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Lorsque le document est trop grand pour Atre reproduit en un seui clichA, 11 est filmA A partir da I'angle supArieur gauche, de gauche A droite, et de haut en baa, an prenant la nombre d'imagea nAcaasaire. ilea diagrammes suivants illustrent la mAthoda. 1 2 3 1 2 3 4 5 6 EMERaENOIES. THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF THE ACCI- DENTS, DISEA&5ES, AND CASES OF POISONING WHICH DEMAND PROMPT ACTION. DESIQNGO FOB STUDENTS AND PRACTITIONERS OF MEDICINE. JOSEPH W.^HOWE, M. D., AurnoB OF "Tne bbeath, and the disrasrs wnicn givk it a fictid ouos; " 11 WINTKB HOMES FOR raVALIPS, ' ETC.; LATE PROFEBgOR OF CLINICAL PURGERY I.» BELLBVUB nOBPITAI, MEDICAL COLLBGE; FELLOW OF THE KEW YORK ACtllEMY OF MEDI- CINE: VEMBER OF THE NEW YORK BUBOICAL, P/TIIOLOOirAL, AND COUNTY MEDICAL SOOnrTIES; CGNSl'LTINO PHYSICIAN TO IIOAPITAI, FOB DISEASES OF THE NOSE, MOrTII. AND THROAT; VISITING BUBGFXIN TO CHABITY AND ST. FBANCIS HOSPITALS. FOURTH EDITION. NEW YORK: D. APPLETON AND COMPANY, 1, 3, Airo 6 BOND STREET. 1890. MEDICAL FACULTY MoGiLL II CoPTBionr, 1871, 1884. By D. APPLETON AND COMPANY. PREFACE TO THE FIRST EDITION. ■ This volume, as its title indicates, is designed as a guide in the treatment of cases of emergency occurring in medi- cal, surgical, or obstetrical practice. I have endeavored to combine, in a narrow compass, all the important subjects, giving special prominence to points of practical import in preference to theoretical considerations, and, with the re- sults of my own personal observation, uniting the latest views of European and American authorities. J. W. H. 86 West 24Tn Street, June 1, 1871. co:ntents. CHAPTER I. U^MOBRUA GE. rtm General Considerations. —Results of Negligence. — Arterial and Venous Hsemorrhage.— Effects of Profuse Htemorrbage.— Natural and Arti- ficial Methods of suppressing Hremorrhage.— Iliomorrhagio Diathesis.— Constitutional Treatment.— Transfusion, . , . , . j CHAPTER II. SPECIAL n^MORPlIAGES. Bleeding from the Nose, Mouth, Lungs, Stomach, Intestines, Kidneys, Ure- ters, Bladder, Urethra, Erectile Tissue of Penis.- Ecchymosis, . . ai CHAPTER III. njEMORRUAOE FROM THE UTERUS, Menorrhagia.— Metrorrhagia.— Accidental Hemorrhage,- Placenta Prnvia. — Post-partum Hteniorrhage, . . . , . . ,41 CHAPTER IV. WOUNDS OF IMPORTANT ORGANS. Wounds of the Throat, Lungs, Pericardium, Heart, Abdomen, Intestines, Bladder, Perinicum, Joints. — Rupture of Liver, Perineal Section, Para- centesis, Thoracio.— Gunshot-Wounds, . , . . .47 CHAPTER V. WO VXDS OF ARTERIES AND VEINS Ligation of large Arteries: Arteria Innominata, Subclavian, Common Carotid, Axillary, Brachial, Radial, Ulnar, Palmar Arch, Femoral, Popliteal, An- terior Tibial, Posterior Tibial.— Air in the Veins.— Causes of Death.— Treatment, .«...,... 66 6 CONTENTS. CHArTEH VI. POISONED W0U2TDS. **•■ DisRectlng Wounds.— Hydrophobia in Dogs.— Hydrophobia in Man.— Battlo- •noko-Bitos.— Insoot-Bites. — Contipede.—Torantula.— Scorpion, . . 74 CHAPTER VII. EXTRACTION OF FOREIOiT BODIES. Foroign Bodies in tho Larynx, Trachea, Bronchiol Tubes, Phorynx, CEsoph- agus. Eyes, Nose, Ears, Urethra, Bladder, and Rectum. — Tracheotomy.— Laryngotomy. — (Esophagotomy, . . . . . .85 CHAPTER VIII. BURNS AND SCALDS-EFFECTS OF COLD. Varieties of Deformities produced by Burns.- Operation for closing the Eye. — Spontaneous Combustion — Classification of Bums — Constitutional Symptoms. — Duodenal Ulcer — Causes of Death— Post-mortem Ap- psaranoe.— Effects of Cold.— Frost-Bite, . . . . .101 CHAPTER IX. STRANGULATED HERNIA. Causes and Symptoms of Strangulation. — Heus. — Volvulus. — Operations for Inguinal and Femoral Hcmise. — Taxis, . . . . .119 CHAPTER J. LOSS OF CONSCIOUSNESS. OOUA. Coma from Cerebral Extravasation, Depressed Fracture, Pressure of Inflam- matory Products, Embolism, Thrombosis, Uraemia, Alcohol, Hysteria, Epilepsy.— Concussion, . . . . . . .118 CHAPTER XI. LOSS OF CONSCIOUSNESS-(Comimm). SYNCOPE. Syncope from Loss of Blood— Thrombi of the Pulmonary Vein — Anromia.— Mental Emotions— Blows on the Ep'gastrium— Collapse, . , |8| CONTENTS. CHAPTEB XII. Reiplrntory ApparatuH.— Effects of Non-aOration of Blood.— Strangulfttion.— f-'omprosxion of tho Tliorox,— Inhalfttlon of Poisonous Oases.— Signs of Death.— Drowuiug.—Ir^juries to tho Spinal Cord. — Strychnia, . . 188 CHAPTER Xin. SUySTJiOKR SynonymoB.— First Recorded Cases.— Sunstroke in Crowded, Overheated Buildings. — Varieties of Sunstroke. — Symptoms. — Treatment. — Post- mortem Appearances, . . . . . . , .158 CHAPTER XIV. DYSPyaA. Causes of Hurried Respiration. — Dyspnoeo in Asthma, True and False Croup, Congestion of tlie Lungs, Cardiac Disease, Pulmonary OEdema, Pulmo- nary Apoplexy, . . . . . . . .161 CHAPTER XV. (EDEJTA GL0TTIDI8, Location of tho Effusion. — (Edema Glottidis in Bright's Disease— Inflamm*- mation — Collatoral (Edema— Symptoms. — Troatment, . . . 178 CHAPTER XVL c NvuLaio N a. Tonic and Clonic Spasms. — Irritation of the Tuber Annulare. — Infantile Convulsions. — Convulsions from Ursemio Poisoning, Cerebral Extrava- sation, Hysteria, Alcohol, Epilepsy, Tetanus, . . , .176 CHAPTER XVII. SUSPEXDSD F ill BO EMERGENCIES, AND HOW TO TREAT TUEM. Beqnont irritability of the nervous Bystem is to bo treated with opiates. Wlicu the loss of blood is bo groat that reaction is im- possible through the ordinary methods, resort must be had to transfusion. This operation consists in abstracting blood from a robust man or woman, and injecting it into the veins of the exsanguinated patient. If an apparatus for the pur- pose is not at hand, or its use but little understood, a com- mon hard-rubber syringe, with a capacity of five or six ounces, will answer. An opening is made in one of the veins of the forearm, and into this a canula, adapted to the point of the syringe, is inserted. A bandage tied below the in- cision prevents further bleeding. The syringe, warmed and charged with the fresh blood, is introduced, and the piston steadily forced down until the instrument is emptied. From ten to twenty ounces may be injected at one sitting, and the operation may be repeated if necessary. Care must be taken to force out all air from the syringe before it is used. The efl&cacy of this operation has Voci fully proved. Patients have beer restored to life under cii jumstances which were such as to almost preclude the hope of recovery. I have lately employed a modification of Dieulafoy's aspirator in transfusion. The arm is bandaged as in the ordinary method for venesection, and a needle of the aspi- rator inserted into the distended median basilic vein. The Btop-cock of the aspirator is then turned, and the blood inishes in and fills up the cylinder. A vein in the patient's arm having been exposed, and an opening made in it for the insertion of a canula, the tube from the opposite side of the aspirator is attached, and the blood forced through it into the vein. See Appendix. CUAPTER II. n. EMORRIIA aE-iCo-snnxvtxt). Blooding ft-om the Noso, Mouth, Lun(f«, Stomoch, TntcstlnoR, KiJnoys, Ureters, Bladder, Urethra.— Ecchymosid. Epistaxis, or Llccding from the nasal passages, is tlio most frequent and least dangerous of all internal hajmor- rhages. It occurs generally from one nostril. Repeated hsEmorrlmge from the left nostril is said to bo a certain indi- cation of splenic disease. Some of the capillary vessels of the nasal mucous mem- brane communicate directly with those of the cranial cavity, and, when epistaxis appears during congestion of the brain, its action is decidedly beneficial in diminishing the quantity of blood in that organ. In inflammations of the mucous membrane, a rupture of the distended and engorged capil- laries may be the commencement of a healthy action. All cases of epistaxis, however, are not attended with the same good results : the bleeding may bo so persistent as to seri- ously endanger life. The ancients considered bleeding from the nose as an indication of fever, and bled and purged the unfortunate patient while any trace of the disorder remained. The blood was supposed to bo overheated, and in a state of ebullition, which rendered its removal necessary. 22 EMEHGEXCIES, AND FIOW TO TREAT TUEM. The catiHca of cpistaxis arc violent oxcrciso after drink- ing, laceration of vessels by blows or fullrf, cunlijic disease, catarrhal inflainiuations, congestion of the brain, syphilitic or Bcrofulons ulceration, the lucniorrhugic diathesis and disordered conditions of the blood, sneh as occur in scor- butis, purpura, and continued fevers. Severe forms of epistaxis are pij3ceded by a feeling of weight, and fulness about the forehead, with pain and ver- tigo. Treatment. — First ascertain whether the blood escapes from both nostrils, or from the right or left ; then, on the affected side, raise the arm above the head, and grasp the nose with a firm pressure between the thumb and forefinger; at the same time, a towel saturated with ice-water may b- laid on the forehead. The arm is raised to diatrlhute the force of the heart's action, and to take the pressure off the carotid vessels, diminishing the strength of the current through them. Some advise the application of ice to the mammce of the female and testes in the male, or simply placing the hands in cold water. "When pressure, raising the arm, or cold applications, are unsuccessful, styptics may bo resorted to. Inject with a syringe a quantity of ice-water, or a solution of common salt, in the proportion of one tabiespoonful to half a tumber of water ; or some of the preparations of iron, such as solutions of the pernitrate or persulphate. The iron may be thrown up the nostril, either diluted or not, or a piece of lint, twisted and moistened with the solution, may be forced up the canal and allowed to remain until the bleeding ceases. When the blood comes from laceration of the naso-palatine artery, all these measures are apt to fail. n.EMORRIIAOE. and tlio poHtcrior nnros imiHt then 1)0 pluggcil. Tho oporii- tion of plii^'^'ing ia fiiinpli', and docs not rocpiiro a great amount of skill. It may ho jjcrfonnud with IJcIoc'h canula or a gum-flastic cathotcr (No. 4 or 5 will do). Through tho eye of tho instrument jiass u string, allowing tho ends to hang down. Introduc'o tho catheter through tho nostril into the mouth, and draw tho string, whieh ia hanging trom its end, out beyond tho lij>9. To this attach a pieeo of sponge suf- ficiently largo to fill up the opening in tho posterior nares. Then withdraw tho catheter from tho