vigorously. Another device worthy of trial is to cause the child to sneeze by tickling the nose with a feather. Occasionally, if the object is readily seen, an attempt to remove it may be made by bending a hairpin slightly and attempting to insert the curved end alongside the object, holding the points in the fingers. These cases generally require the services of a physician, and they should always be taken to a doctor in case the simple treatment above described is not successful.

FOREIGN BODIES IN THE EAR.

Various foreign bodies are occasionally introduced into the ears and may be the source of a great deal of discomfort and pain. An insect in the ear may be removed by turning the head to one side and filling the ear with warm sweet oil poured into it by means of a spoon. The oil will suffocate the insect and it will float out. For the removal of other objects a physician should in all cases be employed, as a great deal of harm can be done by inserting sharp instruments into this cavity. Occasionally a small object may be removed by a gentle syringing with warm water.

FOREIGN BODIES IN THE THROAT.

The beginning of the throat is known as the pharynx. Lower down there are two passages, one of which leads to the stomach, called the gullet or esophagus. The other leads to the lungs, and is known as the larynx at the upper end, lower down the windpipe or trachea. Foreign bodies may lodge in any of these passageways. Commonly such objects are articles of food, but other things which have been held in the mouth-like coins, safety pins, or marbles-may accidentally slip back and lodge in the throat. Young children are especially apt to put any small articles which they get into their hands into their mouths, and occasionally they attempt to swallow them, with disastrous results.

Foreign bodies in the pharynx.-Large foreign bodies in the pharynx cause great interference with breathing. They can generally be removed by opening the mouth and pulling the object forward by means of the fingers or by hooking the index finger behind it. Treatment.-Place the patient on a chair facing the light, open the mouth, and hold the tongue down with the handle of a teaspoon. It may be possible in this way to see the object and to extract it. Inversion can be tried in the case of a child and the same effect produced in an adult by having him lie crosswise on a bed on his abdomen with his head and shoulders hanging over the side. Failing to remove the obstruction in this way, send for a doctor at once. Foreign bodies in the gullet-Symptoms.-When an object lodges

in the gullet the patient has pain, difficulty in swallowing, and breathing may be interfered with. Occasionally the symptoms may be slight, but more often the object produces inflammation.

Treatment. The treatment is the same as advised for foreign bodies in the pharynx.

NOTE. If a child or adult has swallowed some sharp or pointed article like a piece of broken glass or a pin, give him a diet composed largely of mashed potatoes and bread. Encourage him to eat as much as possible of these articles for several days. They will surround the foreign body in large masses and prevent it from injuring the walls of the intestine. Do not give purgatives at once, but after the bread-and-potato diet has been taken for two or three days a mild laxative may be given. Watch the passages carefully for several days to be certain that the object has been passed. Such cases should always be under the care of a doctor when he is available.

Foreign bodies in the larynx-Symptoms.-When a foreign body enters the upper part of the windpipe it immediately sets up a violent attack of coughing which frequently results in its expulsion. A small article may, however, remain in the windpipe and gradually work its way lower to some point in the lung where it remains permanently, causing a continual inflammation characterized by cough, with foul and blood-streaked expectoration. If the object is large it may conpletely close the passage and prevent the entrance of air to the lungs and threaten death by suffocation. In such cases a patient becomes black in the face and makes frantic struggles to secure air.

Treatment.—If the patient is a child, he should be picked up by the feet and held suspended with the head downward, which may cause the object to fall out by its own weight. Failing in this, if the symptoms are not alarming, endeavor to quiet the sufferer and send for a doctor at once.

RUPTURE OR HERNIA.

Rupture is due to a weakening of some part of the abdominal walls and the escape through the opening of some of the contents of the abdomen, usually a part of the bowel. The bowel, of course, is covered by the skin and some of the other tissues, but forms a larger or smaller swelling at the point of the hernia. The commonest form of hernia occurs at the groin. Hernias in this location frequently can be reduced by the patient when he lies upon his back and properly manipulates the mass.

All persons with weak abdominal walls are liable to hernia, especially elderly people. The direct cause of the hernia is often the strain produced by lifting heavy weights.

Symptoms. A painful swelling appears in the groin which may disappear when the patient lies down and presses the mass upward

and backward into the abdomen. If the fingers are held in contact with the hernia and the patient gives a cough, a sharp impulse will be felt by the examining finger at the moment of the cough.

STRANGULATED HERNIA.

The great danger of hernia is that the prolapsed bowel may be caught in the opening through which it has escaped in the abdominal wall, and the swelling which takes place causes an increase in the size of the tissues, which finally result in the blood supply being shut off and the prolapsed part of the bowel becomes first inflamed and then gangrenous.

Symptoms.-Pain at the seat of the hernia and also in the abdomen. The mass can not be replaced and is tender to the touch. There is vomiting, which at first is of the ordinary type but later foul smelling, and in odor and appearance resembles the ordinary passages from the bowels. The pulse is rapid and weak and there is great thirst. There are no stools or passages of gas from the anus.

