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PRACTICAL
GUIDE
SERIES
Clinical Decision-Making
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Preface
Derek Richards, M.Sc., D.D.P.H.
Index
Preface
Evidence-based medicine was first articulated in the early 1990s1,
and by 19952, articles on evidence-based dentistry (EBD) were
starting to appear in the dental literature. While the uptake of EBD
approaches and improvements in the quality of dental research
have been slower than early adopters of the concepts would have
hoped for, this has not been for lack of support from the American
Dental Association.
The establishment of the ADA Center for EBD and its development
of a definition for EBD (that is, a patient-centered approach to
treatment decisions, which provides personalized dental care
based on the most current scientific knowledge3) have been
important milestones along the road to a more evidence-based
dental profession. The ADA has actively promoted EBD in its
journal, The Journal of the American Dental Association, and
organized EBD courses and workshops for a number of years. The
ADA EBD website also provides a broad range of helpful EBD
resources, including a number of evidence-based clinical practice
guidelines, chairside guides, and videos.
References
1. Guyatt GH. “Evidence-based medicine.” ACP J Club 1991;114(ACP J Club,
suppl 2):A-16.
2. Richards D, Lawrence A. “Evidence based dentistry.” Br Dent J
1995;179(7):270-273.
3. “About EBD.” ADA Center for Evidence-Based Dentistry.
https://ebd.ADA.org/en/about. Accessed March 5, 2019.
How to Use This Book
Evidence-based dentistry (EBD) relies on personalization. Dentists
work with each of their patients to make a unique treatment decision
that integrates the dentist’s expertise, the patient’s needs and
preferences, and the most current, clinically relevant evidence.
Melding all three of these elements ensures that the identified
treatment decision appropriately addresses the clinical scenario in
question. There is no one-size-fits-all approach to patient care.
As with EBD, there is no one way to use this book. Some may start
at the very beginning and read to the very end, since each chapter
builds on the one before it. Most will probably open the book when
they’re in need of a handy reference, turning to the section that is
most relevant to them at that time. Others will test their ability to
critically appraise evidence by reading the real-world examples that
are highlighted in some chapters’ call-out boxes and then go back to
review sections that cover self-identified gaps in knowledge. Any
strategy works. There is no one-size-fits-all approach to reading this
book.
Regardless of what tack you take, we hope that you find this book
covers a wide breadth of EBD topics. Perusing the pages ahead
should assist anyone who wants to learn about practicing EBD,
teaching EBD, defining an EBD curriculum, conducting a
journal/study club, or engaging in other activities that incorporate
evidence into patient care. The overall goal is to provide you with
the foundational knowledge you need to improve patient care
through the application of EBD.
In This Chapter:
Definition and Principles of EBD
The Process of EBD
Introduction
Scientific evidence is a crucial underpinning of clinical practice.
Nevertheless, the first series of articles aimed at providing clinicians
with guidelines for critically appraising the evidence that informs
clinical practices did not appear until 1981.1 Ten years later, the term
“evidence-based medicine”2 first appeared in the medical literature.
Subsequently, between 1993 and 2000, a group of evidence-based
medicine enthusiasts3 published a series of 25 articles aimed at
assisting clinicians in understanding and applying the medical
literature to their clinical decision-making in a clinical setting.4
The PICO components of the question at hand are used as the basis
of searching for evidence in the literature by using electronic
databases and other sources. There are a number of sources that
provide clinicians with useful information. Depending on the degree
of detail sought, information from primary studies, summaries and
critical appraisals, and clinical practice guidelines may all provide
evidence.16 How to choose the most relevant source to search in
any particular case is addressed in subsequent chapters in this book.
References
1. “How to read clinical journals, part I: why to read them and how to start
reading them critically.” Can Med Assoc J 1981;124(5):555-558.
2. Guyatt GH. “Evidence-based medicine.” ACP J Club 1991;114(ACP J Club,
suppl 2):A-16.
3. Evidence-Based Medicine Working Group. “Evidence-based medicine: a new
approach to teaching the practice of medicine.” JAMA 1992;268(17):2420-
2425.
4. Guyatt GH, Rennie D. “Users’ guides to the medical literature.” JAMA
1993;270(17):2096-2097.
5. Richards D, Lawrence A. “Evidence based dentistry.” Br Dent J
1995;179(7):270-273.
