash the wound. Dust sterile sulfa powder into the wound and apply sterile dressing. Keep the dressing damp with sterile salt solution or:

Treatment C-paint the wound with a skin antiseptic. Never pour iodine into a wound and never soak a dressing with iodine. Allow a few moments for the drying of the skin antiseptic and then apply a sterile dressing. Always take care not to disturb blood clots.

INTERNAL BLEEDING

A. Most Common Types-

1. From the stomach: Blood from the stomach is usually vomited up and has appearance of coffee-grounds, due to the action of the digestive juices upon it. One must be careful not to confuse blood that has been swallowed from

  the nose or mouth, with that resulting from stomach bleeding. The most common causes are wounds of the stomach and stomach ulcers.

2. From the lungs: Blood from the lungs is usually coughed up and is bright-red in color and frothy in appearance. Tuberculosis is the most common cause of such spontaneous bleeding. Puncture wounds and especially an injury where a rib is broken and driven into a lung will cause bleeding.

3. From the bowels: If the blood is coming from any point fairly high up it is probably partially digested and changed into a black, tarry mass commonly described as "tarry stools." If the blood is bright red in the stool the bleeding is occurring at some point fairly low in the bowels, in vicinity of the rectum.

B. Symptoms-

1. In severe internal bleeding the patient will show signs of shock.

2. Restlessness and anxiety will be present. The patient is usually badly frightened. Air-hunger.

3. The patient is usually thirsty.

C. Treatment-

1. Keep the patient lying on his back. Turn his head to one side for coughing or vomiting.

2. Keep the patient perfectly quiet. Move him only when absolutely necessary and then in a lying position.

3. Keep the patient warm. Conserve body heat with blankets above and below.

4. Do not give stimulants.

5. Reassure the patient. A person suffering from bleeding from the lungs or stomach is usually very badly scared. Fright increases the circulation, retards the formation of a clot and makes bleeding worse.

6. A medical officer's services are always needed at the earliest possible moment.

7. In chest injuries where the lung has been punctured and there is bleeding into the lung, the patient may be unable to breathe if kept lying flat. It is frequently necessary to prop these patients up only enough to allow them to breathe. Note that this is an exception to the general rule of keeping all shock cases lying flat or with feet elevated.

INTERNAL INJURIES

A. Where Extent of Injuries Is Not Clear-Internal injuries resulting from blows in the

 

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abdomen; sudden, violent air or water pressure and the like sometimes occur in which the nature and extent of the injury is not clear, as in blast injuries. Severe shock is often present. Follow the general rules for treatment of shock. Keep the patient lying down and secure the services of a doctor at once. If necessary to move the patient, transport carefully in a lying position.

SHOCK

By the term "shock" is meant a condition in which the body activities are greatly depressed.

APPLICATION OF 'DUMBBELL ADHESIVE' TO A
SMALL WOUND
APPLICATION OF "DUMBBELL ADHESIVE" TO A SMALL WOUND

The adhesive has been flamed on both sides. The adhesive is attached on one side first and then drawn toward the other, thus approximating the wound.

Shock results from injuries, although strong emotions, such as fear, are sometimes important factors. Some degree of shock follows all injuries. If it is at all severe, prompt treatment must be given. Shock is frequently the cause of death, even when accompanying only an apparently minor injury.

SYMPTOMS OF SHOCK

Face pale. Severe chill often develops. Temperature subnormal. (Normal temperature, 98.6 F.)
Pulse weak and rapid. (Normal pulse, 72.)
Skin cold and perspiring.
Breathing shallow and irregular. (Normal respiration, 18.)
Patient often unconscious or semiconscious.
Nausea and vomiting frequent.
Eyelids half closed. Eyes vacant.
Lips, ears and nails bluish.
All senses dulled.

TREATMENT (IN ORDER OF IMPORTANCE)

A. Heat-

1. Blankets, raincoats, rubber blankets, etc., may be used. Papers between the blankets are

  useful in retaining heat. If the victim of shock is lying on a cold deck care must be taken to place blankets below as well as over him.

2. Remember, latest thought in this matter is conservation of body heat. Rubbing the limbs toward the heart is of doubtful value and not as important as warmth.

B. Position-

1. Never allow a patient to sit up. This will not only tend to increase shock but may complicate injuries not apparent when he is lying down, such as a broken neck or back.

2. Keep the patient's feet higher than his head if no fractures of the lower limbs, skull or spine are apparent. This will allow the blood to reach the head more easily.

3. Keep the head low. Never place a pillow under the head.

C. Stimulants-

1. Aromatic spirits of ammonia or smelling salts may be used under the nose of an unconscious person to aid in regaining consciousness. Always test this on yourself first.

2. Aromatic spirits of ammonia (one teaspoonful in one glass of water) is one of the most satisfactory stimulants. This may be repeated every half hour as needed.

3. Hot tea or coffee may be given in small quantities at frequent intervals. Administer a teaspoonful at a time, one cup every half hour if patient is conscious. Larger quantities may cause vomiting. Never Attempt to Make an Unconscious Person Drink. They cannot swallow and will strangle. Never Give a Stimulant in Severe Bleeding, Whether External or Internal, Until the Bleeding Has Been Checked: Stimulants cause the heart to beat faster and more blood will flow when a stimulant has been given. Never Give a Stimulant in Cases Where the Patient Has a Red Face and a Strong Pulse (as in sunstroke); although shock is a serious condition, bleeding and giving artificial respiration are even more important and demand more immediate attention. Bleeding Increases Shock.

4. When a patient begins to recover from shock he will usually begin to vomit. If vomiting begins turn his head to one side so that he will not strangle.

5. A patient who has suffered from even moderately severe shock should not be allowed to stand alone or walk for several hours after the symptoms of shock have subsided. Effort or exercise may cause the return of shock and result in collapse and further damage.

 

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BURNS
 
Since the chief differences between burns and scalds are that burns are usually caused by contact with hot metal, chemicals, flame, or electricity, and scalds are usually caused by hot water or steam, both will be considered as burns in the following work. They require the same treatment.

I. TYPES OF BURNS

Caused by:

A. Thermal (heat) Flame, steam, sun, hot metal, etc.
B. Electric Contact with electric current.
C. Chemical Acids, alkalis, radium, etc.
D. Friction. Brush burns or abrasions by rope, wire, gravel, etc.

II. CLASSIFICATION OF BURNS

Characterized by:

A. First degree Reddening of the skin.
B. Second degree Blistering.
C. Third degree Charring or cooking of the flesh.

III. METHODS OF RESCUING VICTIM FROM BURNING AGENT

A. Thermal-Before opening the door of a room in which burning is suspected always feel the door or bulkhead near the door to determine heat. Throw the door open wide and jump back to avoid possible flame or explosion of gases. The purest air is always nearest the floor. It may be necessary to crawl with a handkerchief over your face but you must always remember that a handkerchief is not a gas mask. Smother flames on victim by beating from head toward the feet with a rug or other heavy material. To remove him to pure air use the fireman's drag.

B. Electric-If the victim is lying upon electric wire either discontinue the current or remove the wire via some nonconductor such as paper, rubber or dry wood. Care must be taken to insulate yourself thoroughly.

C. Chemical-If the victim has been exposed to a chemical, whether acid or alkali, the chemical must be washed off with a stream of water or water must be poured over the burned area for at least thirty minutes. If an acid caused the burn it may be neutralized with a weak solution of bicarbonate of soda. If an alkali caused the burn it may be neutralized with a weak solution of acetic acid (2%) (vinegar), or the juice of citrus fruit, such as lemon juice.

 

IV. TREATMENT OF SEVERE BURNS

A. First Degree-In these burns severe shock rarely occurs. It is necessary to watch for the symptoms of heat exhaustion and, if present, administer treatment for same. These burns may be treated with a (5%) solution of tannic acid sprayed on the skin, or by covering the burned area with vaseline or boric acid ointment or bland oil. If discomfort is acute, ten grains of aspirin may be given.

B. Second Degree-A burn of this type is believed to be fatal if one-third of the body is affected. Any good burn ointment may be used if the burned area is small but if it is extensive the treatment must be limited to sterile normal saline solution compresses. Apply these loosely and keep moist. Severe shock may occur. Watch for symptoms of shock and be prepared to give treatment at once. If blisters are excessively painful, they may be opened with a sterilized needle inserted almost parallel with the nearby skin surface. This must be done with care and followed by a sterile dressing as this creates a potential site for infection.