nose, and make trac- tion on tho string until tho sponge is drawn back into tho posterior narcs, completely liliing its cavity. If necessary, tho sponge may bo dipped in an astringent solution before its introducticni. This method scarcely ever fails to control tho most obstinate hiemorrhagc. Stomatokhuaoia. — Ilnemorrhago from tho mouth. ThiB variety needs scarcely more than a passing notice. It re- quires special treatment only when occurring in persons with tho ha?morrhagic diathesis. Inflammation of the buc- cal cavity, idcers, and injuries, are its principal causes. Rinsing tho mouth with alum-water, or some other astrin- gent preparation, will check it effectually. II-iMATKMKsis. — Hemorrhage from the stomach generally occurs during the progress of some chronic disease of the liver, portal system, or stomach. Any obstruction to the return of blood through tho portal vein, such as exists in tho dram-drinker's liver {cirr/iosls), in inflammation or thrombosis of the vein, will occasion it. Chronic ulcer and cancer of the stomach, gastritis, and corrosive poisons, are also prolific causes. "'^ '-^ 24 EMERGENCIES, AND HOW TO TREAT THEM. i !ll)j II! iitli -n I Mill hii In cirrhosis, tlie liver is diminislied in size by tjie con- traction of navf fibrous tissue, which is formed throughout the organ during tlie inflammatory process. This new tissue is either developed from inflammatory lymph {Rokltanaky), or by the proliferation of connective-tisfeue cells ( Virchow). It is located principally around the hepatic vessels. By its contraction, the ramifications of the portal vein are pressed upon, and their cap;.city diminished or destroyed, and the result is a damming back of the blood in the stomach and intestines. In a short time the distention is greater than the walls of the vessels can resist, and consequently they are ruptured. Coagulation of blood in the veins (thrombosis), with or without inflammation, produces haematemesis in a similar way. In chronic ulcer and cancer, molecular death of the tis- sue proceeds gradually, until the capillary walls are reached and perforated. If a large vessel have been opened, the bleeding may cause death in a short period ; but such an event rarely happens. Instances are recorded of haemorrhage from the stomach occurring at the menstrual period. In this vicarious men- struation, the usual flow from the uterus is absent. In profuse hseraorrhage from the stomach, the patient will have a feeling of fulness and oppression in the epigastrium. The countenance becomes pallid ; there are vertigo and dimness of vision ; and finally a fluid, which imparts a warm sensation to the oesophagus, is vomited. If the blood have been extravasated suddenly and in an empty stomach, there will be little change in its physical or chemical characteris- tics. But if slowly exuded, and allowed to mingle with the gastric juice, or partially-digested food, it takes on a dark r ' HiEMOilRHAGE. 25 color resembling " coffee-grounds." The normal alkaline reaction is changed to acid, and the blood will not coagu- late. These peculiarities are usually present, and in cirrho- sis they arc particularly marked. Blood from wounds of the moutli is sometimes swallowed and afterward thrown up, but a careful examination will reveal the source, and prevent an erroneous diagnosis. The act of vomiting, which forces out the blood in haematemesis, is seldom attended with nausea. In passing out some may enter the larynx and induce a fit of coughing, thereby leading to the sui^position that the blood is from tlic lungs, instead of the stomach. On the other hand, a paroxysm of coughing, with hoemorrhage from the lungs, may bring on nausea ai'.l "smiting, and cause the pliysician to locate the disorder in the stomach. It is necessarv, there- fore, in making a diagnosis, to exercise care and judgment. It is well to remember that blood from the stomach ia generally dark in color, mixed with food, and is acid in re- action. If coagula are present, they will be found black and heavy, from absence of air. There will be a previous history of pain, nausea, vomiting, and a disordered stomach, with the special symptoms of the disease which may have occa- sioned the hffimatemesis. In hemorrhage from the lungs, the blood is generally bright rod, frothy, mixed with bubbles of air, and alkaline in reaction. A fit of coughing precedes and accompanies the bleeding. There are pain in the chest, and signs of tu- berculosis or other afiection of the lungs or cardiac disease, and there is no history of disease of the liver or stomach. Moist rAlcs can be heard on auscultation, near the seat of the pain, and there may also be slight duluess on percussion. ■' ,1 inn in l!!i 26 EMERGENCIES, AND HOW TO TREAT THEM. In all doubtful cases, the mouth and fauces should undergo a careful examination. Haemorrhage from these parts is often mistaken for hajmatemesis. A perfect knowledge of these points of diiference, and their careful investigation at the bedside, will make the diagnosis a matter of almost positive certainty. Treatment. — Absolute rest in the recumbent posture must be rigidly enforced in this and every other variety of internal haemorrhage. The patient's room must be kept free from visitors, and only the nurse and doctor are to bo admitted. Every source of excitement must be removed. These stringent preliminaries are, of course, only required when much blood has been lost. There are many mild cases in which they are not called for. Ice poinds at the head of all remedial agents for the suppression of hseraatemesis. It can be administered continuously in small pieces, or at dif- ferent intervals, as the case may demand. Cloths wet with ice-water, or pounded ice in bags, may also be applied over the epigastrium. Ether-spray, directed over the stomach, produces intense cold, and is worthy of trial. Of the various styptics employed, some prefer the following : 15. Liquor, ferri siibsnlplmtis Aquse .... 3i. M. One teaspoonful of this solution is to be given every half hour, or more frequently if required. Other preparations of iron are also used. Some prefer the acetate of lead in one or two grain doses. Alum, creosote, tannic and gallic acids, answer in some cases. All the solutions employed should be kept on ice, and given in small quantities, as they are apt to be thrown up. HAEMORRHAGE. 27 If vomiting is produced by one preparation, let something else be substituted. The contractions of the stomach in the act of vomiting increase haemorrhage. The subsequent treatment must depend entirely on the accompanying disease and the amount of blood lost. Nu- tritious diet and tonics are indicated to restore the lost vi- tality. When strength is regained, the disease which pro- duced the hajmorrhage should receive special attention. If the bleeding has been so great as to induce collapse, rapid stimulation should be resorted to in the manner described in tlie preceding chajpter. Melmna is a term usually employed to denote haemor- rhage from the bowels, although any dark-colored discharge from the same parts might properly be classed under the same head. Melaena is caused by many of the same disor- ders which occasion hoematemesis. The portal venous sys- tem, which carries blood from the stomach, also takes it from the intestines. Any abnormal condition, therefor.., which obstructs the circulation through the portal vein, such as those previously mentioned, is liable to produce extravasa- tion of blood in any part of the stomach or intestinal canal. Sometimes the blood which is poured out in the stomach passes through the pyloric orifice, and is voided by the bow- els instead of being vomited. Among other causes of bleeding from the intestines may be enumerated u.ijeration of the mucous coat, from chronic or acute inflammations, and rupture of capillary vessels dur- ing inflammatory congestion, as in dysentery and enteritis. HiMmorrhoids, or piles, are also classed as common causes. In low forms of fever, such as tyi)hoid or yellow fever, ha3m- orrhage from the bowels is not of infrequent occurrence. In 88 EMERGENCIES, AND HOW TO TREAT THEM, ) I the first instance, it is due to ulceration ; in the second, it arises from rupture of blood-vessels. "When the blood proceeds from the upper part of the in- testinal canal, or when it is poured out in small quantities, it appears in dark masses resembling tar. In profuse haem- orrhage it has the same characteristics as when occurring from other organs. When the bleeding is due to ulceration, tlie blood is generally redder than in rupture of portal capil- laries or in piles. Haemorrhage from intestinal haemorrhoids (piles) occurs more frequently than any other variety. In cir- rhosis of the liver, the gastric vessels are, as a rule, first rup- tured, and afterward the vessels farther down the canal. Oc- casionally, cases of violent haemorrhage from the bowels, due to cirrhosis, prove fatal in a few moments. Plethoric per- Fons, who feed on the fat of the land, and indulge freely in wine, are at times subject to small haemorrhages while straining at stool. The portal venous system contains a much larger proportion of fluid during digestion than at any other period, and in plethoric men this distent' '^n reaches its maximum, so that, in a violent effort to evacuate the bowels, some of the engorged capillaries rupture and relievo tliemselves. This variety of melaena occurs inde- pendent of any organic disease, not even haemorrhoids being present to account for it. Haemorrhage of this character at ;s as a safety-valve, and should be let alone unless too profuse. Treatment. — The general rules which govern the treat- ment of other varieties of haemorrhage must be followed here ; perfect rest and quiet secured, and every excitement avoided. Cold water poured slowly from a sprinkler or pitcher is advisable in alarming cases. Cloths wet with ice. il'lt: ! uroxysm of coughing increases the internal pressure on these vessels to such an extent that they rupture, and blood 30 EMERGENCIES, AND HOW TO TREAT THEM. ill liill M m .1 appears in the expectorated fluid. The amount of blood poured out will of course depend on the size and number of the ruptured capillaries. In all cases of catarrhal inflamma tions of the air-passages this rapture and extravasation are li- able to occur, independently of other affections. If the blood were expectorated, the heemorrhage would be rather a bene- fit than otherwise; but sometimes it remains in the smaller tubes and air-cells, acts as an irritant, sets up inflammation, and finally may go on to consolidation and subsequent soft- ening and degeneration of the lung-tissue {Niemeyer). Organic disease of the heart is accompanied by haemop- tysis. "When insufficiency of the mitral valve exists, the blood regurgitates into the left auricle, which is therefore partially filled with blood that should have remained in the ventricle. This causes a damming back, or obstruction, to the blood coming from the four pulmonary veins to the auricle, and consequent congestion of the lungs. The capil- lary vessels in the bronchial tubes, and in other parts, are distended, and relieve themselves by rupture. Sometimes, in these cases, large extravasations of blood occur in the parenchyma of the lung {^pulmonary aj^oplexy)^ lacerating and destroying its substance, and hastening a fatal termination. Extravasations of blood in cardiac dis- ease are also due to another cause, viz., the plugging of small arterial capillaries by clots of fibrine detached from the right side of the heart. These clots are carried into the pulmonary artery, blocking up some of its terminal branches. This obstruction necessarily diminishes the current in the capillaries supplied by the plugged vessel ; they become crowded, choked up with blood, the internal pressure soon forces their thin walls to give way, and the blood is extrava- i.iii '.li HEMORRHAGE. 