6. Azarpazhooh A, Mayhall JT, Leake JL. “Introducing dental students to
evidence-based decisions in dental care.” J Dent Educ 2008;72(1):87-109.
7. Cruz MA. “Evidence-based versus experience-based decision making in clinical
dentistry.” J Am Coll Dent 2000;67(1):11-14.
8. Faggion CM Jr, Tu YK. “Evidence-based dentistry: a model for clinical practice.”
J Dent Educ 2007;71(6):825-831.
9. Forrest JL, Miller SA. “Evidence-based decision making in dental hygiene
education, practice, and research.” J Dent Hyg 2001;75(1):50-63.
10. Laskin DM. “Finding the evidence for evidence-based dentistry.” J Am Coll
Dent 2000;67(1):7-10.
11. Scarbecz M. “Evidence-based dentistry resources for dental practitioners.” J
Tenn Dent Assoc 2008;88(2):9-13.
12. American Dental Association Center for Evidence-Based Dentistry. About EBD.
http://ebd.ADA.org/en/about. Accessed Oct. 5, 2014.
13. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. “Evidence
based medicine: what it is and what it isn’t.” BMJ 1996;312(7023):71-72.
14. Guyatt GH, Haynes B, Jaeschke R, et al. “The philosophy of evidence-based
medicine.” In: Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides
to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 2nd
ed. Columbus, Ohio: McGraw-Hill Education; 2008:9-16.
15. Guyatt GH, Meade MO, Richardson S, Jaeschke R. “What is the question.” In:
Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical
Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. Columbus,
Ohio: McGraw-Hill Education; 2008:17-28.
16. McKibbon A, Wyer P, Jaeschke R, Hunt D. “Finding the evidence.” In: Guyatt
GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical
Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. Columbus,
Ohio: McGraw-Hill Education; 2008:29-58.
17. Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical
Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. Columbus,
Ohio: McGraw-Hill Education; 2008.
18. Guyatt GH, Jaeschke R, Meade MO. “Why study results mislead: bias and
random error.” In: Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’
Guides to the Medical Literature: A Manual for Evidence-Based Clinical
Practice. 2nd ed. Columbus, Ohio: McGraw-Hill Education; 2008:59-64.
19. Dans A, Dans L, Guyatt GH. “Applying results to individual patients.” In:
Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical
Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. Columbus,
Ohio: McGraw-Hill Education; 2008:273-289.
In This Chapter:
General Tips for Searching Electronic Resources
Searching Workflow
Resources
• Comprehensive Resources
• Summaries and Guidelines: Point-of-Care Resources
• Preappraised Resources
• Journals
• Nonpreappraised Resources
• Citation Managers
• Gray Literature
• Patient Information Resources
Conclusion
Introduction
To find answers to clinical inquiries, it is necessary to conduct an
evidence-based literature search. This chapter describes the most
commonly used evidence-based resources, recommends search
strategies that will help enable the oral health practitioner to retrieve
the most useful clinical information, and suggests a workflow for
navigating evidence-based information.
** Indicates that this type of evidence may not be available for this type of
question.
For this chapter, our search examples will refer to the following PICO
framework question: Are pregnant women with periodontal disease
at greater risk of preterm birth or low birth weight than pregnant
women without periodontal disease? In this instance, the population
identified is pregnant women. Because this is not a question of
therapy but of harm, the exposure is periodontal disease, with the
comparison as the absence of periodontal disease. Outcomes of
interest are preterm birth and low birth weight.
Resources
Comprehensive Resources
Epistemonikos
Website: www.epistemonikos.org
Cost: Free, with some limited full-text availability
Specialty of resource: Clinical practice guidelines, synopses,
systematic reviews, primary studies, other
Individuals can perform a basic search from the main page or select
the “advanced search” option. We recommend going straight to the
advanced search option as the basic search is meant to search only
one term at a time and does not support Boolean searching. For
instance, entering our search terms “periodontal disease” and
“pregnant women” into the basic search function returns fewer than
20 results, but entering those same terms into the advanced search
returns more than 60 results. The advanced search builder allows for
individuals to enter in PICO elements and combine them as needed.
Filters are available on the main page of search results to further
narrow down the original search results if needed.
Trip
Website: www.tripdatabase.com
Cost: The Trip database, previously only available via a subscription,
is now freely accessible. A premium version of Trip is available to
individuals via a subscription.
Specialty of resource: Clinical practice guidelines, synopses,
systematic reviews, primary studies, other
WARM BATHS.