Treatment. Place the patient in bed and raise the knees on several pillows. Endeavor to return the mass into the abdomen by gentle manipulation, trying to push the part that descended last back first. This maneuver may be assisted by raising the foot of the bed and placing a pillow under the hips so that that part of the body is higher than the chest. Prolonged efforts to return the bowel are dangerous, and if gentle attempts do not succeed, no further manipulation should be tried but a doctor should be sent for immediately. Pending the arrival of the doctor do not permit the patient to take any food.

If the bowel can be reduced by the above manipulation, keep the patient in bed for several days and allow only water for the first 24 hours, gradually permitting small quantities of soft food as time

goes on.

If it is certain that a doctor can not be obtained, an ice bag may be applied to the hernia in the hope that this treatment may reduce the inflammation sufficiently to permit the bowel to slip back into the abdomen. If the desired result is not obtained at the end of several hours, remove the ice bag.

Prevention of strangulated hernia.-Operations on hernia nowadays are very successful. It is advisable that all men who have hernias, and whose occupations require that they go on long sea voyages or into the woods or other places where they will be out of reach of competent medical help, should be operated on in order to get rid of the rupture and escape the dangers of possible strangulation in some remote district where suitable treatment can not be obtained.

INJURIES TO JOINTS.

JOINTS.

Description.-Wherever two or more bones come together they form a joint. The joint is surrounded by a closed sac called the joint capsule. This sac contains a slippery fluid, which serves to lubricate the joint and permits the bones to move smoothly. The joint capsule is not sufficiently strong to prevent the bones from being torn apart, so additional strength is furnished to the joint by strong bands of tissue, which are known as ligaments. It will be noted that some joints, such as those in the fingers, move only backward and forward, while other joints, as, for example, the hip joint, will permit of movement in practically all directions.

SPRAINS.

Description.-Sprains are the injuries produced by wrenching or twisting a joint. Sprains of the ankle, wrist, shoulder, and knee are very common. Severe sprains should always be treated by a doctor, if possible. There was an old saying that bad sprains were worse than fractures. As a matter of fact, many of these "sprains" were in reality small or partial fractures near the joint, especially when involving the ankle. In severe sprains of the shoulder, wrist, or ankle an X-ray examination of the affected part should always be made if it is possible to do so. Sprains of the ankle in which extensive areas of black and blue skin are observed, extending for a considerable distance up the leg, are almost always accompanied by fractures.

Symptoms. Severe pain, always increased by motion of the joint, and hence there is often apparent lack of ability to move the limb. Swelling and sometimes redness, later on possibly discoloration. Treatment.-Absolute rest to the joint. If at the wrist or shoulder, put the arm in a sling. If a knee or ankle is involved, put the patient in bed and rest the joint on a pillow. Apply cold water compresses, using a thick dressing large enough to wrap completely around the joint and extend well above and below it. Hot-water compresses may be used if more agreeable to the patient. Continue the compresses until the pain and swelling subside. This may require from two to five days. Then cautiously begin rubbing with alcohol diluted with an equal amount of water or tincture of arnica. Later, in addition to the rubbing, which should become gradually more vigorous, begin gently moving the joints by grasping the hand or foot and moving it in various directions. These motions should be made by the operator and not by the patient. The injured person

should exercise great caution in beginning to use the part. In recent years severe sprains and strains which resisted ordinary treatment have sometimes been greatly benefited by being baked in dry air at a very high temperature. This treatment, however, requires special apparatus and skilled supervision, hence is not available for home use.

Sprains of the ankle joint are often treated by strapping with adhesive plaster. Cold compresses should be used for four or five days, and when the swelling is somewhat reduced the plaster may be applied. For this purpose take strips about an inch wide and apply them snugly to the sides of the ankle running around the heel and to the sides of the foot encircling the heel. The method of application can be best understood from studying figure 311. Be sure, however, to leave a strip of skin which is not covered by the plaster extending all the way up the front of the foot and ankle. The whole limb must not be encircled by the plaster. Plaster applied in this fashion makes in reality a flexible splint and gives considerable support to the joint. It can be worn for three or four weeks if necessary.

Physicians very frequently use plaster of Paris casts in the treatment of severe sprains. In the case of the ankle, the joint should be thoroughly protected by some resilient material such as a woolen bandage, a smoothly applied layer of cotton batting, or a couple of thicknesses of cotton stocking. The cast is applied from just behind the toes to a little above the middle of the calf. Great care should be taken in putting the cast on that the circulation is not obstructed, and the toes should be frequently examined in order to be certain of this point. If pain follows the application of the cast, or the toes become blue or dark, the cast should be immediately removed.

DISLOCATIONS.

Description. When one of the bones is forced out of its proper place in a joint and remains permanently out, the injury is known as a dislocation. These accidents tear or stretch the ligaments, and even if properly treated the joint is apt to be weak afterwards and will slip out of place more easily a second time. The shoulder joint is more frequently dislocated than any other joint in the body.

Causes.-Dislocations are usually the result of falls or severe

accidents.

Symptoms.-Pain, inability to move the joint in the usual manner, the appearance of the joint differs from the sound one on the other side, the end of the displaced bone may be felt to be in an improper position when compared with its uninjured fellow, and swelling may occur shortly after the injury has been received.