31 Bated into the air-cclla, terminal bronchi, and between tlie ehistic fibres of the cells. These clots, after coagulation, are circumscribed, sharply defined, and dark in color. To this old condition a new name has been given, viz., hmmor^'hagiG infarction, to distinguish it from another variety of pul- monary apoplexy in which tlio clot is difi'used, and lung- tissue destroyed. Tubercular deposit induces hemoptysis in one of three ways : 1. By mechanical pressure it may obstruct the small attenuated vessels so as to cause rupture ; 2. It may create inflammatory congestion, whicli is relieved by the walls giving way ; or, 3. Tlie softening and degeneration of tissue which accompany the second and third stages of tuberculosis, involve the capillaries, destroy them, and hoemorrhage is the result. Gangrene of the lung is seltlom accompanied by Iwemop- tysis. When present, it is due to the morbid process in- eluding the vessels in the general destruction. The haemoptysis which occasions the characteristic rust- colored sputa of pneumonia either arises from laceration of the minute iiapillaries, or by the passage of the red globules through the wall of the vessel without rupture. The latter process is doubtful, to saj'^ the least of it. The inhalation of chlorine gas, sulphuretted hydrogen, and other irritating substances, likewise occasions hcemop tysis. "Wounds of the lung are always attended by more or less expectoration of blood. One curious and rare variety of hemoptysis is that which occurs at the menstrual period, when the discharge of blood from the uterus is absent. There are but few cases on record. Dr. "Watson relates one of a young girl who men- 82 EMERGENCIES, AND HOW TO TREAT THEM. is: I ■■li il Ltniated onco naturally at Bixteen years of age, and, from that time until the age of fifty, she eufibred from hoemop- tysis regularly onco each month. Accompanying the loss of blood were the usual uneasy sensations of pain in the pelvis and general malaise. In slight cases of haemoptysis the patient has first a tick- ling sensation, beneath the sterniTm, which compels him to cough. The effort brings up a warm fluid having a pecu- liar sweetish taste, which when expectorated is found to be blood. It is generally bright red, and filled with bubbles of air. At other times the sputa for some days are simply tinged or streaked with red. In more serious cases, and especially in heart-disease, there is a sharp, intense pain in some part of the chest, followed immediately by excessive dyspnoea, and the expectoration of large quantities of blood. This blood is not so bright as in the former instance, but it still contains air. On auscultation near the seat of extrava- sation, moist rdles, and occasionally bronchial breathing, can be heard. The rdles are more liquid in character than those produced by mucus. There is more or less dulness on per- cussion, in the majority of cases. These large extravasations are usually followed by pneumonia. Its advent is easily recognized by the characteristic physical signs, and by the increased temperature, rapid pulse, and other evidences of febrile excitement. In examining a case of supposed hsemoptysis, it is well always to take into consideration the fears of the patient, when determining the quantity of blood lost. The fright causes the amount to be greatly exaggerated. Investigate carefully the condition of the nose, mouth, and fauces. Blood from these parts may get into the larynx, excite coughing, pi .. n^MORRHAGE. $8 and he expectorated, thus leading to an erroneous diagnosis. The differentiation between lieemoptysis and hoomatemcsis is readily made. In tlie latter the blood is dark-colored, acid in reaction, nncoagulable, does not contain air, and is ex- pelled by the act of vomiting. "With it there is a history of some disorder of the stomach or liver. In the former the blood as a rule is red — it is alkaline in reaction, coagu- lable, filled with bubbles of air, is brought up by coughing, and there is a previous history of some variety of lung- disease {see Ilrematemesis). Treatment. — The patient should bo placed in a sitting posture in bed, propped up with pillows. A cool room is desirable. Every cause of excitement must be removed. The variety of medication demanded depends to a certain extent on the cause of the hajmorrhage. If it be due to cardiac disease, and if the heart's movements be accelerated, it will, of course, be expedient to administer an arterial sedative in conjunction with the astringent. For this pur- pose the following prescription will be found of service : Q. Ext. verat. viridis J9. 3bs. Ext. ergotoo fl. 3 y. Acidi Bulph. aromat 3 ij. Aquee fl. | ij. M. Administered in 30-drop doses, largely diluted, every half- hour, until the desired effect is produced. Digitalis may be substituted for veratrum, or given separately. Great care must be exercised in its administration. For the urgent dyspnoea, which also accompanies this haemorrhage in heart- disease, the application of half a dozen dry cups to the thorax will be found an admirable remedy. They relieve ?l i f %\\ r f 84 EMEROEXCIES, AND HOW TO TREAT THEM. Ill ill !' !i the troublesome sliortness of breath, and, by drawing blood to the surface, diminish the congestion of the lungs. If there be no special contraindication, the following preparation of sugar of lead and opium, although incom- patible, will often answer the purpose : 3> Plumbi Rcotntis Pulv. opil . 3 8. M. Make ten pills. One to be given every half-hour. In sim- ple cases, one of the oldest, and, at the same time, one of the best, remedies is common salt, alone or with vinegar. Half a teaspoonful can be given at intervals of fifteen min- utes until the hoemorrhage is controlled. 3. Acidi salph. dil fl. 3 U< Alaminis 3j. Aqun . fl. S^. M. Can be taken in teaspoonful doses every half-hour. Some prefer the preparations of iron. Inhalation of the vapor of tr. ferri chloridi has been recommended, but its irritating properties would teud to excite coughing, and therefore paould not be employed. Gallic acid in three-grain doses, and other vegetable astringents, are found efficacious. In connection with the internal remedies mentioned, hot ap- plications to the dorsal region of the spinal column, and cold ones in front, will be of service. AVhen all danger from loss of blood has passed away, the disease which pro- duced it, and the inflammation (if any) which follows, should receive careful attention. H.EMATURiA. — Blood in the urine is a symptom of mapy ''aried pathological conditions distinct in character and in BiEMORRnAOE. M location. ITaving its origin in different organs some consid- erablo dibtanco. apart, a correct appreciation of its source is attended with greater difficulty than are hemorrhages from the viscera. Lesions in any part of the genito-urinary tract from the kidneys, ureter, bladder, prostate gland, or ure- thra, may bring on hoRmaturia. Constitutional blood-diseases, as purpura, scurvy, ty- phus or yellow fever, are classed as causes independent of special disorders in the organs mentioned. Iloemorrhage from the kidneys arises from external vio- lence, inflammation of the tubes or parenchyma of the organ ; the passage of renal calculi, or ulceration resulting from the infarction of these bodies, in or near the pelvis. The passage of largo calculi through the ureter tears the mucous membrane, and bleeding results. Blood is found in the urine in injuries of the bladder from introduction of instruments or blows on the hypogas- triura, acute cystitis, fungous degeneration of the mucous membrane, and cancerous disease of the organ. Urethri- tis, chordtB, and injuries of various kinds, are prolific causes of hajmorrhage from the urethra. Various medici- nal agents, such as cantharides, turpentine, etc., etc., given in overdoses, produce excessive congestion in the genito- urinary tract which is often accompanied by hematuria. "When called to a case of supposed hoematuria, it will be well first to determine whether blood is present in the urine or not, and then endeavor to discover its source. Healthy urine is a clear " amber-colored fluid," acid in reaction, and having a specific gravity ranging from 1.118 to 1.125. Urine which contains blood has a smoky tint, if the quan- tity be small ; dark red or chocolate-brown, when the quan- 'I ! I 86 EMERGENCIES, AND DOW TO TREAT THEM. Ml tity Ib largo. The reaction in most cases U alkaline, and tho Bpecitic gravity is increased. On bcin^ allowed to stand, a dark-redd irth mass sinks to tlio bottom, while tho superna- tant fluid still maintains, to a certain extent, its smoky huo. Heating tho liquid will give a ch)udy jtrecipitute of albumen, tinged with tho coloring mutters of tho blood, while tho rest of tho urine renuiins clear. Tho surest method of diagnosis is by microscopical examination. Blood-corpuscles aro recognized by their "yellow color, uniform size and non-granular surface " {Bird). There aro many substances besides blood which give a reddish color to the urine. An excess of urates in other- wise normal urine will induce a red or