ACCIDENTS.
To make a Lotion. The eye to be bathed, by means of a soft piece of linen rag,
with this lotion frequently; and, between times, let a piece of linen rag, wetted
in the lotion, be applied to the eye, and be fastened in its place by means of a
bandage.
The white lily leaf, soaked in brandy, is another excellent remedy
for the bruises of a child. Gather the white lily blossoms when in full
bloom, and pot them in a wide-mouthed bottle of brandy, cork the
bottle, and it will then always be ready for use. Apply a leaf to the
part affected, and bind it on either with a bandage or with a
handkerchief. The white lily root sliced is another valuable external
application for bruises.
280. If a child fall upon his head and be stunned, what ought to be
done?
If he fall upon his head and be stunned, he will look deadly pale,
very much as if he had fainted. He will in a few minutes, in all
probability, regain his consciousness. Sickness frequently
supervenes, which makes the case more serious, it being a proof that
injury, more or less severe, has been done to the brain; send,
therefore, instantly, for a medical man.
In the mean time, loosen both his collar and neckerchief, lay him
flat on his back, sprinkle cold water upon his face, open the windows
so as to admit plenty of fresh air, and do not let people crowd around
him, nor shout at him, as some do, to make him speak.
While he is in an unconscious state, do not on any account
whatever allow a drop of blood to be taken from him, either by
leeches or by bleeding; if you do, he will probably never rally, but will
most likely sleep “the sleep that knows no waking.”
281. A nurse sometimes drops an infant and injures his back;
what ought to be done?
Instantly send for a surgeon; omitting to have proper advice in
such a case has frequently made a child a cripple for life. A nurse
frequently, when she has dropped her little charge, is afraid to tell
her mistress; the consequences might then be deplorable. If ever a
child scream violently without any assignable cause, and the mother
is not able for some time to pacify him, the safer plan is that she send
for a doctor, in order that he might strip and carefully examine him;
much after-misery might often be averted if this plan were more
frequently followed.
282. Have you any remarks to make and directions to give on
accidental poisoning by lotions, by liniments, etc.?
It is a culpable practice of either a mother or nurse to leave
external applications within the reach of a child. It is also highly
improper to put a mixture and an external application (such as a
lotion or a liniment) on the same tray or on the same mantle-piece.
Many liniments contain large quantities of opium, a teaspoonful of
which would be likely to cause the death of a child. “Hartshorn and
oil,” too, has frequently been swallowed by children, and in several
instances has caused death. Many lotions contain sugar of lead,
which is also poisonous. There is not, fortunately, generally sufficient
lead in the lotion to cause death; but if there be not enough to cause
death, there may be more than enough to make the child very poorly.
All these accidents occur from disgraceful carelessness.
A mother or a nurse ought always, before administering a dose of
medicine to a child, to read the label on the bottle; by adopting this
simple plan many serious accidents and much after-misery might be
averted. Again, I say let every lotion, every liniment, and indeed
everything for external use, be either locked up or be put out of the
way, and far away from all medicine that is given by the mouth. This
advice admits of no exception.
If your child has swallowed a portion of a liniment containing
opium, instantly send for a medical man. In the mean time, force a
strong mustard emetic (composed of two teaspoonfuls of flour of
mustard, mixed in half a teacupful of warm water) down his throat.
Encourage the vomiting by afterward forcing him to swallow warm
water. Tickle the throat either with your finger or with a feather.
Souse him alternately in a hot and then in a cold bath. Dash cold
water on his head and face. Throw open the windows. Walk him
about in the open air. Rouse him by slapping him, by pinching him,
and by shouting to him; rouse him, indeed, by every means in your
power, for if you allow him to go to sleep, it will, in all probability, be
the sleep that knows no waking!
If a child has swallowed “hartshorn and oil,” force him to drink
vinegar and water, lemon-juice and water, barley-water, and thin
gruel.
If he have swallowed a lead lotion, give him a mustard emetic, and
then vinegar and water, sweetened either with honey or with sugar,
to drink.
283. Are not Lucifer Matches poisonous?
Certainly, they are very poisonous; it is therefore desirable that
they should be put out of the reach of children. A mother ought to be
very strict with servants on this head. Moreover, lucifer matches are
not only poisonous but dangerous, as a child might set himself on
fire with them. A case bearing on the subject has just come under my
own observation. A little boy, three years old, was left alone for two
or three minutes, during which time he obtained possession of a
lucifer match, and struck a light by striking the match against the
wall. Instantly there was a blaze. Fortunately for him, in his fright, he
threw the match on the floor. His mother, at this moment, entered
the room. If his clothes had taken fire, which they might have done,
had he not thrown the match away, or if his mother had not been so
near at hand, he would, in all probability, have either been severely
burned, or have been burned to death.