C. Third Degree-These burns are considered sufficiently similar to wounds, as to require the same sterile treatment. Great care must be taken to prevent germs from entering the burn. The area of skin surrounding the burn may be washed with soap and water or, if greasy, with turpentine, ether or gasoline. Always wash from the burn toward the unburned skin to prevent dirt or infection from being washed into the wound. If clothing is sticking to the burn do not try to remove it. Leave it alone but trim or tear away the loose cloth about it. Either sulfa powder may be sprinkled into the burn and a sterile dressing used over it, or a battle dressing may be applied and sterile normal saline solution poured on the gauze. In all third-degree burns treat for shock. Sulfathiazole-tannic acid jelly is valuable, if available. It is now present in all abandon-ship first-aid kits and first-aid kits in lifeboats. Shock is often severe in instances of third-degree burn. Watch carefully for any sign of shock and begin treatment at once if it appears. A syrette of morphine, 1/4 grain, may be given to ease pain. If a medical officer cannot be reached for several days watch carefully for retention of urine. If a patient cannot urinate he may develop uremic poisoning. Constipation and lack of fluid in the

 

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system may be guarded against with weak, saline enemas and hot fluids given by mouth in small doses at frequent intervals. Do not underestimate the severity of an extensive burn. Although the patient may not complain of great pain at first (because of shock) it may require blood plasma and tetanus antitoxin to save him.

Never allow absorbent cotton, adhesive tape, wool, or any strong antiseptic to come in contact with a burn. Never put any greasy or oily substance over a large burn. Matter of this sort will have to be removed bit-by-bit by the medical officer. It is a tedious and painful procedure.

In burns of the joints, such as the back of the knee, the wrist and hand or the neck, the portion burned must be held in extension. That is, the fingers must be splinted in an outstretched position, the neck must be held with the chin up and the back of the leg must be kept straight in order that the scar tissue will be formed over the largest possible area. Scar tissue usually contracts and so it must follow that if the fingers are allowed to heal in a relaxed or contracted position that the scar, when it eventually contracts, will draw the fingers so tightly to the hand that it will be impossible to

SYRETTE OF MORPHINE
SYRETTE OF MORPHINE

  extend them normally. Although this does not ordinarily come within the province of emergency treatment it must be considered when a long period of time elapses before a doctor can be obtained.

Burns about the eyes, the genitalia and the fingers should neither be treated with tannic acid nor bandaged. Apply sulfa powder or cod liver oil or any mild, sterile oil, sterile vaseline or boric acid vaseline.

Morphine is prepared for emergency use in a small hypodermic tube called a syrette (see illustration). The tube has a sterile needle attached to one end. In the needle is a plunger which, when forced into the needle, will open the needle so that it is ready for use. Over both needle and plunger is a cellophane case which protects the needle until it is ready for use. Whenever a patient is in severe pain, such as that caused by an extensive burn, he should be given a syrette of morphine. If his pain continues another syrette may be given in thirty minutes.

DIRECTIONS FOR ADMINISTERING A SYRETTE OF MORPHINE

1. Paint a small area of the skin on a fleshy part of the patient's arm or leg with alcohol, iodine, or a similar antiseptic. This is to kill dangerous bacteria and prevent an infection.

2. Remove the cellophane cover from the syrette of morphine. Take care not to touch the needle.

3. Push the wire plunger down into the needle and then draw it out.

4. Insert the needle into the skin previously painted. Squeeze the tube empty. Withdraw the tube.

5. Remember, morphine should never be given in cases where there is serious bleeding or where skull fracture is suspected.

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UNCONSCIOUSNESS
 
Unconsciousness, either partial or complete, may be caused by a variety of conditions. Frequently it is impossible for the First Aider to determine the cause, and treatment must be given along general lines. When in doubt always treat the patient for skull fracture or apoplexy. In examining the patient always look carefully for bleeding, the stoppage of breathing, poison or heatstroke as a special treatment must be given for each of these at once. All unconsciousness may be roughly divided into three groups on the basis of easily determined symptoms. General treatment for each type is listed.

TYPE I. RED UNCONSCIOUSNESS

A. Chief Symptoms-Red or flushed face and a strong pulse.

B. Treatment-Put in lying position, head slightly raised. Keep patient quiet. Apply cold applications to head. Loosen any tight clothing. Give no stimulants. Transport very carefully in a lying position. When treating for heatstroke the most important First Aid procedure is to reduce the patient's temperature. This may be done with icebags, cold baths, wrapping in wet sheets, etc. When the temperature drops to 102 degrees all cooling agents should be removed to prevent the sudden fall of temperature to subnormal. Small amounts of cool, salt water may be given. Salt tablets available in dispensers aboard ship, especially in the engine room, to use for prevention of heat exhaustion and heatstroke.

C. Most Common Causes-Additional symptoms:

1. Heatstroke; Skin dry, high fever, headache, dizziness. (See above.)

2. Apoplexy; Unequal size of pupils of eyes, one side of body or one limb more limp than other, mouth often drawn to one side, snoring breathing.

3. Drunkenness; Usually odor of alcohol on breath, face flushed at first but later becomes pale; pulse strong at first but later becomes weak. (Note shift from red to white unconsciousness.)

4. Skull Fracture; There may be a bump or wound on the head. The patient may or may not be unconscious. The pupils may be unequal in size. There may be bleeding from the nose or from one or both ears; or there may be a clear

  fluid discharge in the ears. (See Fractures; Fractures of the skull.)

5. Epilepsy; Patient utters a hoarse cry; muscles become tense and breathing stops from five to thirty seconds; face is pale; arms and legs begin to jerk spasmodically; face becomes bluish; tongue is often chewed and frothing at the mouth is common; bladder and rectum may be emptied involuntarily; after a few moments the patient either falls into a deep sleep or wakens immediately. Care is taken to prevent injury when falling. Place gag through mouth to keep him from throwing himself against surrounding objects during convulsions. Do not attempt to hold him still or to pour any liquids into his mouth.

TYPE II. WHITE UNCONSCIOUSNESS

A. Chief Symptoms-Pale face and a weak pulse.

B. Treatment-Keep patient quiet and in a lying position. Keep head level or low. Apply external heat. Use inhalation stimulants if there is no bleeding and no head injury. Transport carefully in lying position. The treatment of heat exhaustion is the same as the treatment for shock. Warmth is the most important factor. Conserve the body heat.

C. Most Common Causes-Additional Symptoms:

1. Bleeding, external and internal. (See Wounds and Hemorrhage.)

2. Shock; (See Shock.)

3. Heat exhaustion; Face pale (unless sunburned); skin cold and damp; pulse weak and fast; body temperature subnormal; occasionally cramping pains in stomach and limbs; respiration shallow. (See above.)

4. Fainting; The face is pale; forehead usually covered with perspiration; dizziness; pulse weak and usually slow.

5. Poison; Tongue or mouth may be burned or stained; cramps in stomach; nausea; vomiting. If overdose of sleeping tablets is taken a deep sleep with other symptoms of white unconsciousness is noted. (See Poisons, General Treatment.)

TYPE III. BLUE UNCONSCIOUSNESS

A. Chief Symptoms-Face white or bluish; lips, ears, and nails blue; patient always unconscious and usually not breathing.

 

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B. Treatment-Keep patient in lying position. Begin artificial respiration at once if needed. Do not regard rigidity or stiffening as a sign to cease artificial respiration. Treat shock. If electric burns are present, treat as under "burns." Artificial respiration should always be continued without pause for at least four hours as cases have been known to revive after eight hours of treatment. The patient should not be considered dead until pronounced dead by a medical officer or until all reasonable efforts fail.

C. Most Common Causes-Additional Symptoms:

1. Electric shock; Body frequently very rigid.

2. Gas poisoning; Yawning; headache; dizziness; nausea; weariness; ringing in the ears; later a fluttering or throbbing of the heart. Or unconsciousness may come very suddenly. The skin in carbon monoxide poisoning sometimes becomes cherry red, but it may be blue. (See Poisons; Carbon Monoxide Gas Poisoning.)

3. Drowning; None.

4. Hanging; None. The neck is usually not broken unless the person jumps from a considerable height.

5. Freezing; Begins with consciousness but this is followed by marked feeling of depression, drowsiness and unconsciousness. Treatment is the same as the treatment for shock_ Do not rub or chafe the frozen part. This is very dangerous. Warm the affected area slowly

  by covering it or placing it next to a warm part of the body. Never allow pressure on a frozen part. If a foot is frozen and waterlogged and the patient attempts to stand, his weight may force the bones of the foot through the flesh.

Unconsciousness Is Not a Reason to Begin Artificial Respiration. Only Start Artificial Respiration When It Is Clear That the Patient Is Not Breathing.

Important points to remember in giving artificial respiration: The first attempt to breathe may be a faint sigh or gasp. Stop the artificial respiration administration immediately and watch carefully to make sure that the breathing continues. If it does not, resume artificial respiration. The breathing may begin very slowly, four to six times a minute. As breathing is resumed the patient may try to get up and even become violent in his semiconscious efforts to help himself. He must be gently restrained and kept in a prone (flat) position. His heart has been under a very severe strain and any attempt to walk, if begun too soon, may cause sudden heart failure and collapse.

In electric shock the breathing center of the brain is affected. The victim may be alive but unable to breathe for several hours. Artificial respiration over a four- to eight-hour period may be indicated.