brown deposit when tho liquid cools. To datermino their presence ai>ply heat, and the urine will resume its natural transparency. The use of beet-root, madder, logwood, etc., also occa- Bions a red color. Tho applications of heat in these cases will not produce a precii>itate, showing that the tinge is not duo to blood. When the blood proceeds from the kidneys, it will be, generally, diffused throughout tho urine. It will bo attend- ed with a history of injury, tho passage of a calculus, or signs of nephritic inflammation. A microscopical investi- gation will show small blood-easts of the uriuiferous tubules, red globules, and epithelium from the pelvis of the kidney. If the blood come from the commencement of the ureter, small plugs of fibrine, resembling maggots, may sometimes be seen in the bottom of the glass. In hseraorrhage from tho bladder, more blood comes away at the end of micturition than during the act; it is clotted, and not diffused through the liquid, as in the former III EiEMORRIIAOE. w instance. There is a liirttory of injury, signs of cystitis, such as frequent desire to micturate, pain during the act, and paia on pressure over the pubes, or signs of stone. When the ])lccdirig takes place from the urethra, the blood precedes the stream of urine. There is one exception to this rule, namely, where partially-healed ulcers exist in the canal. The contraction of the urethral walls, as the last dro])B of urine pass out, lacerates some of the delicate vessels in the ulcer. I have known this to occur in several instances. A careful connlderation of the foregoing points of differ- ence will, in most cases, enable the practitioner to make a correct diagnosis. Treatment. — AVhen injury or disease of the kidney causes hcemorrhago, little treatment is necessary, except that which is calculated to remove the existing morbid condition of the organ. In hrcmorrhage from the bladder the cause is different. Profuse bleeding from this organ is not infre- quent in malignant disease, or fungous degeneration of the mucous membrane. The patient should be placed on his back, and cold wet cloths applied over the hypogastric region and perimcum. Ice-water, or pounded ice, can be thrown into the rectum at the same time. Should the blad- der bo distended with clots, a large-sized catheter must be introduced, the clots broken up and removed ; warm water injected through it will soften the clots and assist in their discharge. If further measures be necessary to suppress the bleeding, the following solutions may bo injected into the bladder, by means of the catheter : 9 . Acidi gallici Aqua) 3Hj. fl.|iv. M. 88 EMERGENCIES, AND HOW TO TREAT THEM. Or, Q . AluminiB AqufB . 3j. . fl. I iv. M. Many of tlie vegetable astringents, as uva ursi, hydras- lis, krameria, may be used in a like manner. In urethral bleeding, cold cloths and pressure generally answer all requirements. If there be laceration of the erec- tile tissue surrounding the urethra, accompanied by danger- ous haemorrhage, a steel sound, or catheter, must be intro- duced in the canal, and the penis bandaged over it firmly. This procedure is allowable in every case which cannot be controlled by other means. In case injections into the ure- thra are considered advisable, solutions of iron may be em- ployed diluted, such as — 111! I ■ ' I 'ill lili sin 3 . Liquoris ferri subsulphatis Aquee . . . . fl3j. fl ? iv. M. Any thing stronger than this creates much irritation and pain. After amputation of the penis, or the removal of tumors, the subsequent hsemorrhage from the erectile tissue is some- times 80 profuse and uncontrollable by ordinary means aa to compel the surgeon to apply the actual cautery. See Ap- pendix. EccHYMosis is an extravasation of blood in the meshes of the cellular tissue, generally occurring underneath the integument. It is especially apt to take place in those parts which are loosely attached to the underlying tissues, and where there is little subcutaneous fat. A characteristic ex- ample of this lesion is found in the ordinary " black eye." >\ HEMORRHAGE. 39 Ecchymosis follows blows and contusions of all kinds. Its extent depends on the tissue bruised, and the amount and kind of violence which produced it. Very slight injury will occasion large ecchymosis in old persons, and in those who suffer from anremja or other debilitating affections. In pur- pura and Fcorbutis, blood is effused in small, irregular patches. This is due to deterioration of the circulating Huid, and not to injury. Tlie ecchymosed spot may be black, green, yellow, or crimson. Sometimes there is a mix- ture, the central part being dark blue, while the rest varies in color from a crimson to light green and yellow. The coloration is due to the red globules which have escaped from the ruptured capillaries, and to the hematine of the blood staining the parts. Where the staining is caused by hematine alone, the colors are light, and microscopical ex- amination of the extravasated material shows that no cor- puscles are present. All bruises which are not attended with grave destruc- tion of tissue may be treated with water-dressings. The injured part is to be kept at rest and covered with cold, wet cloths. If preferred, the bruised tissue may be bathed or kept moist with the following preparation : 5. Aininoniro muriat. Tinct. arnica) Spts. vin. rect. Anna) 3j. fl-SJ. fl-|ij. fl-liij. M. For children, a further dilution is necessary, as their in- tegumental covering is much more delicate tlian that of adults. One or two ounces of water added will weaken it sufficiently. This solution has an admirable effect in pro- M iO EMERGENCIES, AND HOW TO TREAT THEM. ducing rapid absorption of the effused material, preventing inflammation and excessive discoloration. If there be much pain, the officinal lead and opium wash will give relief. A large extravasation of blood should be removed by incising the integument. I !|i i lliili'i; i lii CHAPTER m. n^MORIiHAOE FROM TEE UTERUS. Metrorrliagia. — Accidental Iloeinnrrhngc. — I'lacentia Pitevia. — Post-partnm Hemorrhage. The periodical discharge of blood from the uterus, which takes place every twenty-eight days, is a i)hysiological occurrence, and docs not require attention here. It rarely calls for active treatment, even when in excess {inenor- rhagid). METROREnAGiA, or blccding between the monthly periods, may keep up so constant a drain on the system r.-j to destroy by exhaustion, or predispose to fatal disease j. Congestion of the uterus from chronic inflammation, tumors, ulcers, and abrasions of the cervix, are its principal causes. The treatmeit of metrorrhagia consists principally in the application of coM to tiie hypogastrium, vulva, and nejk of the uteruS; and the internal administration of ergot, gallic acid, acetate of lead, etc. India-ru^!)er Lags, filled with ice- water, introduced into the vagina and pressed against tuo cervix uteri, may be u jd with good effect. The diseases causing the hsemorrha-^e should subsequently be removed, and the patient's strength increased by fresh air, exercise, good diet, and tonics. Ante-paetum IIjiaioKRirAGE is that variety which occurs i2 EMERGENCIES, AND HOW TO TREAT THEM. mm II >i in the pregnant female before delivery. It is due either to partial beparation of the after-birth from blows or falls {acci- dental Tia&morrhage)^ or to placenta praevia. In the latter case, the after-birth is attached around the os internum. The natural dilatation of the cervix and contraction of the uter- ine fibres at " full term " cause its detachment, and bleed- ing follows {una/voidable hoBmorrhage). Phacenta praevia is attended with great danger, both to mother and child. It requires to be diagnosed from accidental hsemorrhage. In accidental haemorrhage, the patient has received a blow or fall on the abdomen, the cervix is not relaxed, and the flow of blood occurs between the uterine contractions. In una- voidable haemorrhage, the bleeding appears near -^ time of labor, and is not accompanied by a history of injury. The cervix is soft and patulous, the placenta can be felt over the internal os, and the haemorrhage occurs with^ and not be- tween, the uterine contractions, as in the former variety. A patient suffering from accidental haemorrhage should be kept at rest in the recumbent posture, with the hips ele- vated. Cold may be applied to the vulva, and astringent medicines given. Some advise small doses of ergot. If these measures do not succeed, premature labor must be induced and the uterus emptied {see Puerperal Convulsions). Placenta Previa is treated in one of four ways : 1. The vagina can be tamponed^ and the patient kept quiet until labor sets in. The placenta is then removed, totally, and the child's head, pressing against the open vessels, prevents further loss of blood. 2. If the haemorrhage is profuse, the cervix may be dilated rapidly, the placenta detached as in the first instance, and the child extracted by means of for- ceps or version. 3. The after-birth may be partially detached HAEMORRHAGE FROil THE UTERUS. 48 at one side when the os is dilated, and the child delivered by version. 