284. If a child’s clothes take fire, what ought to be done to
extinguish them?
Lay him on the floor, then roll him either in the rug or in the
carpet, or in the door-mat, or in any thick article of dress you may
either have on, or have at hand—if it be woolen, so much the better;
or throw him down, and roll him over and over on the floor, as by
excluding the atmospheric air, the flame will go out: hence, the
importance of a mother cultivating presence of mind. If parents were
better prepared for such emergencies, such horrid disfigurations and
frightful deaths would be less frequent.
You ought to have a proper fire-guard before the nursery grate,
and should be strict in not allowing your child to play with fire. If he
still persevere in playing with it when he has been repeatedly
cautioned not to do so, he should be punished for his temerity. If
anything would justify corporal chastisement, it would surely be such
an act of disobedience. There are only two acts of disobedience that I
would flog a child for—namely, the playing with fire and the telling of
a lie! If after various warnings and wholesome corrections he still
persists, it would be well to let him slightly taste the pain of his doing
so, either by holding his hand for a moment very near the fire, or by
allowing him to slightly touch either the hot bar of the grate or the
flame of the candle. Take my word for it, the above plan will
effectually cure him—he will never do it again! It would be well for
the children of the poor to have pinafores made either of woolen or
of stuff materials. The dreadful deaths from burning, which so often
occur in winter, too frequently arise from cotton pinafores first
taking fire.[268]
If all dresses, after being washed, and just before being dried,
were, for a short time, soaked in a solution of tungstate of soda, such
clothes, when dried, would be perfectly fire-proof.
Tungstate of soda may be used either with or without starch; but
full directions for the using of it will, at the time of purchase, be
given by the chemist.
285. Is a burn more dangerous than a scald?
A burn is generally more serious than a scald. Burns and scalds are
more dangerous on the body, especially on the chest, than either on
the face or on the extremities. The younger the child, of course, the
greater is the danger.
Scalds, both of the mouth and of the throat, from a child drinking
boiling water from the spout of a tea-kettle, are most dangerous. A
poor person’s child is, from the unavoidable absence of the mother,
sometimes shut up in the kitchen by himself, and being very thirsty,
and no other water being at hand, he is tempted in his ignorance to
drink from the tea-kettle: if the water be unfortunately boiling, it will
most likely prove to him to be a fatal draught!
286. What are the best immediate applications to a scald or to a
burn?
There is nothing more efficacious than flour. It ought to be thickly
applied, over the part affected, and should be kept in its place either
with a rag and a bandage, or with strips of old linen. If this be done,
almost instantaneous relief will be experienced, and the burn or the
scald, if superficial, will soon be well. The advantage of flour as a
remedy is this, that it is always at hand. I have seen some extensive
burns and scalds cured by the above simple plan. Another excellent
remedy is cotton wool. The burn or the scald ought to be enveloped
in it; layer after layer should be applied until it be several inches
thick. The cotton wool must not be removed for several days.[269]
These two remedies, flour and cotton wool, may be used in
conjunction; that is to say, the flour may be thickly applied to the
scald or to the burn, and the cotton wool over all.
Prepared lard—that is to say, lard without salt[270]—is an admirable
remedy for burns and for scalds. The advantages of lard are: (1) It is
almost always at hand; (2) It is very cooling, soothing, and
unirritating to the part, and it gives almost immediate freedom from
pain; (3) It effectually protects and sheathes the burn or the scald
from the air; (4) It is readily and easily applied: all that has to be
done is to spread the lard either on pieces of old linen rag, or on lint,
and then to apply them smoothly to the parts affected, keeping them
in their places by means of bandages—which bandages may be
readily made from either old linen or calico shirts. Dr. John Packard,
of Philadelphia, was the first to bring this remedy for burns and
scalds before the public—he having tried it in numerous instances,
and with the happiest results. I myself have, for many years, been in
the habit of prescribing lard as a dressing for blisters, and with the
best effects. I generally advise equal parts of prepared lard and of
spermaceti cerate to be blended together to make an ointment. The
spermaceti cerate gives a little more consistence to the lard, which, in
warm weather, especially, is a great advantage.
