CHAPTER XIX THERAPEUTICS (Part 4)

hemostat, having an assistant hold it out. In the absence of a hemostat or tongue- ig. 102. — Resusiitation after drowning: first movement (J. P. C Griffith). forceps the tongue may be grasped between the index and second linger, covered with a handkerchief. Clear the mouth of mucus by inserting the forefinger as far as possible and bringing up the froth with a scooping motion. Sylvester's Method. — Stand or kneel behind the head of the child. Bend its arms so that the hands meet on the chest, grasp the child's forearms firmly, as close as possible to the elbows, i. Firmly press the child's elbows against the sides of the body, so as to force the air out of THERAPEUTICS 387 the lungs. 2. Raise the arms slowly, with a sweeping motion, until the child's hands meet above (or behind) its head. 3. While the arms are extended in a line with the body, give them a slow, strong pull, until the chest is fully expanded. 4. Bring the arms, with bent elbows, down against the sides and press them firmly, as before. This action should be continued about fifteen times a minute until the child begins to breathe. Care must be exercised against a tendency to make these motions too fast; they must be done slowly. A good plan is to count Fig 103. — Resuscitation after drowning: second movement (J. P. C. Griffith). four slowly — "one," as the pressure is made on the sides of the chest; "two," as the arms are being extended above the head; "three," as the strong pull is given; and "four," when the arms are again being bent and returned to the side. Do not let the hands on the forearm slip away from the elbows; the best results are obtained with the hands in this position. The operator must appreciate the fact that this manipu- lation must be executed with methodic deliberation, just 388 DISEASES OE CHILDREN EOR NURSES as described, and never hurriedly or half-heartedly. To grasp the arms and move them rapidly up and down like a pump-handle is both absurd and absolutely useless. Each time the arms are extended above the head the tongue should be drawn outward and downward. The chest should be slapped from time to time with a wet towel, and the extremities vigorously rubbed. After the child has responded to treatment stimulate it and surround it with hot-water bottles. In performing artificial respiration, if the child does not show any signs of returning vitality, do not be dis- couraged, but continue the motion regularly for at least one hour, summoning such assistance as you may need. ASPHYXIA IN THE NEWBORN At times the child fails to breathe after birth. Under such conditions it is necessary to stimulate the respiratory centers. This usually can be accomplished by slapping - the child, pouring ether or cold water over the chest, and removing mucus from the mouth; or if these methods fail, by grasping the base of the ribs between the thumb and fingers, the thumb on one side of the body and the remaining fingers on the other; by firmly squeezing the fingers together the air is forced out of the lungs, and upon relaxing the fingers the chest expands, filling the lungs. The base of the ribs should be forced together in this manner at the rate of about thirty times to the minute. HYPODERMOCLYSIS This is the introduction of normal salt solution under the skin. For this purpose is used a sterile fountain syringe or glass reservoir with a special needle attached THE RAPE UTICS 389 to the end of the rubber tube. The needle of a "horse hypodermic" can be used. The bag is filled with the necessary quantity of normal salt solution, at a temperature of 1200 F., which has been sterilized on three successive days. After the cold water has run off, the needle is plunged through the skin. The pectoral and gluteal regions are usually selected as the places for injections. When the needle is in place the normal salt solution is allowed to run slowly, and continued until the amount ordered, varying from 1 to 8 oz., has entered the sub- cutaneous tissues. A small collodion dressing is applied to the puncture. Use a sterile thermometer for taking temperature of salt solution. INTRAVENOUS INJECTIONS This consists of the introduction of normal salt solution into a vein. The physician usually selects a vein at the inner side of the elbow-joint. A bandage is tied tightly around the arm above the joint to engorge the vein. He dissects the vein away from the surrounding tissue and places a grooved director beneath it. A ligature of catgut is thrown around the vein, below the point of inserting the needle, and tied. A second ligature is placed in position above the point of insertion, but it is not tied until after the injection has been given. A sterile fountain syringe or glass reservoir is filled with the required amount (usually a quart) of normal salt solution, which has been sterilized on three successive days, and a hypodermoclysis or horse hypodermic needle attached to the end of the rubber tube. The normal salt solution should be at a temperature of no° to 120° F. (use sterile ther- mometer). When the physician is ready to introduce 390 DISEASES OF CHILDREN FOR NURSES the needle into the vein the solution is allowed to run; it should be running when it is introduced into the vein, as this avoids the entrance of air into the vessels, which is a very dangerous accident. The bandage should be cut as soon as the needle enters the vein. When the solution has run into the vein the upper ligature is tied before the needle is removed. The skin wound is then stitched and an aseptic dressing applied. The instruments needed in this operation are a