In carbon monoxide poisoning the red blood cells (which have a greater affinity for carbon monoxide) must be helped to discharge the carbon monoxide and accept oxygen. An oxygen inhalator is definitely indicated here, when available.

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POISONS
 
Cardinal points:

1. Dilute the poison in the stomach.

2. Wash the poison out of the stomach.

This is one of the emergencies demanding immediate attention by the First Aider. Once the poison has been absorbed by the system there is not too much that even a medical officer can do. If the poison can be removed from the stomach before it has been absorbed the harm done to the body is usually not too great. It is not necessary to remember a long list of antidotes. Much better work will be done if the simple remedies at hand are used. In the first section only the poisons taken into the stomach are considered.

Symptoms vary considerably with the drug taken. There may be no early symptom. Pain in the stomach, nausea, vomiting and cramps frequently occur. If a corrosive poison has been taken, the mouth and tongue may be stained or burned. Sedatives (sleeping tablets or powders), cause drowsiness, sleep or even unconsciousness.

I. GENERAL

Two main points are to be remembered in general treatment.

Dilute-A poison diluted with a large amount of fluid is never absorbed as rapidly as when in concentrated form. Vomiting is much easier to induce when the stomach is full.

Wash Out-When the poison is removed it can do no further damage. Repeatedly induce vomiting until the fluid is as clear as when swallowed. The following emetics may be used:

1. Soapsuds (use any ordinary mild soap).
2. Salt water.
3. Soda water (use baking soda).
4. Lukewarm water or dishwater.
5. Milk (particularly in corrosive poisons).

When the stomach is sufficiently washed out (four to seven glassfuls) one may give the antidote if known and on hand. Do not waste time getting the antidote before diluting and washing out the poison. A large glass of Epsom salts should be given after almost any poison. This should be followed by soothing drinks of milk, eggs (raw), or milk and eggs beaten together.

If shock is present give the proper treatment as outlined under the lesson of shock. Look for

  stoppage of breath and apply artificial respiration. This is most likely to be needed in sleep-producing drugs. In opium, morphine, or wood-alcohol poisoning it is advisable to keep the patient awake. This may be done in numerous ways. Moving the patient in bed; walking him without exhausting him, inducing slight pain as gentle hair pulling or pinching and frequent, strong cups of coffee (one every half hour) will usually suffice.

In strychnine poisoning do not give a stimulant. Keep the patient as quiet as possible, away from drafts of air, jarring, sudden noises, or bright lights. In addition to the general emergency treatment given above it is advisable to wash out the patient's stomach with a weak solution of potassium permanganate (twenty grains to one pint of water).

II. FOOD POISONING

Food poisoning is caused by the presence of harmful bacteria in spoiled or contaminated foods. The most common offenders are meats, fish and potatoes. Food in swollen or bulging cans should never be eaten. In severe cases (sometimes called "ptomaine"), the symptoms are nausea, vomiting, dizziness, headache, diarrhea, cramps in the stomach, double-vision and fainting. The treatment is the same as for dry poisons; dilute the poison in the stomach and wash the poison out of the stomach. Even though diarrhea is present, castor oil should be given. Food should be withheld from the patient for twenty-four hours, and fluids should be given copiously.

III. CARBON MONOXIDE GAS POISONING

The symptoms of carbon monoxide poisoning vary considerably with the concentration of gas in the air breathed. In all cases it may not begin in the same way. First Aid must be given at once. In mild cases the symptoms begin with yawning, headache, dizziness, nausea, weariness, ringing in the ears and later a fluttering or throbbing of the heart. However, the symptoms may come on so suddenly that the victim is unaware of any trouble until the knees suddenly give way and the victim, even though conscious, cannot walk or crawl. Unconsciousness and death may follow. The skin is either a bluish-white, or usually has a peculiar cherry-red color.

 

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Treatment-The first thing to do is to get the patient into fresh air quickly. Fresh air need not mean the out-of-doors in cold weather. Many men have walked from a warm room containing gas to collapse in the cold air outside. Take the patient to a room free from gas but comfortably warm. Be quick, but not unnecessarily rough.

If breathing has stopped or is present in only occasional gasps, start artificial respiration at once and continue until normal breathing is

  resumed. If the patient does not die in the gas but is removed to fresh air and given artificial respiration (if needed) the carbon monoxide gradually leaves the blood. Additional oxygen, given by an oxygen inhalator, is often a great help in saving the life of a carbon monoxide victim. This must be given by someone trained in the use of the machine. Most fire departments have rescue squads who will provide both inhalator and operator. If no medical officer is available call these men at once, if ashore.
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ARTIFICIAL RESPIRATION
 
To recognize and treat a respiratory emergency is one of the most important problems in emergency care. If the tissues are deprived of oxygen for ten minutes life cannot be maintained (see The Body; the respiratory system). As in the treatment of severe hemorrhage, every moment counts when a patient has stopped breathing. When it is certain that breathing has stopped begin artificial respiration at once. Do not stop to loosen clothing, nor cover the patient with a blanket.

There are four recognized methods of giving artificial respiration. Each of these has special advantages and should be considered as treatment when the other methods are impractical.

A. SCHAEFER PRONE PRESSURE METHOD

1. Lay the patient face down with one of his arms extended overhead. Bend the other arm at the elbow, the palm of the hand down. Place the cheek of face on the back of this so that the mouth and nose are free for breathing. Examine the mouth for foreign objects such as false teeth, chewing gum, tobacco, etc. Which may obstruct breathing.

2. Kneel straddling one of the patient's thighs. This should be the thigh on the side toward which the face is turned. Your knees should be about halfway between the patient's crotch and his knee. If working on a wet slippery deck, sliding may be prevented by crossing your feet beneath the patient's ankle. This will keep you from pushing the patient away from you when giving artificial respiration.

3. Place the palms of your hands on the small of the patient's back with the thumb against the first finger. The little finger should rest on the patient's lowest rib. The tips of your fingers should be just out of sight.

4. Without bending your arms, swing forward slowly. This brings your weight to bear on the patient. At the end of the forward swing your shoulder should be directly over the heel of your hand. Do not push down on the patient; just allow your weight to rest on him. The forward swing should take about two seconds. The

size of the patient should determine the amount of pressure needed. A small victim, such as a child, requires very light pressure.

5. Now immediately swing backward so that all pressure is quickly removed.

  6. After two seconds swing forward again. Repeat unhurriedly for from twelve to fifteen times per minute this cycle of compression and release. This produces a complete respiration every four or five seconds.

7. Continue artificial respiration without interruption until natural breathing is restored. This may require four hours or more.

8. While you are giving the patient artificial respiration an assistant should determine whether or not the tongue has slipped backward so as to prevent air from entering the throat. If it has, he should grasp it with a clean piece of cloth and pull it gently forward to a normal position. The patient should be kept warm and all tight clothing loosened. No attempt should be made to give liquids by mouth until the patient is fully conscious.

9. When the patient revives he should not be allowed to sit or stand. Keep him in a lying position. Stimulants such as hot tea, coffee or aromatic spirits of ammonia may be given at this time. The patient should be kept warm.

10. Artificial respiration should always be given as near as possible to the place where the injury was received. He should not be removed until breathing normally and then only in a lying position. If he must be moved, due to weather conditions, etc., artificial respiration should be continued while he is being moved.

11. When the patient resumes breathing he must be watched closely to make sure that breathing does not stop. If breathing stops, artificial respiration should be started again, immediately.

12. If artificial respiration is carried out over an extended period it is necessary to change operators. This must be done without changing the rhythm. The relieving operator kneels by the operator straddling the patient's free leg and follows the operator through the motion of artificial respiration. At a given signal (usually the word "change") the relief operator takes over the treatment.

B. SILVESTER METHOD

Under certain conditions it is advisable not to place a patient in a prone position (face down) to give him artificial respiration. When it is desirable to keep a patient lying on his back to receive artificial respiration the Silvester method may be used.

 

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1. Place the patient on his back with his face up.

2. Pull his chin slightly upward.

3. Be sure that his mouth is empty.

4. Kneel at the patient's head, facing his feet.

5. Bend his elbows and grasp his forearms just below the elbows.

6. Pull his arms in an arc outwards and upwards toward you. Keep his elbows close to the ground.

7. Now rotate his arms in another arc, forward, downward and inward. When the arms lie upon the chest again press downward with enough pressure to compress the chest and cause additional expiration.

8. Repeat this cycle about twelve times per minute.

C. MOUTH-TO-MOUTH FORCED RESPIRATION

Since exhaled air contains sixteen per cent oxygen it will suffice to maintain life if blown into the lungs of a patient who is not breathing.

Both the mouth-to-mouth and mouth-to-nose methods are valuable in cases of chest, back or

  abdominal injury where neither the Silvester nor Schaefer methods would be safe.