Another valuable remedy for burns is, “carron oil;” which is made
by mixing equal parts of linseed oil and lime-water together in a
bottle, and shaking it up before using it.
Cold applications, such as cold water, cold vinegar and water, and
cold lotions, are most injurious, and, in many cases, even dangerous.
Scraped potatoes, sliced cucumber, salt, and spirits of turpentine,
have all been recommended; but, in my practice, nothing has been so
efficacious as the remedies above enumerated.
Do not wash the wound, and do not dress it more frequently than
every other day. If there be much discharge, let it be gently sopped
up with soft old linen rag; but do not, on any account, let the burn be
rubbed or roughly handled. I am convinced that, in the majority of
cases, wounds are too frequently dressed, and that the washing of
wounds prevents the healing of them. “It is a great mistake,” said
Ambrose Paré, “to dress ulcers too often, and to wipe their surfaces
clean, for thereby we not only remove the useless excrement, which
is the mud or sanies of ulcers, but also the matter which forms the
flesh. Consequently, for these reasons, ulcers should not be dressed
too often.”
The burn or the scald may, after the first two days, if severe,
require different dressings; but, if it be severe, the child ought of
course to be immediately placed under the care of a surgeon.
If the scald be either on the leg or on the foot, a common practice
is to take the shoe and the stocking off; in this operation, the skin is
also at the same time very apt to be removed. Now, both the shoe and
the stocking ought to be slit up, and thus be taken off, so that neither
unnecessary pain nor mischief may be caused.
287. If a bit of quicklime should accidentally enter the eye of my
child, what ought to be done?
Instantly, but tenderly remove, either by means of a camel’s-hair
brush or by a small spill of paper, any bit of lime that may adhere to
the ball of the eye, or that may be within the eye or on the eyelashes;
then well bathe the eye (allowing a portion to enter it) with vinegar
and water—one part of vinegar to three parts of water, that is to say,
a quarter fill a clean half-pint medicine bottle with vinegar and then
fill it up with spring water, and it will be ready for use. Let the eye be
bathed for at least a quarter of an hour with it. The vinegar will
neutralize the lime, and will rob it of its burning properties.
Having bathed the eye with the vinegar and water for a quarter of
an hour, bathe it for another quarter of an hour simply with a little
warm water; after which, drop into the eye two or three drops of the
best sweet oil, put on an eye-shade made of three thicknesses of linen
rag, covered with green silk, and then do nothing more until the
doctor arrives.
If the above rules be not promptly and properly followed out, the
child may irreparably lose his eyesight; hence the necessity of a
popular work of this kind, to tell a mother, provided immediate
assistance cannot be obtained, what ought instantly to be done; for
moments, in such a case, are precious.
While doing all that I have just recommended, let a surgeon be
sent for, as a smart attack of inflammation of the eye is very apt to
follow the burn of lime; but which inflammation will, provided the
previous directions have been promptly and efficiently followed out,
with appropriate treatment, soon subside.
The above accident is apt to occur to a child who is standing near a
building when the slacking of quicklime is going on, and where
portions of lime, in the form of powder, are flying about the air. It
would be well not to allow a child to stand about such places, as
prevention is always better than cure. Quicklime is sometimes called
caustic lime: it well deserves its name, for it is a burning lime, and if
proper means be not promptly used, will soon burn away the sight.
288. “What is to be done in the case of Choking?”
Instantly put your finger into the throat and feel if the substance
be within reach; if it be food, force it down, and thus liberate the
breathing; should it be a hard substance, endeavor to hook it out; if
you cannot reach it, give a good smart blow or two with the flat of the
hand on the back; or, as recommended by a contributor to the
Lancet, on the chest, taking care to “seize the little patient, and place
him between your knees side ways, and in this or some other manner
to compress the abdomen [the belly], otherwise the power of the
blow will be lost by the yielding of the abdominal parietes [walls of
the belly], and the respiratory effort will not be produced.” If that
does not have the desired effect, tickle the throat with your finger, so
as to insure immediate vomiting, and the consequent ejection of the
offending substance.[271]
289. Should my child be bitten by a dog supposed to be mad, what
ought to be done?
Instantly well rub for the space of five of ten seconds—seconds, not
minutes—a stick of nitrate of silver (lunar caustic) into the wound.