scalpel, forceps, hemostats, grooved director, ligatures, and a foun- tain syringe with proper needle; also roller bandage. The arm should be prepared as for an operation. EXTENSIONS FOR FRACTURES AND COXALGIA A strip of adhesive plaster, 2 inches wide, is cut long enough to extend from the outer portion of the knee or middle of the thigh to a point 2 inches below the sole of the foot and from there to the middle of the thigh or knee on the opposite side of the leg. The adhesive is applied to the outer portion of the leg, as far as the ankle- joint. It is not attached to the foot, and 4 inches are allowed for the loop around the foot. It is then carried to the opposite ankle-joint and applied to the inner side of the leg. A bandage starting at the ankle- joint is applied to the leg as far as the adhesive strips extend. A small block of thin wood, 3 inches long and 2 inches wide, is covered with adhesive, a hole bored in the center, and the board placed in the middle of the loop below the foot and held in place by a strip of adhesive. Through the perforation in the block a wire is passed, which is firmly attached on the inner side of the block. THERAPEUTICS 391 The wire should run over a pully at the foot of the bed and have a four or five-pound weight attached at the base which should clear the floor by several inches. A wad of cotton is placed beneath the tendo Achillis to prevent pressure at this point. The foot of the bed is elevated to obtain counter-extension. Fig. 104 iuck's extension apparatus. The foot of the extension. clt'v.iU'.l (o obtain counter- Care must be taken in the removal of old adhesive strips that the skin is not pulled off with the plaster. Alcohol or ether will render this task easier. DRESSING FOR FRACTURE OF THE FEMUR IN CHILDREN OVER TWO YEARS OF AGE Hamilton Splint. — This is the best dressing to apply in childhood. It consists of (1) two long splints; the ex- ternal reaches from the axilla to the sole of the foot and the internal extends from the groin to the sole. They 39^ DISEASES OF CHILDREN FOR XL'RSES are 4 or 5 inches wide at the hip-joint and taper to 3 inches at the ankle. (2) Two long bags filled with bran, the external reaching from the axilla to the ankle and the internal extending from the groin to the internal malleolus. (3) A Buck's extension apparatus applied as described above. (4) A sand-bag reaching from the axilla to the ankle along the uninjured side. Method. — A piece of unbleached muslin of sufficient length to reach from the axilla to the sole and a yard wide Fir,. 105. — Hamilton splint. First apply a Buck's extension. The injured leg is held in position by bran-bags between wooden side-splints, a long sand-bag balances the dressing on the sound side, to which is tied the uninjured ankle. A shot-bag is placed over upper fragment of fractured bone. is placed beneath the child. At a point corresponding to the level of the groin the muslin is cut through half its width. The extension apparatus is applied and the bran-bags put in their proper places in close apposition to the leg. The splints are then laid on the edge of the muslin and folded in until they fit close to the bran-bags and hold them snugly to the leg. Three or four strips of bandage placed around the dressing keep the splints in place. The sand-bag is placed along the uninjured THERA PE UTICS 393 side. The upper portion of the unbleached muslin, which has not been folded in by the internal splint, is then carried around the body, including the sand-bag, and over the external splint, to hold the upper end in position. A weighted shot-bag is placed over the upper fragment of the bone and the foot of the bed is elevated. The necessity of frequent changing of the dressings and clothing of the child, from contamination with urine and the stools, renders it necessary, at times, to apply a moulded pasteboard splint beneath the fractured thigh, which should extend upward as far as the waist and be firmly held in place. This method of dressing does away with the pain from motion which always attends the process of redressing. MOLDED PASTEBOARD SPLINTS Technic. — The pasteboard is cut in the proper shape and of the proper length, and dipped in hot water. When Fig. 106. — Jaw-cup, unfolded. A moulded pasteboard splint (Da Costa). thoroughly wet it can easily be moulded to the part, which shape it holds when dry. It should be padded with cotton before application. SPLINTS Splints are used to keep the broken fragments of bone in apposition after a fracture. According to the location of the fractured bone different 394 DISEASES OF CHILDREN FOR NURSES kinds of splints have been devised. The principal forms are as follows: shoulder-cap, for fracture of the upper portion of the humerus; the internal angular and anterior angular splints for fractures of lower end of humerus Fig. 107. — Bond's spl Fig. 108. — Anterior angular splint (Da Costa). and upper portion of the bones of the forearm; and the Bond splint for fracture of the lower portion of the bones of the forearm. FRACTURE-BOX This is a special box used for fractures of the lower portion of the leg. It is so constructed that the sides are movable and the foot-piece perforated. THERA PE UTICS 395 A pillow is placed upon the bottom of the box, while the sides are down, upon which is rested the fractured leg in such a manner that the foot is held firmly at a right angle against the foot-piece of the box, being secured in this position by a strip of bandage through the perforations. A wad of cotton should be placed beneath the heel and sole of the foot. The sides of the box are then turned Fig. hi. — Fracture-box (Da Costa) up and held in the upright position by three or four strips of bandage surrounding the box. This causes the leg to be held firmly between the two sides of the pillow. AIR-BEDS AND CUSHIONS Air-beds are useful at times in injuries to the back. Water-beds are also used. Air-cushions are very useful in relieving a part from pressure. PLASTER CASTS Plaster casts are very useful in childhood. They arc used for fractures, for keeping joints immobile, and for keeping the bones straight after an osteotomy. Specially prepared bandages are used, which should be soaked in luke-warm water immediately before application. 