1. Place the patient on his back.

2. Cover the patient's mouth and nose with a clean handkerchief or gauze, if available.

3. With one hand hold his nostrils closed and his chin up while placing your own mouth over his and blowing in. If there is no obstruction this will inflate the lungs.

4. After blowing your breath into the patient's lungs, place your hand on his chest and exert a gentle pressure. This assists his expiration. However, this should not be done if the chest has been injured.

5. Repeat this cycle of respiration about once every four or five seconds.

D. MOUTH-TO-NOSE FORCED RESPIRATION

This can be done just as in mouth-to-mouth respiration. The only difference is that the patient's mouth is held closed and the operator's breath is blown into his nostrils.

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FRACTURES
 
A fracture is a broken bone. For emergency purposes all fractures may be divided into general types; simple and compound.

In a simple fracture there is no connecting wound from the break in the bone to the outer skin.

In a compound fracture there is a connecting wound from the break in the bone to the skin. The wound may be made by the sharp end of the broken bone being forced through the flesh or by some object (such as a bullet) entering the break from the outside. A compound fracture may result from the improper handling of a simple fracture. Compound fractures are usually more serious than simple fractures because of the danger of infection.

Symptoms-The patient frequently feels or hears the bone snap. Pain and tenderness are present at the point of the break. The broken part may be deformed. Partial or complete loss of motion is present in adjacent joints. Crepitus (grating of the broken bone) may be felt but no intentional attempt should be made to feel this. Shock is almost invariably present. If the fracture is compound, additional symptoms may be torn flesh, hemorrhage, signs of infection and, perhaps, protruding bone.

General emergency treatment for a simple fracture:

1. Prevent further damage.
2. Treat shock.
3. Make the patient comfortable (mentally as well as physically).
4. Do not attempt to set a bone.
5. Apply and maintain traction.
6. Apply the proper splint.
7. Do not attempt to transport the patient at all before splints have been applied.

Additional general emergency treatment for a compound fracture:

1. Stop bleeding.
2. If no bleeding is present, place a tourniquet loosely around the limb and be prepared to tighten it at once should bleeding occur.
3. Treat the wound.
4. Apply and maintain traction.
5. Dress the wound.
6. Apply the proper splint.
7. Do not attempt to transport the patient at all before splints have been applied.
 
8. Use sterile sulfa powder directly into the wound produced by a compound fracture.

When a bone has been completely broken, the affected part may show deformity. When the break is not through a joint the ends of the broken bone must be brought back into position before splints are applied. The pulling process by which the bone is restored to its proper position is known as traction. Traction should always be gentle. Once the pull has been started it should never be stopped until splints are applied. If traction should be released before the broken bone is supported by a splint, a sudden muscle spasm will jerk the bone to its previous position of deformity, causing great damage. If the upper arm bone, for example, has been broken, and the arm is in an unnatural position, one operator should grasp the shoulder and the other operator should begin a gentle pull at the elbow. This pull must be maintained constantly until splints are applied. It should continue for from five to ten minutes to allow the muscles to relax and the bone to return to its normal position. If no skull fracture or severe bleeding is present a syrette of morphine, 1/4 grain, should be given to reduce pain and ward off shock.

FRACTURES OF THE SKULL

Symptoms-In fractures of the skull varying degrees of unconsciousness may be seen; but, it does not necessarily follow that unconsciousness will always be present. Occasionally the patient will merely be stunned or dazed and this condition may vanish, remain, or later lapse into true unconsciousness. The appearance of the patient is seldom normal. The symptoms of either white or red unconsciousness may be present. If bleeding from the ears or nose is seen, or a clear, watery discharge comes from the ears, or if blood is spit out or vomited up, the skull has very probably been fractured. In some cases the scalp itself will be broken or torn and a fracture will be clearly visible but this will not always be true and the general rules for treatment for fractures must be followed when a fracture of the skull is suspected.

Treatment-The patient must be kept as quiet as possible. Keep him in a lying position and do not allow any pressure over the portion of the skull believed to be fractured. Place a loose,

 

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sterile dressing over the wound if bleeding is present. In deep lacerations of the scalp where a fracture of the skull is obvious and it is possible to see brain tissue, use no iodine or other disinfectant upon the brain. Use no stimulants where skull fracture is suspected. Transport the patient carefully in a lying position and keep him warm.

FRACTURE OF THE NOSE

Symptoms-The usual symptoms of fracture will be present. Fractures of the nose are not difficult to detect. The patient has usually received a severe blow and the resultant injury

FOUR-TAILED BANDAGE USED IN THE FIRST AID TREATMENT OF FRACTURES OF THE MANDIBLE
FOUR-TAILED BANDAGE USED IN THE FIRST AID TREATMENT OF FRACTURES OF THE MANDIBLE

will be obvious. However, it is possible for the bones of the nose to be broken and not to be so radically displaced as to show deformity. When nose fracture is suspected because of severe pain the nasal septum will usually show deviation to one side or the other. Bleeding may or may not occur.

Treatment-If bleeding is present treat as a nosebleed. If the nose shows deformity it may be gently manipulated into position. Unless further trauma is sustained, no packing or bandaging is necessary.

FRACTURE OF THE LOWER JAW

Symptoms-In a simple fracture of the lower jaw the usual symptoms are pain on movement of the jaw with difficulty in eating, drinking and talking and irregular or loose teeth. There may be bleeding from the gums and in more severe cases the mouth may hang open with drooling of saliva. In compound fractures the symptoms remain in the same but are complicated by the presence of a lacerated wound in the region of the jaw.

  Treatment-Shock is often present in fractures of the jaw, and usually occurs soon after the fracture has been sustained. This must be treated first. The jaw may be secured by a four-tailed bandage which will hold the jaw in place and thus alleviate pain. Feeding may be accomplished either through a rubber tube inserted behind the back teeth or by pulling out the cheek and allowing liquid to run between the teeth and thus enter the mouth. If at all feasible the bandage should not be loosened until the patient has been placed under the care of a doctor or a dental officer.

FRACTURE OF THE CLAVICLE

Symptoms-The collar bone is frequently broken, since it is fixed at either end, it will break near the middle if one falls upon the point of the shoulder or upon the hand when the arm is outstretched, slightly bent and rigid. The part of the bone which lies toward the midline of the body usually is displaced higher than that toward the shoulder. The part which is nearer

DIAGRAM SHOWING DISLOCATION OF THE MANDIBLE
DIAGRAM SHOWING DISLOCATION OF THE MANDIBLE

the shoulder is usually depressed. In the type of fracture just described the ends of the overlapping bone can be seen and felt beneath the skin. The inner fragment makes a prominence above the normal position of the bone. It rarely pierces the skin and still more rarely injures any of the large blood vessels which lie near it.

 

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LEFT: FIGURE-OF-EIGHT BANDAGE FOR FRACTURE OF THE CLAVICLE
The forearm on the affected side is placed in a sling.
RIGHT: 'T' SPLINT FOR FRACTURE OF THE CLAVICLE
The forearm on the affected side is placed in a sling.
LEFT: FIGURE-OF-EIGHT BANDAGE FOR FRACTURE OF THE CLAVICLE
The forearm on the affected side is placed in a sling.
RIGHT: 'T' SPLINT FOR FRACTURE OF THE CLAVICLE
The forearm on the affected side is placed in a sling.
 

The shoulder falls forward and the patient is unwilling to try to raise his arm. He sits supporting the elbow with the opposite hand, his head inclined toward the injured side.

Treatment-The greatest difficulty in treatment of fractures of the clavicle lies in the fact that there is no way of directly splinting the broken bone and therefore reduction may only be made by forcing the shoulder backward until the edges of the broken bone are brought into proper position. This position is best maintained by the use of a figure-eight bandage made from two triangular bandages or by using a Clavicular Cross Splint. Care must be taken that the bandage passing under the shoulder does not cut off the blood supply to the arm.

FRACTURE OF THE SCAPULA

Symptoms-The scapula is rarely fractured without additional injury to the ribs as this

  bone is only broken when considerable violence is involved. Pain is felt in the region of the scapula and shoulder. The shoulder may be depressed and show a slight forward dip.

Treatment-Treatment for fracture of the scapula, due to the anatomical position of the t one, is rather simple. The arm of the affected side should be supported in a sling and the scapula further immobilized with either a circular bandage or circular adhesive tape strapping.

FRACTURE OF THE RIBS

Symptoms-Severe pain at the point of fracture on deep breathing or coughing is the chief symptom. The break may sometimes be felt by running the fingers along the ribs. Breathing is usually shallow because deep breathing increases pain. If the lung has been punctured the patient will cough up bright red, frothy blood. The lung is punctured in only a few cases.