4. An opening may be made in the centre of the placenta, the hand introduce 1 through it, and version performed. Ergot should be freely administered while the uterus is being emptied. This drug is likewise useful after comple- tion of delivery, in producing perfect tonic contractions of the uterine muscular fibres, and preventing further bleed- ing. PosT-PAETCM II^-jioEKnAGE is ouc of the most dangerous sequela; of labor. Perhaps in no other hoeraorrhage is there such urgent necessity for presence of mind, or active inter- ference. There are few varieties which so readily yield to proper treatment; yet inferior remedial agents, or a few moments of indecision, may place the patient beyond hope. The stream of blood poured out in the space of half a minute has in some instances been sufficient to destroy life. Protracted labors which fatigue and lessen the vital forces of the paiturient woman, or labors which have been attended by operative procedures, are apt to be followed by profuse bleeding. Xeglect on the part of the physician or of his assistant to follow the uterus with the hand down into the pelvis during delivery, and to keep it contracted when there, is one of the most common causes. It is not too much to say that, if this precaution were observed with all patients, a case of immediate post-partum haemorrhage would be exceedinglv rare. "Women habitually subject to inertia uteri are especially liable, even in ordinary labors, to lose large quantities of blood. These cases require extra attention. Injuries to any part of the internal genitals, with laceration, and the 14 EMERGENCIES, AND HOW TO TREAT TUEM. ^'" mm m heemon'liacric diathesis, are also causes of immediate lieemor* rhage. When portions of the after-birth remain behind after delivery of the child, haemorrhage usually occurs. It does not, however, show itself to any great extent for some days subsequent to the labor. Ketained placenta may be sus- pected in all cases where a few days elapse after delivery be- fore the bleeding manifests itaolf. In post-partum haemorrhage the blood may be eflPused into the cavity of the uterus, or, as is generally the case, it may be poured out through the vagina. The first indication of haemorrhage which may attract the attention of the attendant, especially if the woman be covered or the bleeding internal, will be a sudden blanching or pallor of the patient's countenance, and sighing respira- tion. The pulse becomes rapid and weak, or may be com- pletely absent. In short, all the constitutional symptoms of profuse haemorrhage are present {see page 12). In another class of cases the bleeding is slower, the constitutional effects less suddenly manifested ; but in all they appear to a greater or less degree. Treatment. — The preventive treatment consists in press- ing the uterus firmly down into the pelvic cavity as it is being emptied of its contents, and to keep the hand over it until it is felt to be contracted like a hard ball in the pelvic cavity. Some recommend the administration of ergot before and after the delivery of the placenta, as a preventive meas- ure. I administered it quite frequently for that purpose in the Lying-in Department of Bellevue Hospital, and with good results. For suppressing the haemorrhage, several methods are n.EMORRlIAGE FROM TUE UTERUS. 45 advised. "NVlieii the bleeding is very profuse, the sures' method is to introduce one hand into the uterus, turning out all the clots, while at the same time the other hand grasps the organ on the outside, and firm pressure ' . made until the hand is forced out by the uterine contractions. A piece of ice may be carried into the cavity, and applied to the in- ternal surface of the uterus, if necessary. The physician must be governed by circumstances in its use. There are cases which cannot be controlled without it. ^ jme object to the introduction of the hand into the uterus, because they think it apt to injure the walls, produce endo-metritis and other disorders. This danger is probably somewhat exag- gerated. The pressure of the closed hand for a few moments on the ini'er surtace of the contracting uterus will certainly not produce greater harm than the pressure on the irregular prominences of the chihrs body during a labor of several hours' duration. The only danger there can be is from septic material finding its way inside on the hands of the physician, and this, to say the least, is very improbable. Another method is to grasp the uterus firmly and knead it with the fingers until contractions ensue. Lumps of ice may be rubbed over the abdomen at the same time, or ice- water poured on the abdominal walls. Prof. Thompson, of this city, claims to have obtained good results from the application of ether-spray over the hypogastrium. Injections of astringent medicines into the cavity of the uterus have been employed, but are considered extremely dangerous by most obstetricians. In conjunction with all the varieties of local treatment mentioned, erjxot should be administered in large doses at repeated intervals. Its use is always indicated. The subsequent treatment 1 r! 1 i 1 1 16 EMERGENCIES, AND HOW TO TREAT THEM. depends on the amount of blood lost. If there be much exhaustion, tlie usual stimulants, together with small doses of opium, may be given ; and, as a last resort to save from im- pending death, the operation of transfusion, referred to in a former chapter, may be employed. Injections of hot water have also been employed with great advantage. :!i CHAPTER IV. WOUXDS OF IMPORT AJ^T ORG AM. Wounds of the Throat, Lungs, Pericardium, Heart, Abdomen, Intcstinei, BUd« ddf, Perinaeum, Joints, Arteries, Veins. — Periueol Section. — ParuccnteBiB, Thoracis. — Gunshot Wounds, etc. Wounds of the throat vary in extent, from simple in- cision of the integument to complete severance of the larynx, trachea, and oesophagus. They are inflicted with razors or other sharp cutting instruments, and are usually the result of attempted self-murder. The upper part of the throat seems to be the point of selection in these cases : rarely is the cut made at the lower portion. The carotid artery and jugular vein are thus saved, and a better chance of re- covery given to the patient. In the majority of wounds of the throat an opening is made into the air-passages. The most common seat of these wounds is between the thyroid cartilage an*! hyoid bone, and over the larynx. In the former the tliyro-hyoid mem- brane is cut through ; the epiglottis may be cut off, or in- jured so as to serio isly affect the power of swallowing. The food may pass without hinderance into the larynx and out of the external opening, as the epiglottis is not in place to prevent it, or is in a se.ni-paralytic condition from the injury, and fails to appreciate, or prevent the passage of the food down the wrong canal. The appearance of food in the 48 EMEROEXCIES, AND HOW TO TREAT TUEM. ijiij: 1:1:1 i j^iljli;' 1 ■ ! :. •'' ■ . wound 19 therefore not a positive indication of injury to the CBsophagUB. Woundd inflicted on the side of tlio neck may ciit the pneumogastric or phrenic nerves. In such cases there is interference witli tlio respiratory movements, and subse- quent congestion of tlie lungs, which may ultimately destroy life, independent of any other complications. AVounds of the hack of thf. neck, unless implicating the spinal cord, are not fatal. Some autiiorities say tliat they are followed by paralysis of the lower limbs and loss of sexual power ; this is doubtful. Wounds inflicted between the lower jaw and hyoid bone are the least dangerous of anterior wounds, although they are sometimes attended with great htemorrhage and with difficulty in swallowing (dysphagia). The danger and causes of death in wounds of the throat are: 1. Hflemorrhage ; 2. Asphyxia. 3. Inflammation of the air-passai,'08 and lungs, as laryngitis, bronchitis, and pneumonia. 4. Nervous depression and starvation. The principal danger is from excessive bleeding. Bleed- ing may be profuse even in superficial wounds. The blood from the numerous plexuses of veins in front of the neck and around the thyroid gland may flow in sufficient quan- tity to destroy life. When the large vessels, such as the carotid arteries or jugular veins, are cut, death occurs in a few moments. Secondary hemorrhage not unfrequently takes place from sloughing of the walls of the vessels, between the tenth and the twentieth day. Asphyxia may arise from infiltration of serum into the raucous membrane of the larynx at its upper part (cedema WOUNDS OP IMPORTANT ORGANS. 49 glottidU\ or from blood flowing down into tlio air-paasagcs. Internal hncmorrhago may go on Blowly for somo time with- out attracting special attention, tho shock nj'iry and deficient uiiration of tho blood benumbing tho sensibility of tho mucous membrane. Laryngitis may occur from extension of inflammation from surrounding parts, or directly from a wound of the larvnx. Tho most dangerous inflammations are bronchitis and pneumonia. Those complications arise principally from the inhalation of cold air through tho opening in tho throat. In ordinary breathing, tho air is heated by passing through tho nose, and thus loses its irritating qualities. In all suicidal attempts upon life, there is extreme men- tal depression, which tends to prevent recovery. Treatment. — As tho great danger arises from loss of blood, the first efibrts are directed to suppress the flow. This is accomplished either by means oi pressure ^ or with the ligature. If the bleeding vessel cannot bo reached in the wound, suflSicient pressure may be made to stop the ha3m- orrhage, while the upper or lower portions of the wound are enlarged and the vessel searched for. Should it not be found, and the hcemorrhage be still threatening, the carotid arteries must be tied. If the wound does not implicate the air-passages, the edges may be drawn together with strips of adhesive plaster. In doing this, care should bo taken to leave an opening for the discharges from the wound. The cellular tissue of tho neck is very loose, and, unless this be done, pus and other inflammatory products will burrow at the base of the neck, between the muscles and vessels, and produce serious trouble. The same rule holds good when the wound extends into the air-passages. No attempt m i ii. tl 50 EMErOENCIES, AND nOW TO TREAT THEM. !1 \w VI >,' should bo miido to close tho aperture for several hours, or until all datij^or from hiurnorrhago has passed away. Even then tho central portion of the wound should remain un- clobed for the exit of the subsequent discharges. In closing tho wound and preventing gaping, the head should bo flexed on the neck, and retained there by means of bandages passed over the head and under tho arms. Cloths wet with cold water may then be applied to lessen inflammation. If there is venous oozing in tho canal, a 'nrge tube may bo in- troduced, and pressure made by plugging' around it {Erico- son). When the oesophagus is wounded, tho patient can be fed through tho opening by means of a flexible catheter, or the tube of an ordinary stomach-pump. I have found the latter to bo much bettor for the purpose than tho catheter, as a larger quantity of food can bo introduced in a given space of time, and tho wound therefore sooner relieved from the presence of an irritating substance. Patients should always be removed to a very warm room, with a temperature of from 80 to 85° Fahr. Stimulants, and nourishing diet, in tho shape of beef-tea or chicken- broth, should be freelv administered. Wounds of the Thorax, Lungs, etc. — Non-penetrating wounds of the thorax are treated like simple wounds in other parts of the body. They do not require consideration here. Penetrating wounds may involve the internal mammary and intercostal arteries, tho pleura, lungs, heart, and great vessels, either alone or collectively. When the iutemal mammary