396 DISEASES OE CHILDREN EOR NURSES FRAMES Frames arc used in Pott's disease, in order that the backbone may be kept immobile. The child is placed upon the frame in such a position that the buttocks are situated at the opening in the canvas. This permits bowel movement without removal from frame. The child is held in position by unbleached muslin, which is attached to the two side bars of the frame and cut of sufficient length to extend from the axilla to the base of O FlG. 112. — Modified Bradford frame. Devised by Dr. Fauutleroy. The daily tightening of the nuts A and B keeps apparatus rigid. the frame. This covering should be tightly drawn across the child and firmly attached to the opposite bar. The Bradford frame, or some of its modifications, is the best. Fauntleroy's modification permits of the taking up of the slack by daily tightening the nuts in the upper and lower bars. This saves the trouble of constant tightening of unbleached muslin. OILED-SILK JACKET This is a very good method of obtaining a mild, con- stant counter-irritation of the chest, formerly used exten- sively in cases of pneumonia and bronchitis. The jacket is prepared by cutting out three layers, according to the pattern shown on the following page. THE J? A PE UTICS 397 The outer layer is oiled silk, the middle layer is cotton batting, and the inner layer gauze. For a child one year 0 Fig. 113 — Pattern for oiled-silk jacket. of age the dimensions should be 12 by 12 inches. A properly prepared jacket should last about two weeks. STRAIT-JACKET When it is necessary, in very restless children, to con- trol their movements the strait-jacket is of use. Fig. 114.— Model for the dressing shown in Fig. 115. The opening in the calico strip .1 is for the head, so as to prevent slipping of the pasteboard splints (Friihwald and Westcott). It is made of unbleached muslin, double thickness, a yard wide and cut long enough to reach from one side of the bed to the other. It is attached to the frame of 39^ DISEASES OF CHILDREN FOR NURSES the bed on both sides and fastened securely enough to hold the child flat upon its back. Two armholes are cut at the proper Level and distance apart and these Fig. i 1 5. — Dressing to prevent scratching in eczema of the head (Friihwald and Westcott). should be bound. A wad of cotton should protect the skin of the axillae from chafing. CUFFS Cuffs are necessary in children who have a tendency to pick at their dressings or to scratch irritating lesions of the skin. Celluloid cuffs can be purchased which should be well padded before being applied. THERA PE UTICS 3 99 Pasteboard cuffs are made by cutting stiff pasteboard of sufficient length to extend from the armpit, or axilla, to the wrist, and wide enough to encircle the arm. They should be well padded with cotton and held in place by a bandage (see Fig. 115). This form of dressing pre- vents the child from bending the elbow. MASKS Masks are useful in the treatment of skin diseases of the face. They are made so as to cover completely the head and face, small apertures being cut for the eyes, nose, and mouth. It is the only means by which applica- tions to the face can be properly applied. MASSAGE Massage is useful in infancy after attacks of infantile paralysis. The affected limbs should be massaged daily to increase the circulation to the part, so that the unaf- fected muscles will be under the most favorable conditions for hypertrophying or overdeveloping, upon which de- pends a fairly good use of the leg. In childhood, massage is one of the best measures to employ in chronic constipation. It should be practised twice a day, after retiring and in the morning. The proper method of giving massage in these cases is to use only the hand, without grease of any kind, rubbing the abdomen with a circular motion, the idea being to move the abdominal wall over the intestine, and in this way to excite peristalsis. In older children the same causes for massage exist as in the adult. 40o DISEASES OF CHILDREN FOR NURSES ELECTRICITY Electricity has a limited scope in childhood. In paralytic conditions it is useful and should be applied in the same manner as in the adult. SKIAGRAPHY For the purposes of diagnosis, especially of fractures, the Rontgen ray is of the greatest use. Medicinally it is not employed. DISINFECTION All discharges should be immersed in carbolic acid, 1:40; bichlorid of mercury, 1:2000; or chlorinated lime of equal strength, and allowed to stand fifteen minutes. All bed-clothing should be thoroughly boiled for a half hour. Disinfection of Hands.— Remove all dirt from under and around nails. Nails and hands should be thoroughly scrubbed with soap and hot water. Immerse them in 95 per cent, alcohol for not less than one minute, then plunge the hands in a solution of bichlorid of mer- cury, 1:2000, or carbolic solution, 1:40, and thoroughly wash them for at least a minute. A clean wound should never be dressed after an infected wound. The hands should be disinfected between each dressing. Full