 

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Treatment-Make a cravat bandage by folding a triangular bandage. Tie this loosely about the chest over the broken ribs, with a single knot. Place a pad under the knot. Tell the patient to expel the air in his lungs and, while this is being done, tighten the bandage around his chest and finish the knot (square knot). Repeat with at least two other cravats. Release the bandages if the patient complains of increased pain. If the patient is coughing up blood, and it is believed that a lung is punctured, apply no bandages. Keep the patient in a lying

METHOD OF STRAPPING CHEST FOR A FRACTURE OF THE RIB
METHOD OF STRAPPING CHEST FOR A FRACTURE OF THE RIB

The straps are applied very firmly from the top downward while the patient holds his breath in exhalation.

position with his chest and shoulders sufficiently raised to allow him to breathe easily. Keep him warm, move only when necessary and then in a lying position. Obtain medical aid as soon as possible.

FRACTURES OF THE NECK

Symptoms-The neck may be fractured without injury to the spinal cord. Improper handling may cause paralysis of the victim's arms and legs by causing the unprotected spinal cord to

  be damaged. Handle spine cases where fracture is suspected with the utmost of care. If the spine was injured when the fracture occurred the arms will probably be paralyzed. The patient may or may not be unconscious. If he cannot open and close his fingers rapidly or grasp your hand firmly the neck is probably broken. If he can move his arms and fingers but not his legs and toes the back is probably broken. In any case, the spinal cord may be injured but not severed. When in doubt, treat as a broken neck.

COMPLICATIONS WHICH MAY ARISE FOLLOWING WOUNDS OF THE CHEST
COMPLICATIONS WHICH MAY ARISE FOLLOWING WOUNDS OF THE CHEST

Note the pneumothorax (air in pleural cavity), collapsed lung, and hemothorax (blood in the pleural cavity).

Treatment-The victim of a broken neck should be lain on his back. No pillow should be placed under his head. Support his head on either side with two blocks of wood or two bricks, to prevent his head from moving. The head must not be raised or turned sideways or bent forward or backward. If the patient must be moved it should be done with the utmost care. The head, neck and shoulders must be moved as one unit with the body. This requires the help of four men; one to support the head, one his shoulders and chest, one the hips and one the legs and feet. If placed on a stretcher the arms must be securely bandaged to the chest, the head supported and great care taken that the head does not fall sideways. In handling the victim of a broken neck care is more important than haste.

 

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FRACTURES

From left to right
Single complete transvere fracture
Oblique fracture
Greenstick (incomplete) fracture

From left to right
Complete transverse fracture with displacement
Complete transverse fracture with angulation
Complete transverse fracture with rotation and separation of fragments

From left to right
Transverse fracture with partial lateral displacement
Transverse oblique fracture with over-riding Comminuted fracture

 

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FRACTURES OF THE BACK

Symptoms-The victim of a broken back is unable to move his legs and feet. He may or may not be conscious. As in case of a broken neck, he must be moved with great care.

Treatment-In handling any case where a broken back is suspected it is always necessary to preserve the normal curve of the low back to prevent pinching of the spinal cord by the vertebrae. This may be done by allowing the patient to remain on his face if he is already in that position or by using a pad under the small of his back just above the top of the pelvic bone if he is already lying on his back. It must be remembered that the less the patient is moved the less the chance of injurying him further. As for a fractured neck, four men are required to lift him properly. They assume the same positions described for lifting a man with a broken neck and care is taken to avoid bending or twisting the back. The head, shoulders, hips and legs should move as a single unit. When in doubt, treat as a broken neck.

FRACTURES OF THE UPPER ARM (HUMERUS)

Symptoms-All the usual symptoms of fracture will be present.

Treatment-Apply traction to the upper arm. This is most successful when the traction is gentle and maintained over a period of from five to ten minutes. In this way the muscles relax their spasm and allow the bones to resume their proper position. Then splint the upper arm with a padded splint that extends slightly above the shoulder and beyond the elbow. Bend the arm at right angles at the elbow and place a cravat bandage to prevent accidental motion.

FRACTURES OF THE ELBOW

Symptoms-These fractures are usually caused by a fall upon the bent elbow. There is usually severe pain and swelling and a reluctance on the part of the patient to attempt to move the joint.

Treatment-If the fracture appears to be at or near the elbow and the arm is straight, apply a single well-padded splint on the inner or palm side of the arm from the axilla to the finger tips. Traction is seldom necessary in these fractures but when it is indicated by the deformity of the arm it must be applied slowly and gently. If the elbow is fractured and the arm is bent place the arm in a full sling and encircle the

  injured arm above the elbow and the chest with a single cravat bandage.

FRACTURES OF THE FOREARM AND WRIST

Symptoms-If both bones of the forearm are broken the patient has all the symptoms of fracture, but in those cases where the fracture is confined to one bone the ability to move the part may still be present.

Treatment-The most satisfactory position for the treatment of this fracture is to have the patient lying on his back with the injured arm supported by his chest. This will prevent his fainting, falling and thus injuring himself further. Have the patient's hand extended with the palm toward his chest. Secure the forearm with two well-padded splints which reach from the elbow almost to the tips of the fingers. Support this with an arm-sling which elevates the tips of the fingers about four inches higher than the elbow. If no proper splints are available, pad the wrist well with a soft cloth and splint the arm with enough folded newspapers or similar material to insure rigidity.

FRACTURES OF THE THIGH

Symptoms-If, following an injury near a hip joint, the patient is unable to lift his heel from the ground when lying on his back, he should be treated for a fracture of the thigh. If the limb is shortened or the foot turned so that it rests on its outer side one assumes that such a fracture is present.

Treatment-Begin treatment for shock at once as the shock accompanying the fracture of a femur is usually severe. Steady the leg by grasping the foot with one hand in back of the heel and apply traction. Move it carefully to a normal position so that it is in line with the body and the same length as the other leg. Hold it in this position with continued traction. Two well-padded splints should be used; the outer one to reach from the armpit to the foot and the inner from the crotch to the foot. These should be secured to the leg and body by three cravat bandages around the trunk and four around the injured leg. When only one splint is available place it on the outside, pad well between the legs and tie all together. If no splints are available pad well between the thighs and legs and tie both together. In this way the sound leg will serve as a splint.

 

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FRACTURE OF THE KNEECAP

Symptoms-This fracture may be caused by either trauma or by muscular action. Usually a groove or separation is felt in the kneecap. The usual symptoms of fracture are present.

Treatment-Straighten the limb. Use a board that will reach from the buttock to the heel and that is at least four inches wide, if available. Place this board under the injured limb. Pad well with extra padding just under the kneecap and just above the heel. If no splint is available one may be improvised from either a pillow or from a folded blanket. Use four cravat bandages to secure the splint to the leg; two above the kneecap and two below. Do not use a cravat bandage directly over the patella as swelling may be very rapid.

FRACTURE OF THE LEG BONES

Symptoms-One or both of the leg bones may be broken anywhere between the knee and the ankle. If both bones are broken, all the symptoms of fracture are apt to be present. If only one bone is broken there may be no noticeable

  deformity. A fracture just above the ankle joint may be mistaken for a sprain.

Treatment-Grasp the foot firmly and apply traction as previously described. Raise the leg high enough off of the floor so that a pillow may be placed under the ankle and secured with cravat bandages to form a splint. If a pillow is not available a folded blanket may be used instead. Greater stiffness may be obtained by placing a stick or board outside the pillow or blanket on either side. If no splints are available, place padding between legs and thighs and tie feet, legs and thighs together.

FRACTURE OF THE FOOT OR TOES

Symptoms-All the symptoms of fracture are usually present, in these cases, of a crushing injury.

Treatment-Apply a well-padded splint to the sole of the foot. This should extend to about one-half inch beyond the toes. Use two cravat bandages to tie this in place. Take care not to fasten this too tightly. Keep the foot elevated to prevent swelling and support it at right angles to the leg.

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DISLOCATIONS, SPRAINS, AND STRAINS
 
The displacement of one bone on another at a joint or at a place of motion is known as a dislocation. When force is applied to a joint one of the bones is dislocated by the tearing of the joint capsule and tendons (see The Body; Joints). Dislocations may occur in any joint but are most common in the fingers.

Symptoms-The symptoms are the same as for any simple fracture; chiefly pain, deformity and swelling but no crepitus is present. The swelling usually becomes noticeable more suddenly.

DISLOCATIONS OF SHOULDER AND HIP
DISLOCATIONS OF SHOULDER AND HIP

A. Normal shoulders and normal hip.
B. The most common type of dislocation of the shoulder is forward and medial.
C. The posterior (upward and backward) dislocation of the hip is more common than the anterior (forward and downward).

Treatment-As a general rule no one but a physician should attempt to reduce a dislocation as there is a probability of injuring blood vessels, nerves, etc., near the joint. However, the less complicated dislocations may be reduced by one trained in emergency care.

  Dislocation of the Lower Jaw-When the lower jaw is dislocated the mouth hangs open and the injured person is unable to close it. Before attempting to reduce a dislocation of the lower jaw one must be sure that the jaw is not fractured (see Fractures; Fracture of the lower jaw).