arteiy is cut, the blood flows slowly into the an- terior mediastinum, or into one or tho other pleural cavities. It is diagnosed by the location of the wound and the grad- WOUNDS OF IMPOniANT ORGAN'S. 51 nal doveloptnciit of pyncopo consequent upon tlio loss of blood. Tlio protection nflTordod to tho intercostal vesaelfl, l)y tlio long groove in which they run, liappily prevents them from being wounded, except in very raro instunccB. In wounds of these vessels, tho luvinorrhage may take i)lace in tho cavi- ties of the pleura, underneath tho muscles and fascia of tho chest, or escape internally. Tho immediato danger to lifo is not very great, but tho utmost difficulty in suppressing the hremorrhago is commonly experienced. Penetrating wounds of the chest, without injury to the lungs, are exceptional. Injury to tho lungs may be ex- cluded, if there is no expectoration of blood, or luemorrhage from the wound. If the hole is large, sulKcient air may pass into the cavity of the pleura to compress the lung and completely destroy its action. In such a case, death may ensue. The most dangerous wounds of the lung are produced by bullets. Foreign bodies in tho delicate structures of the lung cause great irritation, and more inflammation than simple laceration would. They are not, however, necessarily fatal. Many instances are on record of foreign bodies re- maining enbedded in the lung-substance for years, without interfering specially with respiration. In the summer of 1868, I made a post-mortem examinat'on on the body of Major D , an old Mexican veteran who had received a gunshot- wound twenty years before. In the upper portion of the left lung was embedded a large, old-fashioned musket-bullet, completely encysted. The lung was about one (piarter its original size, and was carnified around the projectile. The major had enjoyed comparatively good health, notwithstand- (t- 52 EMERGENCIES, AND HOW TO TREAT THEM. 1 I 1 pill 1 ii -IN' ing its presence. He, strangely enough, supposed that the bullet was in the lung of the opposite side, and his friends were of the same opinion. The signs of a wound of the lung are plain and well marked. There is great difficulty in breathing (dysprum), expectoration of blood {hcBmoptysia), and of red, frothy mucus from the air-passages, and emphysema. There may or may not be hsBmorrhage from the external open- ing. Cn auscultation, small moist rales may be heard near the seat ol injury. The patient's face is pallid and anxious, and the pulse small and rapid. In some cases the bleeding goes on inside the chest, until the lung is compressed by it, and signs of syncope show themselves. Internal haemor- rhage may be diagnosed by the increased paleness of the countenance, flickering pulse, vertigo, and dimness of vision, increased dulness over the affected side, absence of the res- piratory murmur. If the blood be poured out to any ex- tent in the parenchyma of the lung, there will be dulness on percussion nea.- the wound, and bronchial breathing. The passage of air into the cellular tissue {erriphysema) is a common accompaniment of wounds of the lung. It may o'icur when a part of the lung-tissue is ruptured by pressure on the chest-walls, or penetrated by the broken end of a rib, independent of any external wound. "When it proceeds from rupture of the vesicles alone, and extends to the surface, its usual course is tlirough the cellular tissue of the posterior mediastinum up to the neck, whence it travels to other parts of the body. A case of this kind came under ray care in Bellevue Hospital, in a patient whose chest had been severely injured by a derrick. The ribs were not, however, broken. In a few hours after ad- ?\ WOUNDS OF IMPORTANT ORGANS. 58 mission to the ward, emphysema manifested itself, and spread slowly over the neck and face, and finally involved the thorax and abdomen. The face, arms, and trunk, became distended to an extreme degree. He suffered greatly from pain and difficult respiration. There was some expectora- tion of a reddish-colored, tenacious mucus, circumscribed bronchial breathing over the left lung, near the apex, a hot skin and rapid pulse, with other indications of pneumonic inflammation. It was regarded as a hopeless case. In ten days from the time of admission, the emphysema diminished rapidly, and, at the end of three weeks, no trace of it was present. The patient was discharged cured. In wounds which open externally, the air is drawn in with each inspiration, and forced out during expiration, some of it passing into the cellular tissue. It may remain localized near the wound, or it may extend gradually to other parts. Emphysema is always recognized by the elasticity of the swelling, and by the peculiar crack- ling, crepitant sensation, communicated to the fingers on pressure. The air, instead of passing out into the cellular tissue, may accumulate in the pleural cavity, giving rise to pneumo- thorax. In certain cases of haemorrhage, this has a salutary rather than in injurious effect, as the compression of the lungs will stop the flow of blood. PNEUMi..OELE, or hcmia of the lung, may take place be- fore the external wound heals, or after it is entirely closed. "When protruded through the wound, it may be pushed partly back, and the aperture closed by a compress. Some cases of pneumocele have been treated by cutting, and by strangulating the extruded portion. If the hernia be a 1 ^ . M I! 54 EMERGENCIES, ANr HOW TO TREAT THEM. ii 111 ilii! ! I remote result of tlie wound, and covered by the integument, all that is necessary is to protect it by a hollow pad. Treatment. — When the intercostal arteries are wound- ed, they may be either compressed or ligated. Ligation is almost impossible. The best method is to fasten a piece of sponge to a ligature and force it through the wound into the cavity of the chest, and then draw it partially outward so as to make it press directly upon the arteries {Poland). Digital compression, kept up by relays of assistants, has in some cases been effectual. Some recommend passing a silk or wire ligutnre around the rib, drawing tightly, and thus closing the wounded vessel. See Appendix. Others close the external wound, and allow the blood to escape into the cavity of the chest. A large quantity of blood may be lost in this way, but not enough to destroy life. "Wounds of the internal mammary arteries are more diffi- cult to reach than the preceding. Pressure may be tried, in the manner described above. If it do not succeed, ligation may be resorted to. This operation is usuolly performed at Bome point above the fourth interspace ; below this point, the operation cannot succeed. The method of Hgating the art ^ry is described by Dr. Poland * as follows : " An incision is made two inches in length along the side oi the sternum, and in an oblique direction, from above downward, and from^ without inward, forming with the axis of the body an angle of forty-five degrees : the centre of the incision to be three or four lines from the border of the sternum. " Having divided the skin, cellular tissue, and origin of the pectoralis major muscle, the intercostal space is brought • Holmes's Surgery, article Wounds. !\ WOUNDS OF IMPORTANT ORGANS. 55 into view ; the intercostal muscle is now carefully divided upon a director, and the edge drawn apart by retractors, and the arteries exposed." In WouxDs OF THE LuNG an attempt must be made to con- trol the lia3morrhage by internal medication. Small dosea of acetate of lead, sulphuric acid, alum, or other astringents, may be given. Ice applied externally is always of service. Should the blood accumulate in the interior, it must be removed. If it does not flow out by changing the position of tlie patient, a cupping-glass may be placed over the aperture, and the fluid started in this way. Of course, this procedure should not be instituted while any danger of further hajmorrhage remains. Some prefer enlarging the external wound, while others allow it to heal, and after- ward perform pai'acentesia thoracis. This operation is usually made posteriorly near the angle of the scapula, between the seventh and eighth ribs. The best instrument to employ is a small trochar and canula. "When the point of opening is selected, the integument is incised with a scalpel, and the trocliar introduced. As the stylet is withdrawn, the patient should be turned over on the affected side, and firm pressure made on the thoracic walls. In this way there is little danger of air entering the cavity. Dr. 13owditeh, of Boston, uses a suction apparatus to prevent air from passing in, and to assist in evacuating the liquid. Dieulafoy's aspirator answers all purposes. When the haemorrhage has ceased, the external wound is thoroughly closed, and the lips hold together by adhesive plaster. Simple water-dressings, dipped in a solution of car- bolic acid, are then applied over the part until it is healed. If pneumo-thorax exist of sufiicicnt extent to comprees m 'H; H': I '^% 1. ' up 1 56 EMERGENCIES, AND HOW TO TREAT THEM. the lung, the enclosed air may be extracted by suction, through the external wound, or by making a new puncture in the chest-walls. The subsequent inflammation of the lung-tissue is treated by counter-irritation over the chest, diaphoretics, anodynes, etc. Wounds of the Peeioakdium. — A punctured wound in the prsecordial region, which does not implicate the heart or great vessels, is of rare occurrence. Such a wound may prove fatal from the entrance of blood or air into the peri cardial sac, pressing upon the heart so as to paralyze its movements. The inflammation of the pericardium which follows a wound of this kind may also destroy life. This wound is recognized by the ordinary signs of peri- carditis. Upon auscultation there is heard a dry, rubbing friction-sound accompanying the cardiac impulses. This is succeeded by an augmentation of the area of precordial dulness from effusion, and by diminished intensity of the heart-sounds, and feeble pulsations. The constitutional effects are shown by a rapid, irritable pulse, hot skin, and anxious face. When the hflemorrhage has been controlled, the wound is closed in the ordinary way, and opium is administered in full doses. Blisters, dry or wet cups over the prsecordia, are effective agents in subduing the inflammation. Wounds of the Heart may be instantaneously fatal, or life may be prolonged for several days. The case of a noted pugilist of this city, named Poole, will be remembered. He received a bullet-wound in the