The stick of lunar caustic should be pointed, like a cedar-pencil for
writing, in order the more thoroughly to enter the wound.[272] This, if
properly done directly after the bite, will effectually prevent
hydrophobia. The nitrate of silver acts not only as a caustic to the
part, but it appears effectually to neutralize the poison, and thus by
making the virus perfectly innocuous is a complete antidote. If it be
either the lip, or the parts near the eye, or the wrist, that have been
bitten, it is far preferable to apply the caustic than to cut the part out;
as the former is neither so formidable, nor so dangerous, nor so
disfiguring as the latter, and yet it is equally as efficacious. I am
indebted to the late Mr. Youatt, the celebrated veterinary surgeon,
for this valuable antidote or remedy for the prevention of the most
horrible, heart-rending, and incurable disease known. Mr. Youatt
had an immense practice among dogs as well as among horses. He
was a keen observer of disease, and a dear lover of his profession,
and he had paid great attention to rabies—dog madness. He and his
assistants had been repeatedly bitten by rabid dogs; but knowing
that he was in possession of an infallible preventive remedy, he never
dreaded the wounds inflicted either upon himself or upon his
assistants. Mr. Youatt never knew lunar caustic, if properly and
immediately applied, to fail. It is, of course, only a preventive. If
hydrophobia be once developed in the human system, no antidote
has ever yet, for this fell and intractable disease, been found.
While walking the London Hospitals, upwards of thirty-five years
ago, I received an invitation from Mr. Youatt to attend a lecture on
rabies—dog madness. He had, during the lecture, a dog present
laboring under incipient madness. In a day or two after the lecture,
he requested me and other students to call at his infirmary and see
the dog, as the disease was at that time fully developed. We did so,
and found the poor animal raving mad—frothing at the mouth, and
snapping at the iron bars of his prison. I was particularly struck with
a peculiar brilliancy and wildness of the dog’s eyes. He seemed as
though, with affright and consternation, he beheld objects unseen by
all around. It was pitiful to witness his frightened and anxious
countenance. Death soon closed the scene!
I have thought it my duty to bring the value of lunar caustic as a
preventive of hydrophobia prominently before your notice, and to
pay a tribute of respect to the memory of Mr. Youatt—a man of talent
and genius.
Never kill a dog supposed to be mad who has bitten either a child,
or any one else, until it has, past all doubt, been ascertained whether
he be really mad or not. He ought, of course, to be tied up, and be
carefully watched, and be prevented the while from biting any one
else. The dog, by all means, should be allowed to live at least for
some weeks, as the fact of his remaining will be the best guarantee
that there is no fear of the bitten child having caught hydrophobia.
There is a foolish prejudice abroad, that a dog, be he mad or not,
who has bitten a person ought to be immediately destroyed; that
although the dog be not at the time mad, but should at a future
period become so, the person who had been bitten when the dog was
not mad, would, when the dog became mad, have hydrophobia! It
seems almost absurd to bring the subject forward; but the opinion is
so very general and deep rooted, that I think it well to declare that
there is not the slightest foundation of truth in it, but that it is a
ridiculous fallacy!
A cat sometimes goes mad, and its bite may cause hydrophobia;
indeed, the bite of a mad cat is more dangerous than the bite of a
mad dog. A bite from a mad cat ought to be treated precisely in the
same manner—namely, with the lunar caustic—as for a mad dog.
A bite either from a dog or from a cat who is not mad, from a cat
especially, is often venomous and difficult to heal. The best
application is immediately to apply a large hot white-bread poultice
to the part, and to renew it every four hours; and, if there be much
pain in the wound, to well foment the part, every time before
applying the poultice, with a hot chamomile and poppy-head
fomentation.
Scratches of a cat are best treated by smearing, and that freely and
continuously for an hour, and then afterward at longer intervals,
fresh butter on the part affected. If fresh butter be not at hand, fresh
lard—that is to say, lard without salt—will answer the purpose. If the
pain of the scratch be very intense, foment the part affected with hot
water, and then apply a hot white-bread poultice, which should be
frequently renewed.
290. What is the best application in case of a sting either from a
bee or from a wasp?