Seat the patient and stand in front of him. Wrap your thumbs in several layers of cloth (this is to prevent them from being bitten when the jaw snaps into position) and place them on the lower, back teeth of the patient. Place the fingers under the chin. Press down and back with the thumbs on the back teeth and press up

SIMPLE THUMB SPLINT MADE OF TONGUE DEPRESSORS AND ADHESIVE
SIMPLE THUMB SPLINT MADE OF TONGUE DEPRESSORS AND ADHESIVE

with the fingers beneath the chin. After the dislocation has been reduced, apply a four-tailed bandage to the jaw. Do not attempt to reduce a dislocation of the jaw if an open wound is present in the region of the jaw.

Dislocation of the Finger-Grasp the dislocated finger firmly with one hand on each side of the dislocated joint. Then slowly pull the end of the finger away from the hand until it slips into place. If the reduction is not successful by the second attempt do not try again. Protect the injured hand until it can be seen by a

 

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physician. Do not attempt to reduce a dislocation if a wound is present near the joint. Dress the wound and send the patient to a physician. Never attempt to reduce a dislocation of the second joint of the thumb or the big toes. No one but a doctor should attempt to do this.

Sprains-Sprains are considered as minor tears in tendons or ligaments, strains may be differentiated from these by considering the term as referring to damage caused by the stretching of muscles and tendons beyond normal limits under unfavorable conditions but without the tearing of tissues. The symptoms include pain and sometimes limited motion. The treatment consists

  of bed-rest, heat therapy and massage for severe strains, and local applications of heat and massage for less severe cases.

Strains-Strain is usually caused by the enforced function of muscles in a position of imbalance, or the attempt to force the wrong muscles to lift too heavy an object. In the prevention of muscle strain it is important to remember that most strains can be avoided by the judicious use of one's body. In lifting a small, heavy object, for example, the back should be kept rigid to allow the weight of the burden to be borne chiefly by the muscles of the legs and thighs.

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DENTAL FIRST AID
 
Dental First Aid is the application of the principles of primary dental treatment. Primary dental treatment consists of giving temporary relief from dental pain in the absence of a dental officer or dentist. The treatment given in dental conditions varies with each individual case, although some cases may appear to be quite the same as others.

TOOTHACHE

A. Due to Decay or Loss of Tooth Structure Through Disease-

1. Clean the cavity. Remove all food debris, broken tooth particles and any other substance that is lodged in the tooth cavity.

2. Dry the cavity with small pledgets of cotton. Be sure to keep the cavity free from saliva.

3. Moisten a small amount of cotton with Oil of Cloves and apply this to the dry cavity.

4. If possible, place a small amount of gum or wax over the pledget of cotton to secure the medicament in the cavity.

5. Advise the individual to see a dental officer or dentist as soon as possible. The above treatment is only temporary and should not be mistaken for a cure.

B. Due to Ulceration or Abscess Formation-

1. Use hot, strong, salt solution within the mouth and preferably a cold pack on the outside of the face over the area of greatest soreness. The strong salt solution may be made by dissolving two tablespoonsful of table salt in a pint of hot water. This solution should be used at least twice an hour. A towel or other suitable piece of cloth soaked in cold water may serve the purpose of an ice pack.

C. Due to Fracture of the Enamel or Broken

  Teeth Resulting from Outside Trauma or Violence-

1. Dry the fractured tooth with cotton pellets, keep it dry and cover the gum with wax.

2. In the above condition it is absolutely necessary that the victim be seen by a dentist as soon as possible after the accident so that treatment can be given which may possibly save the tooth or teeth.

FRACTURE OF THE JAW

See Fractures; Fracture of the lower jaw.

SORE GUMS OR BLEEDING GUMS

1. Salt solution, made by dissolving one-half teaspoonful of table salt in a glass of water, is an excellent mouthwash to use in alleviating mouth soreness.

2. Sore gums are sometimes caused by the presence of tartar or calculus below the gum line of the tooth or teeth. The removal of this irritant usually gives immediate relief.

MEDICATIONS

The use of drugs for the alleviation of dental pain has been omitted from each of the above-mentioned cases because the prescribed drugs are practically the same in each case although the dosage is determined by the individual case.

The drugs most commonly used for the relief of pain due to dental factors are:

DRUGS DOSAGE
Acetylsalicylic Acid (Aspirin) 10 grains
Codeine Sulphate 1 1/2 grains
Amidopyrine 5 grains
Phenacetin 5 grains

Oil of Cloves is used on the tooth itself while all listed above are taken by mouth.

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OTHER CASES WHICH REQUIRE EMERGENCY CARE
 

APPENDICITIS

Symptoms-The symptoms of acute appendicitis are usually abdominal pain and tenderness, nausea and vomiting, cramps and, at times, diarrhea. The pain may be in any part or all over the abdomen at first but usually sifts to the lower, right part of the abdomen. Gentle pressure will usually show tenderness in this same region. The patient may have had a recent, normal bowel evacuation or he may have severe abdominal cramps and diarrhea or he may be constipated. If fever is present it is usually low and frequently the patient's temperature, pulse and respiration are normal.

Treatment-When a doctor is available he should be sought at once. If one cannot be reached, the treatment consists of complete bed-rest with pillows under the head and shoulders and also the knees. This relaxes the abdominal muscles and places them in a position of rest. The patient should be given neither laxatives nor enemas. Sulfa tablets should be given by mouth (dose: 2 grams every four hours). He should have no food until twenty-

  four hours after his symptoms subside. He may be given liquids in the form of fruit juices and clear soups. The patient should not be moved roughly or unnecessarily.

HERNIA

On each side of the abdomen at the point where the large blood vessels pass between the abdomen and legs there is a weak spot. Violent muscular strain, coughing, etc., can cause a loop of intestine to be pushed through this weak spot into the scrotum where it causes swelling and pain. If the pain is severe the patient should have a syrette of morphine, 1/4 grain, injected into the fleshy part of his upper arm. Then he should be placed in bed with pillows under his knees to relax the abdominal muscles. Cold compresses may be used over the swollen groin to reduce the swelling and allow the intestine to slip back into its proper place. In some cases the patient is best able to relax in a warm tub of water. In all events, he should not exert himself and should be moved only when necessary. The services of a medical officer should be obtained as soon as possible.

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GENERAL HYGIENE
 
"Personal hygiene concerns itself with those things which the individual must do for himself to preserve his health," The Ship's Medicine Chest and First Aid at Sea.

Due to the high standards of American living the average citizen of the republic usually knows right from wrong in matters of physical health. To review a few of the more basic rules:

INTESTINAL HEALTH

Cathartics and laxatives are placed in the medicine chest to prevent excessive constipation. A bowel movement every day is necessary to maintain a normal elimination of body poisons. If, due to the diet, ill health, or other causes, it is not possible to defecate properly a cathartic or laxative may be used. However, these should never be given in case of severe abdominal pain. This may be a symptom of appendicitis and the use of a laxative may cause a rupture of the appendix. Proper foods (including the fresh fruits, vegetables, salads), thorough chewing of food, and establishing the habit of regular time will generally do all that is necessary to insure intestinal health. If no prepared laxative is available, a very effective one is the juice of three lemons before breakfast. This must be taken unsweetened. If a

  less powerful dose is required the juice of two lemons may be used.

BATHING

Thorough, regular bathing will do as much to insure general health as any one factor. Many diseases are directly caused by uncleanliness and never appear on a clean body. Soap and water will aid in protecting the body from numerous infectious diseases, and enable the skin to always appear to good advantage.

DIET AND TASTE

An easily adaptable taste is the mark of a mature, experienced man who has cast aside boyish prejudice against certain foods and learned to appreciate each for whatever virtue it may have. This is very important in maintaining the proper intake of body vitamins. It is not always possible when preparing meals for a large number of men aboard ship to suit every taste, however it is not only possible but also imperative that well-balanced meals be served. To reject a certain portion of that diet can mean a serious deficiency of the elements needed to build up bone and muscle. By forcing one's self to consume the undesired item one may develop a taste for it which will eventually make it rank with one's favorite dishes.

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EMERGENCY TREATMENT FOR SHIPWRECK SURVIVORS
 
General Considerations-In addition to a knowledge of the usual emergency treatment and first aid procedures, certain additional considerations must be taken before treating the survivors of a shipwreck. These conditions may be complicated by the presence of any of the previously mentioned cases requiring emergency treatment.

A. BLAST AND SUBMERSION BLAST INJURIES

Symptoms-During naval combat men either aboard, lying upon life rafts, or swimming or floating in the water may sustain blast or submersion blast injuries. A blast victim is one who is in the near vicinity of an explosion. The symptoms may include shock, internal injuries with or without hemorrhage, pain in the chest, abdomen and head, partial or complete unconsciousness and other evidence of internal injury. A submersion blast victim is usually injured while in the water. The symptoms of submersion blast and blast victims are the same. The chief difference is that the latter is caused by violent air pressure and the former by excessive and sudden water pressure. These injuries may not be recognized immediately because of the lack of external evidences. Shock may be the first and only symptom.