heart, and walked home afterward. Death did not occur for hours after the injury was inflicted. lilil 1^' WOUNDS OF IMPORTANT OROANa 67 Small punctured wounds of tlie heart have been known to terminate in recovery. A wound of the auricles is more rapidly fatal than a wound of the vtMitricles. The walls of the former are thin- ner, and tho fibres more uniformly arranged, and their con- tnctions less likely to prevent hsenf/orrhage. The muscular walls of the ventricles are thick, and the fibres interlaced, and, if the wound be small, profuse bleeding cannot occur. The signs of wounds of the heart are those of shock and loss of blood. The patient becomes rapidly insensible, and the pulse ceases. Tliere is extreme pallor. The extremities are cold and sometimes clammy. When the immediate danger has passed, signs of pericarditis appear. If life be prolonged sufficiently to give chance for treatment, the pa- tient is to be kept perfectly quiet, the wound closed, and covered with cold-water dressings. Opium is given inter- nally, and, when inflammation appears, remedies are em- ployed as in the preceding case. AVouNDs OF THE Abdomen ob ITS CoNTENTS. — Penetrat- ing wounds of the abdomen are generally either punctured or incised. Lacerated wounds are not frequent. If the bleeding is in any way profuse, the vessels should be tied. If the wound is small, so as to make it impossible to reach the vessel, the opening must be enlarged to make it acces- sible. When there is simply an oozing from the wound, in- terference is not necessary. It is better for the blood to escape outside than into the peritoneal cavity. The great danger in these cases, as in all wounds of the abdomen or its contents, is peritonitis. This dreaded complication is made known by the occurrence of a sharp pain near the wound, which soon extends over the whole abdomen. There BUi "11 I ^ li'M'ti!'; » f 4!!l lit!! ftS EMERGENCIES, AND HOW TO TREAT THEM. are also tympanitis, constipation, and vomiting. The pulse is hard, tense, and wiry. The skin is dry and the temperature increased. When th'j intestines are wounded, there is still greater liability to peritonitis. If t.'ie opening is large, there is always an escape of fecal matter into the peritoneal cav- ity. This irritating material is certain to excite peritonitis, even when in minute quantities. A small wound of the intestines may be closed by eversion of the mucous mem brane. Treatment. — If the intestines protrude externally, and cannot easily be returned through the wound, the opening should be enlarged. The intestine should be cleansed thor- oughly in tepid water before it is returned. If the intestinal wound is more than three or four lines in length, its edges should be drawn together by means of sutures. An opening, of such a size as to be completely closed by the everted lining membrane, may be let alone. Ericceon recommends passing a ligature around this variety, in order to make the escape of fecal matter an impossibility. In dealing with wounds of the abdominal wall, there is some discrepancy of opinion. Some believe that the sutures should merely include the skin, and not the deeper structure below. It is reasonable to suppose that, in closing the wound in this way, a separation to a greater or less extent would take place in that portion below the integument. Inflam- matory products must fill up the gap, and there is nothing to prevent their getting into the peritoneal cavity and giving rise to peritonitis. Unless there are special indications to prevent it, it is better to pass the needle down to the peri- tonaeum, and bring all parts of the wound in complete ap« position. If there is much suppuration following the wound, WOUNDS OF IMPORTANT ORGANS. 59 it should be opened, kept clean with carbolic-acid wash, and free escape of pus allowed. Opium is given internally to control the inflammation and allay pain. The patient should be brought under its influence until his respirations are down to 14, and his bkin perspiring. Light poppy fomentations are also of much benefit. Contusion of the abdominal walls may lacerate the in- tegument or muscles, and the viscera within. The internal organs alone may be injured, without any perceptible lesion of the walls. Severe contusions are scarcely ever recovered from. As a good example of the manner in which these wounds are received, and their mode of termination, the fol- lowing case may be of interest : James D., aged twenty-seven ; occupation, laborer ; was admitted to Ward 11, Bellevue Hospital, sufi'ering from a severe contusion of the abdomen. He had been riding on the rear platform of a Third-Avenue car, which was driven at considerable speed. The car suddenly came to a halt at the comer of a street. A hack running behind, on the track, failed to stop at the same time, and, its im- pulse being continued, the pole of the vehicle struck D. in the abdomen, near the umbilicus, pressing him with great violence against the back of the car. On admission, the patient was suffering somewhat from sliock, and the abdo- men was exceedingly tender at the point of injury. The day following, inflammation set in. The abdomen enlarged, and was so tender that the weight of the bed- clothes could scarcely be borne. Peritonitis, in all its phases, was well marked. Death took place on the fourth day. A. post-mortem examination showed that a portion of ' ' 1 J i!| lift Iff 60 EMERGENCIES, AND HOW TO TREAT THEM. the small intestine was much bruised, but its walls had not been torn through. Pus anl lymph in considerable quanti- ties covered the intestines, gluing them together in several places. "When the liver and kidneys are ruptured, there is usually more collapse than in injury of the intestines. The patient rarely lives long enough to develop peri- tonitis. A. puncture oV rupture of the bladder is succeeded by peritoneal inflammation. The urine may p.asa into the ab- dominal cavity or irto tJ ; abdominal walls. In the latter case, the wound is below the part where the perftonoenm is reflected over the organ. If the laceration is ut the base, the point of a catheter may pass through and be felt in the rectum. The escape of urine into the peritoneal cavity is attended with a sharp pain, which rapidly increases till the peritonaeum, through its extent, is involved in inflammation. In the cellular tissue of tlie pelvis or groin, it excites diffuse suppurative inflair.mation. Treatiiient. — When the urine accumulates in the cellular tissue, free incisions are made to give it exit. It is prevent- ed from accumulating in the bladder by allowing it tg run out through a catheter introduced for that purpose. Opium, in full doses, is beneficial. "Wounds op the Pe-'Inzsum. — Lacerated wounds o*^ this part occur frequently in women during labor. The child's head, as it is forced down by the uterine contractions, is pressed against the distended perinaeum, and, if it is at all resistant, rupture takes place. As soon as labrr has termi- nated, che edges of the wound Fhould be brought together by sutures. WOUNDS OF IMPORTANT ORGANS. m. In the male, these wounds arc liable to injure the ure- thral canal, and operative measures are necessary to relieve the resulting retention of urine and eftect a cure. Perineal section is usual!} performed. When the patient has hecn fully aiuestlietized, a staff or steel sound is passed down to the laceration and through it, if possible, and the tissue of the perinajum divided in the median line down to that point. The external incision ex- tends from the termination of the scrotum to within half an inch of the anus. The knife is then carried on in the di- rection of the urethra until the injured portion has been passed. A catheter is then introduced into the bladder and retained for f ji'<^y-eight hours, to keep the canal open and allow free passage of the urine. A steel sound is afterward occasionally introduced to prevent narrowing of the urethra. As this operation is performed in its most difficult point without a guide, the anatomical relations must be borne in mind. The urethra passes through the triangular ligament from three-quarters to an inch below the pelvis. The open- ing in this ligament, when appreciated by the touch, will be sufficient to keep the operator from cutting in wrong di- rections. "When a deep, perineal wound bleeds profusely, and the vessels cannot be tied, a small Barnes dilator may be pushed into the opening and filled "Tith ice-water. Dr. Synott, one of the Belle rue house-surgeons, first employed this metliod. It has proved successful. Another plan is to place a piece of oil-silk, or other suitable material, around a lead-pen jil, pass it into the wound, and pack tightly between the oil-silk and pencil a quantity of lint. Ice-bags may afterward be applied to the wound to prevent inflammation. if the blood from the urethra flows out at the meatus uri- 4 ■ =1 ■- 1", m II* [ ■m I.' Hi 'Mi 02 KMKIIGEXCIKB, AND IIOW TO TREAT TIIEM. ii '■' iiarius, r .ioiiml is passed down the canal and the pcnia uoiii[)ro!JSud agaiiirit it with a bandage. Fractures of the pelvis are sometimes associated with hicerated wounds of the perinajum. Tlie following case is a good illubtration . Patrick C, aged forty ; occupation, laborer; was injured while exposing himself in an unnecessary manner over the end of a dock. A ferry-boat, coming into the slip at the time, crushed him against the timbers of the wharf. Ho was brought to Ward 16, Bellevue no3[»ital, a few hours afterward. An external examination failed to detect a frac- ture. A catheter was introduced, but met with an obstruc- tion about tlio termination of the membranous portion of the urethra. As tlioro was considerable urine in the blad- der, it was decided to perform perineal section without de- lay. Ethor was administered to the patient. An incision was then made through the tissues in tlie median line, com- mencing near the base of the scrotum and carried within half an inch of the anus. When I reached the mondiranouB por- tion of the urethra, I found fnigmojits of bone pressing upon, and completely obliterating, the canal. The ramus of the pelvis, and a portion of the body of that bono, were broken in several fragments. The debris of soft tissue and bone blocked up the rest of the urethra to the bladder. An open- ing was, however, made into the organ, and the obstruction removed. The amount of fracture and destruction of tissue rendered his case hopeless. Inflammation set in afterward, and the jmtient died on the third day. Penetratixq Wounds op Joints, and non-penetrating contused wounds, are always serious. They may result in synovitis, complete or partial anchylosis, or loss of the whole WOUNDS OF IMPORTANT ORGANS. 