Extract the sting, if it have been left behind, either by means of a
pair of dressing forceps, or by the pressure of the hollow of a small
key—a watch-key will answer the purpose; then, a little blue (which
is used in washing) moistened with water, should be immediately
applied to the part; or, apply a few drops of solution of potash,[273] or
“apply moist snuff or tobacco, rubbing it well in,”[274] and renew from
time to time either of them: if either of these be not at hand, either
honey, or treacle, or fresh butter, will answer the purpose. Should
there be much swelling or inflammation, apply a hot white-bread
poultice, and renew it frequently. In eating apricots, or peaches, or
other fruit, they ought to, beforehand, be carefully examined, in
order to ascertain that no wasp is lurking in them; otherwise, it may
sting the throat, and serious consequences will ensue.
291. If a child receive a fall, causing the skin to be grazed, can you
tell me of a good application?
You will find gummed paper an excellent remedy; the way of
preparing it is as follows: Apply evenly, by means of a small brush,
thick mucilage of gum arabic to cap paper; hang it up to dry, and
keep it ready for use. When wanted, cut a portion as large as may be
requisite, then moisten it with your tongue, in the same manner you
would a postage stamp, and apply it to the grazed part. It may be
removed when necessary by simply wetting it with water. The part in
two or three days will be well. There is usually a margin of gummed
paper sold with postage stamps; this will answer the purpose equally
well. If the gummed paper be not at hand, then frequently, for the
space of an hour or two, smear the part affected with fresh butter.
292. In case of a child swallowing by mistake either laudanum, or
paregoric, or Godfrey’s Cordial, or any other preparation of opium,
what ought to be done?
Give, as quickly as possible, a strong mustard emetic; that is to
say, mix two teaspoonfuls of flour of mustard in half a teacupful of
water, and force it down his throat. If free vomiting be not induced,
tickle the upper part of the swallow with a feather; drench the little
patient’s stomach with large quantities of warm water. As soon as it
can be obtained from a druggist, give him the following emetic
draught:
Take of—Sulphate of Zinc, one scruple;
Simple Syrup, one drachm;
Distilled Water, seven drachms:
To make a Draught.
Smack his buttocks and his back; walk him, or lead him, or carry
him about in the fresh air; shake him by the shoulders; pull his hair;
tickle his nostrils; shout and holla in his ears; plunge him into a
warm bath and then into a cold bath alternately; well sponge his
head and face with cold water; dash cold water on his head, face, and
neck; and do not, on any account, until the effects of the opiate are
gone off, allow him to go to sleep; if you do, he will never wake again!
While doing all these things, of course, you ought to lose no time in
sending for a medical man.
293. Have you any observations to make on parents allowing the
Deadly Nightshade—the Atropa Belladonna—to grow in their
gardens?
I wish to caution you not on any account to allow the Belladonna—
the Deadly Nightshade—to grow in your garden. The whole plant—
root, leaves, and berries—is poisonous; and the berries, being
attractive to the eye, are very alluring to children.
294. What is the treatment of poisoning by Belladonna?
Instantly send for a medical man; but, in the mean time, give an
emetic—a mustard emetic;—mix two teaspoonfuls of flour of
mustard in half a teacupful of warm water, and force it down the
child’s throat; then drench him with warm water, and tickle the
upper part of his swallow either with a feather or with the finger, to
make him sick; as the grand remedy is an emetic to bring up the
offending cause. If the emetic have not acted sufficiently, the medical
man when he arrives may deem it necessary to use the stomach-
pump; but remember not a moment must be lost, for moments are
precious in a case of belladonna poisoning, in giving a mustard
emetic, and repeating it again and again until the enemy be
dislodged. Dash cold water upon his head and face; the best way of
doing which is by means of a large sponge, holding his head and his
face over a wash-hand basin, half filled with cold water, and filling
the sponge from the basin, and squeezing it over his head and face,
allowing the water to continuously stream over them for an hour or
two, or until the effects of the poison have passed away. This
sponging of the head and face is very useful in poisoning by opium,
as well as in poisoning by belladonna; indeed, the treatment of
poisoning by the one is very similar to the treatment of poisoning by
the other. I, therefore, for the further treatment of poisoning by
belladonna, beg to refer you to a previous Conversation on the
treatment of poisoning by opium.
295. Should a child put either a pea or a bead, or any other
foreign substance, up the nose, what ought to be done?
Do not attempt to extract it yourself, or you might push it farther
in, but send instantly for a surgeon, who will readily remove it, either
with a pair of forceps, or by means of a bent probe, or with a director.
If it be a pea, and it be allowed for any length of time to remain in, it
will swell, and will thus become difficult to extract, and may produce