Treatment-Treatment for shock should be given at once. If necessary, morphine may be given. (See Wounds and Hemorrhage; Internal injuries where the extent of the injury is not clear.) Keep the patient warm, in a lying position, and reassure him. If internal hemorrhage is suspected the services of a medical officer must be obtained as soon as possible. Always transport these patients in a lying position.

B. VICTIMS OF EXPOSURE AND STARVATION

Due to exposure, immersion in sea water over an extended period, and lack of sufficient food and water certain conditions are found frequently among survivors. These are:

1. Extreme thirst
2. Starvation
3. Painful and swollen feet ("immersion foot")
4. Frostbite and other effects of exposure to cold
5. Sunburn
 
5. Inflammation of the eyes caused by oily water, sun glare or exposure
7. Mental disturbances

In the case of survivors in whom these symptoms are present, common sense and good judgment are essential. No set treatment for these cases can be given because every person responds differently to various deprivations. Always assume that shock is present or will be present and begin treatment at once. Always move the survivor in a lying position. Clothes should be removed gently with particularly careful attention given the feet and legs. The patient should be kept warm but external heat should not be applied to the feet if the condition known as "immersion foot" is present. The patient should be kept at rest in a warm bed until all symptoms of shock, exhaustion and mental distress have disappeared.

It is important to know the length of time of exposure, the weather conditions encountered, the average, daily intake of food and water, and the nature of the distress encountered. If survivors have a history of extensive time at sea a serious vitamin deficiency is to be expected. A careful physical examination should be made and the patient questioned about pain in the extremities. Small sores, like boils or ulcers, may appear on parts of the body not protected by clothing after severe exposure. The skin surrounding these sores should be cleansed, the crusts removed from the sores, an antiseptic applied and, after the latter has dried, a sterile dressing. If the condition known as "immersion foot" is present do not attempt to treat the sores on the feet or legs.

C. TREATMENT FOR CONDITIONS CAUSED BY CONTACT WITH OIL

Heavy, dirty, oil, remaining on the body surface or swallowed as a result of immersion of oil-covered water can cause various inflammatory conditions. By the use of another oil (such as castor oil, mineral oil, lard, clean Diesel oil, etc.) as a wash to be followed by soap and water cleansing, the oil coating may be removed. Special detergents, such as "Drene," "Dreft," or "Orvus" in a five per cent solution can be used to remove oil. Soap and water must be used afterwards.

1. Eye Inflammation Caused by Oil-

Symptoms: Eyes, inflamed by contact with

 

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oil, present an oil-stained, dirty appearance. They are usually red, bloodshot and overflowing with tears. The lids are often covered with a sticky crust and the victim complains of pain, particularly when confronted by a bright light.

Treatment: Every three or four hours the eyes should be irrigated with a two per cent solution of sodium bicarbonate (one level teaspoonful to one-half pint water), or with a boric acid solution. One drop of clean mineral oil should be placed in each eye three or four times per day. Cold compresses should be applied over the eyes for ten minutes every hour if no ulcers are present. The eyes should not be bandaged or covered, but should be protected from bright light. If the patient complains of burning pains in the eyes either butyn ophthalmic ointment, one-half per cent pontocaine or other weak, local anaesthetic may be used in the eyes. If ulcers or other signs of severe damage are present the patient requires immediate medical attention.

2. Other Medical Conditions Caused by Oil-

If oil gets into the ears it may cause earache. This may be relieved by gently flushing the ears with lukewarm water. Oil that is swallowed may cause vomiting, diarrhea and abdominal pain. These symptoms are relieved when the patient is given bed-rest and a soft or liquid diet.

D. EMERGENCY TREATMENT FOR SURVIVORS SUFFERING FROM DEHYDRATION (WATER-LOSS)

With the exception of shock and serious injuries, the greatest suffering and the most deaths among survivors are caused by dehydration. In the presence of extreme thirst, starvation is a secondary consideration. The water and food requirements of a survivor will vary with weather conditions, physical exertion and individual resistance. Without food, the average man may be expected to survive for about twenty-one days if sufficient drinking water is available. Without food or water death may ensue in four or five days. On numerous occasions survivors have lived for ten days or more on water rations of two or three ounces per day without causing appreciable body damage.

Symptoms-In severe cases of dehydration there will be diminished saliva, difficulty in swallowing and a lowering of the output of urine. In extreme emaciation a high fever, rapid pulse, inability to urinate, convulsions, shock, semi-consciousness and unconsciousness may occur.

  Treatment-In the cases of severe shock caused by dehydration no attempt should be made to give the patient water if the services of a physician are immediately available. Salt water or sea water should neither be swallowed nor given rectally. In cases in which there is difficulty in swallowing, diminished saliva and some disturbances in the output of urine, a few ounces of water with sugar added (about one teaspoonful to one glass of water) should be given every few hours in gradually increasing amounts. These cases are usually suffering from starvation and the feeding of soft or liquid food will aid in restoring the water balance of the body. It is best to avoid giving alcoholic stimulants to survivors.

After the water balance of the body has been partially or completely restored, the extremities, especially the feet, may begin to swell. This symptom may indicate either the condition known as "immersion foot," or a vitamin deficiency or a protein deficiency in the diet. When it occurs, the foot should be kept in an elevated position until the swelling subsides.

No sulfa tablets should be given by mouth (as in the treatment of burns or wounds) until dehydration is overcome.

Following the relief of severe dehydration, frequent urination may occur and persist for a week or more.

E. EMERGENCY TREATMENT FOR SURVIVORS SUFFERING FROM STARVATION

Symptoms-The symptoms of dehydration frequently accompany starvation, and these must be overcome before treatment for starvation can be started. The victims are usually very weak, emaciated and sometimes mentally dull.

Treatment-Preferred liquids and soft foods for treating the starved survivor are:

1. Hot tea or coffee with sugar added.
2. Sweetened fruit juices (particularly the juice of citrus fruit).
3. The juice from canned tomatoes (this is preferred to tomato juice).
4. Fresh milk or canned evaporated milk with sugar added.
5. Soups and broths if not made from fat stock.
6. Oatmeal, cream of wheat, or other well-cooked cereals with sugar and milk.
7. For the average case, bread or toast may be given on the second day. Usually, on the third day ordinary feedings with a full, well-balanced diet are permitted.
 

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Severe vitamin or protein deficiency may cause sore mouth, swollen and bleeding gums, ulcers of the eyes, skin disorders and an almost painless swelling of the extremities. If at all possible, this should be treated by concentrated vitamin capsules or tablets in addition to a high protein diet. These should contain vitamins B and C, and should be given in doses of three to four times the normal daily requirement.

Survivors who have been on small food and water rations or without food for several days may become alarmed because they have no, or very few, bowel movements. This is to be expected and no treatment is necessary. However, if desired, an enema may be given to relieve constipation.

F. IMMERSION FOOT

Symptoms-Immersion foot is a very painful swelling of the feet and legs that may occur after the feet have been wet and cold for several days. It may develop even though the victim has been wearing shoes and boots. The usual history is that the feet have been immersed in icy water for considerable periods of time while sitting in an open boat. Ordinarily the pain occurs first and a few days later the swelling of the feet and legs is noticed. If this condition is allowed to persist, blood or water blisters, ulcers, discoloration of the skin, and even gangrene (death of the tissues) may occur. There may be a sensation of numbness in the feet and paralysis may develop.

If the affected limb or limbs must be handled, it should be done with extreme care to prevent local injury. The feet should be kept elevated and cold compresses should be applied to the affected parts for fifteen or twenty minutes out of every hour for relief of pain. An electric fan to blow cool air over the extremities may be as comforting as the use of cold compresses. Or the limb may be placed in dry cotton or wool and kept cool.

Heat may be applied to the rest of the body. If only one foot is affected, the other may be placed in hot water; if both feet are affected the arms may be placed in hot water. This will cause the blood vessels in the affected part to dilate and thereby increase the blood supply to this part.

Massage is harmful, and the legs should not be washed nor antiseptic applied until the "immersion foot" condition has disappeared. Sulfa powder may be dusted into any cuts, sores or ulcers that may be present. Days or weeks may

  be required before the symptoms of "immersion foot" disappear. As long as paralysis, swelling, or decided pain persist, the patient should not be allowed to walk, and the affected part should be kept in an elevated position to assist drainage of blood back to the heart.

Emergency treatment in this condition is very important. When the vitality of the legs and feet are lost the tissues are very easily damaged. A too rapid return of circulation causes severe pain and further damage.

G. FROSTBITE AND PROLONGED EXPOSURE TO COLD

General Considerations-Remember that the general effects of prolonged exposure to cold as well as frostbite are likely to occur among individuals who are poorly nourished and in a weakened condition. When the whole body is exposed to severe cold, the individual becomes numb, movement is difficult, eyesight fails, and unconsciousness may occur. The victim should be placed in a cool room and, if breathing has ceased, give artificial respiration. Rub the limbs with cloths wet in cool water. When the patient begins to respond, the temperature of the room should be raised slowly and a hot stimulating drink such as coffee, tea or cocoa should be given. He should then be moved to a warm bed. In cases where the patient is only chilled and no parts of the body are frozen, and he is not unconscious, put him in a warm bed at once and give hot stimulating drinks.

Frostbite-Frostbite is the local effect of exposure to cold. The nose, cheeks, ears, toes, and fingers are the places most frequently frosted. There is usually considerable pain if the hands or feet are involved, but often the frosted ears, cheeks, and nose are not painful and the victim is not aware of his condition until told by someone else.

a. First Degree: In first degree frostbite, sometimes called chilblain, the part of the body affected is painful and the skin is of a dark red hue. Treatment consists of applying cloths wrung out of cold water. Do not rub snow or ice to the frozen part. The temperature of the water in which the cloths are soaked should be raised gradually until it is lukewarm.

b. Second Degree: In second degree frostbite, where the skin is of a livid hue and blisters have formed, rubbing should not be resorted to as there is danger of increasing the ill effects. Too rapid applications of heat cause pain and swelling; the skin may peel off and leave a raw

 

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surface. Cold cloths should be applied and the temperature of the water should be raised gradually a degree or two every two minutes. The blisters should not be disturbed. When the color of the skin has returned to normal, the treatment should be stopped.

c. Third Degree: In third degree frostbite, the frozen part is pale, stiff, and brittle. Severe cold in a part prevents the flow of blood and if the blood is completely cut off for a considerable time, death of the tissue results. If heat is applied suddenly to a badly frozen part of the

  body, the liability of gangrene (death of the tissue) is increased on account of the intense reaction that takes place in the tissue that is still living. Treatment is the same as that for second degree frostbite, but the response to the application of wet cloths will not occur in parts that are dead. After response occurs (color change and return of warmth to the skin with reestablishment of circulation) boric acid ointment may be applied. In parts that are dead, gangrene occurs. For such cases the prompt attention of a medical officer should be secured.
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THE PREVENTION OF VENEREAL DISEASE
 

INTRODUCTION

Every person should understand the simple precautions against venereal diseases. Diseases like syphilis ("sill") or gonorrhea ("clap") are serious; they require long treatment and may lead to serious damage to the body. They are diseases which are infectious (can be transferred from person to person), and this transfer can be prevented.

Everyone has certain health habits which he has formed to protect himself against disease. These habits may save him from many days of ill-health, and may even save his very life. He will not permit another person to cough in his face; will not eat food that is "dirty" or contaminated; will not wear filthy clothing. These are some of the general health habits that are simple and effective.

The prevention of such diseases as syphilis or gonorrhea should also form a part of this habit. However, the social, emotional and technical aspects of venereal disease prevention are more complicated. They force the person into situations where he should think, and should remember technical information. Meanwhile, his emotions are trying to run away ! This indicates that every man must know protective measures with certainty and thoroughness, to assure that such measures will be used.

THE IMPORTANCE OF VENEREAL DISEASE

Venereal diseases are among the chief causes of loss of efficiency and loss of manpower, due to the resulting physical and mental damages they create. In the first World War, they ranked second to influenza in causing loss of manpower. Venereal diseases cost the U. S. Army over 2,000,000 man-days of service between April 1917 and September 1918. In 1918, an Act of Congress created a Division of Venereal Diseases in the U. S. Public Health Service to cope with the problems of these diseases.

In spite of all efforts. hundreds of thousands of Americans still contract venereal diseases every year. Every day hundreds of infants are born with these diseases; every day men die because of venereal diseases; every day thousands of hours of manpower are lost. These figures are shameful, in view of the fact that the diseases are preventable.

 

SYPHILIS

Syphilis is called a venereal disease because it is spread by sexual relations. The disease is caused by a microbe called a spirochete. A person who has syphilis may have millions of these microbes in his blood stream and body tissues. Many of these microbes may be localized in sores called "chancres." Since these sores are often located on the sex organs. the contact of sex acts can easily cause the infection of the healthy partner. Sometimes the sores are located on the tissues of the mouth, or on body surfaces, so that kissing or skin contact, or objects such as towels may transmit syphilis. However, the sex act is responsible for most of the cases of infection.

Remember that you cannot always recognize whether or not a person has syphilis. Sometimes a severe case can be recognized at a glance. More often, however, blood tests are required; sometimes the sores are scarcely noticeable, and only a blood test can determine the presence of syphilis. Even after a person has received a clean bill of health, with a "negative" blood test, that person may acquire syphilis a few hours later.

The first sign of syphilis is usually the appearance of a small ulcerated sore or chancre at the point where the spirochetes entered to begin the infection. The sex organs are the most likely spot for such development. The sore may be small and painless, and may even escape notice. It usually develops in about ten or twenty days after the time that the victim contacted the original diseased person. At the time the chancre appears, the disease may have a strong foothold. The blood test may still remain negative for another week or so during this early stage. Treatment should be started immediately upon knowledge that syphilis is present.

The next stage of syphilis may take weeks, or months or years to develop. This second stage results in sores on skin and mucous membranes, enlarged lymph nodes, and perhaps fever, headache, sore throat, and pains in the joints. This is followed by the third stage, during which the spirochetes invade various tissues and body organs, causing varied damage. The disease is often called "The Great Imitator" because it shows so many different effects,

 

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resembling different diseases, depending upon what particular damages the spirochetes cause.

GONORRHEA

Gonorrhea is another venereal disease, caused by the microbe "gonococcus." Like syphilis, it is transmitted during the sex act and rarely by other means.

In the male, the symptoms include pain during the passage of urine, itching sensations, and discharge of creamy pus material from the urethra. (The urethra is the duct which carries urine and sperm through the penis to the outside). Also there may be retention of urine, enlargement of lymph nodes in the area of the sex organs, and perhaps a general fever.

These symptoms of gonorrhea may begin to appear within three to eight days after exposure. As in syphilis, immediate treatment by competent and qualified persons is needed to prevent serious damage and complications. Do not attempt self-medication, and do not resort to so-called patent medicines or to "quack doctors." Do not feel embarrassed or degraded, but regard the disease like any other that requires careful and skilled medical attention.

Prevention

"Keep away from the women" is sound advice as far as prevention of venereal disease is concerned. Almost all prostitutes have syphilis or gonorrhea, and a very high percentage of prostitutes have both diseases. Remember that the prostitute is not concerned about the health of the men she deals with; she has other interests, and the man is on his own responsibility. "Pickups" are also very likely to be infected; a woman who is "picked up" today, was probably "picked up" yesterday, and the day before also. Complete avoidance of such casual sex contacts is the best method of preventing venereal disease. No other method is completely safe. Remember too that no one is immune to syphilis or gonorrhea.

The next safest method is the use of the condom (also called "sheath," "safe" or "rubber"). This is a thin elastic covering, usually of rubber, which fits snugly over the penis. Its purpose is to form an unbroken area over the organ. Thus, any syphilis or gonorrhea microbes present on the organs of one person cannot be transferred directly to the partner.

  The condom must be bought from a reliable source, since inferior condoms are often peddled; an inferior condom offers nothing except a false sense of security. The condom should be kept in its original container to prevent damage such as tearing or puncturing; also it should not be stored in inner clothing, since temperature and sweat may cause deterioration.

A condom must be placed over the penis before any actual contacts are made. The condom comes rolled, or should be rolled before use. In placing it on the penis, the tip of the condom should be held to provide a small empty pocket, without air, to receive the male fluid. The rest of the condom is then rolled down to cover the entire penis. If the condom breaks during intercourse, soap and water, followed by chemicals, should be used immediately.

After the male fluid is discharged, the penis should be withdrawn before it softens. If this is not done, the condom may loosen and expose the parts to infection. The condom is then removed by grasping its base with fingers and pulling quickly so that it comes off inside out. It should be discarded without further handling, since it may contain infectious matter. Urination, followed by thorough soap and water washing, is the next step. Remember that the condom has protected only the penis, while the rest of the area has been exposed to possible infection. A thorough scrubbing of the entire area, hairy parts, and thighs is necessary. The sooner a complete bath is taken, the better.

After urination and washing, "chemical prophylaxis" should be used to destroy any germs that may still be present.

A "silver protein" solution is injected into the canal of the penis, and held there by clamping the thumb and forefinger on the end of the penis. This should be kept for 5 minutes by the clock, in order to kill gonorrhea germs.

Next, calomel ointment is rubbed thoroughly into the parts and into the surrounding skin of thighs and abdomen.

These "chemical prophylaxis" measures can be learned by the individual, or can be applied by physicians. Service men can obtain treatment at prophylaxis "stations." "Prophylactic packets" can also be obtained to supply the individual with the needed supplies.

In all of these protective measures, time is very important, to destroy the germs before they can get beyond reach.

 

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