03 limb. TIio joint is known to l)0 [.crforatcd by the appear- ance of a thick, traiisi)ai*eiit lliiid (si/n&vid) from the joint. Thia may bo absent when the wound passes into the part from above downward. Treatment. — If the wound is sms'!!, the edgot* sliould bo drawn together as closely as possible and held in close ap- position by adhesive plaster. Ice-bags, applied afterward, may prevent, or at all events modify, the amount of inflam- mation. Large wounds should not be entirely closed. In- flammation of the joint is an invariable accompaniment, and a space must be left through which the discharges may puss. GuNsiioT-WouNDS. — Uudcr this head are included all wounds which result from the explosion of gunpowder. They may be made with bullets, cannon-balls, or splinters of wood and stone. The worst wounds are those inflicted by cannon-projectiles and splinters. All gunshot-wounds, whether external or internal, are attended with danger. A greater amount of shock, contu- fiion, and laceration, accompanies gunshot-wounds than is found in other varieties. Inflammaticn and sui^puration i'" -'ow in tl'O track of the bullet. Pus is liable to be re- tained and burrow in the neighboring tissues. Deep suppu- ration is one of the principal dangers. The wound made by the bullet is smaller where it enters than where it leaves the body, and its edges are inverted, while at the point of exit the edges of the wound are everted. A bullet is easily driven out of its course by bony projections. The missile rnay strike a rib on the left side, and, passing under the tissues, emerge on the right side of the body. Ilenner relates a case where the bullet entered the upper portion .'l.i.Ui "'-IVI^ ;»i I 64 EMERGENCIES, AND HOW TO TREAT THEM. of the ami and pasaod down to tlio tliigh on tho opposite eido. Treatment. — Tho first efforts of tho surgeon are directed to coi\trol the hoiinorrliago, and to arouse the patient from tho state of collapse by stimulants. When this is done, foreign bodies, such as pieces of clothing, bullets, splinters of wood or bone, are to be extracted. The presence of a bullet may bo made out in doop wounds by the use of N6- laton's probe. This instrument consists of a silver shaft and a bulbous extremity formed of porcelain. "When the bullet is touched a leaden-colored mark is produced on the porcelain. The wound is afterward syringed with a weak solution of carbolic acid, and covered with cloths dipped in an ice water solution of the acid. Ice-bags are then found serviceable in limiting the amount of inflammation. When suppuration commences, warm fomentations may be used to hasten its progress, and the debris prevented from remaining by fre- quent syringing. In the suppurative stage, there is great danger from secondary hcemorrhage. Therefore, ^y\xen the wound is in the vicinity of large vessels, it should bo care- fully watched, and a compress or tourniquet should be placed loosely around the limb, ready to be used at a moment's warning. Gunshot-wounds of viscera are treated in the same man- ner that ordinary wounds are after extraction of foreign bodies. CHAPTER V. WOUNDS OF ARTERIES AND VEINS. Ligation of largo Artoricn.— Air in Ycini, etc.— Cauics of Suddon D«ath.-> Treatment. AViiEN largo vessels aro wounded, there is a great and immediate danger to life. The blood may bo poured out externally, or become diffused in the tissues near the artery, or dissect up the sheath of the vessel. Efforts should in every case be made to tie both ends of the bleeding artery in the wound. {See article on IIcDmorrhage.) If this cannot be done, the artery is then tied between the wound and the heart. Ligature of largo vessels is generally followed by complete obliteration of their canals. The ligature divides the middle and internal coats, and brings the external walls together. The blood coagulates at each end of the ligature. The coloring matter of the clot is absorbed. Lymph is poured out between each coat of the artery, between the clot and the lining membrane, and ex- ternal to the vessels, blending all these parts together, and becoming ultimately a fibrous cord. The ligature, mean- while, makes ita way out by a process of ulceration, and the space formerly occupied by it is filled up by granulation. From ten to fourteen days after the operation the ligature comes away, and then there is the greatest danger of sec- ondary hoemorrhage. 0| rj i ll [i*j;l!i '41 1!L..?' 66 EMERGENCIES, AND HOW TO TREAT THEM. As wounds may involve any of tlie arteries in the body, a sliort description of the operation in different locations, upon important arteries, will be necessary in this connec- tion. In wounds of the common carotid or subclavian, it may be necessary to place a ligature on the arteriainnorainata, an operation rarely attended with success. "When the patient is fully anaesthetized and in position, an incision about two inches in length is made along the inner edge of the sterno-mastoid muscle to the articula- tion of the clavicle with the sternum, meeting it with a second incision commencing about half an inch from the posterior border of the same muscle, and carrying it along the clavicle. "VYhen the integument is turned back, the pla- tysma myoides and sterno-mastoid muscles are divided on a director, the platysma being first cut. The handle of the scalpel is now used to push aside some thick cellular tissue, and the sterno-thyroid and thyro-hyoid muscles are brought into view and carefully divided. A plexus of veins, com- posed principally of branches of the inferior thyroid, next appears, and must be moved upward and kept out of the way. A thick layer of deep cervical fascia is next incised ; the fingers can now be carried down, using the common carotid as a guide, until the arteria innominata is reached. This vessel is situated behind the right sterno-clavicular ar- ticulation of the right side. The right vena innominata, in- ternal jugular vein, and pneumogastric nerve, are displaced to the right, and the left vena innominata pressed downward and to the left. An aneurism-ncedlo, armed with a liga- ture, is tlien passed around the vessel from below upward. The coinmon carotid artery is ligated either above oi WOUNDS OF ARTERIES AND VEINS. 67 5 ^ 4 below the omo-liyoid muscle. When the vessel is ligated above the omo-hyoid, an incision is mode from the angle of the jaw to the cricoid cartilage. This incision is carried three inches farther than this point when the artery is tied below that muscle. The inner edge of the sterno-mastoid is the guide for both incisions. The integument, superfi- cial fascia, platysma, and deep fascia, are cut through (the three latter on a director) ; the descendens-noni nerve is moved aside, and the sheath of the vessels lifted with a for- ceps and opened. The internal jugular vein swells up in the wound as the sheath is cut ; it should be compressed above and below the opening, and drawn outward. The pneumogastric nerve is situated here between the artery and vein, and on a plane posterior to both, and great care is necessary to avoid it in passing the ligature. The needle is carried from without inw^ard around the artery. In ligating the carotid on the left side in its lower portion, the jugular vein will be found to have altered its relation to the artery. Instead of lying external to it, it crosses in front of it. Another point to be remembered in connection with the op- eration below the omo-hyoid is, that the sterno-mastoid ar- tery and the middle thyroid vein run along in the course of the incision, and must be avoided. The sterno-thyroid and sterno-hyoid are drawn toward the median line of the neck. Ligation of the common carotid arteries is sometimes fol- lowed by hemiplegia. The suhdavlan, artery is usually ligated in the third portion. In this operation the shoulder is depressed as much as possible, the integument drawn down on the clavi- cle, and an incision made through it, extending from the an- terior margin of the trapezius to the posterior border of the m n ' 51 31 .*»'1 68 EMERGENCIES, AND HOW TO TREAT THEM. Btemo-mastoid. The fascia and platysma having been di- vided, the external jugular vein is seen near the edge of the Btemo-mastoid muscle, and the supra-scapular and transver- salis colli nerves and vessels running across the space. These are pushed aside, the deep fascia scratched through, and the finger of the operator carried along the edge of the scalenus-anticus muscle to the tubercle of the first rib, at which point the subclavian artery will be found. The aneu- rism-needle is carried around the vessel from before back- ward, and the ligature tied. The third portion of the axillary artery is the most con- venient part for ligation. An incision is made about two inches in length, over the head of the humerus, near the centre of the axillary space. The integument and fascia are cut through, the axillary vein drawn inward, the median nerve outward, and the ligature passed from within out- ward. The brachial a/rtery, in the upper part of its course, is exposed by cutting through the integument and fascia at the inner margin of the coraco-brachialis muscle. The ulnar and internal cutaneous nerves, which lie at the inner side of the artery, and the median nerve, which is situated exter- nally, are separated from the vessel, and the ligature applied. The brachial may also be tied at the bend of the elbow. The incision is made at the inner border of the biceps mus- cle. At this joint the artery lies internal to the tendon, with the medirin nerve still farther insMe, close to the ves- sel. The median basilic vein passes over the artery, separated from it by the bicipital fascia. The radial artery should not be tied at its upper por- tion, because of its depth from the surface. In the middle ?p 1 :'' WOUNDS OF ARTERIES AND VEINS. 69 third it is exposed by cutting along the inner margin of the supinator longus. The radial nerve, a continuation of the muscle spiral, is found in close relation with it externally .- The ligature is passed from the radial to the ulnar side. In the lower portion of the forearm, the artery is found between the flexor carpi radialis and supinator longus. It is superficial at this point, and easily tied by cutting between those two muscles. The ulnar artery, in its lower portion, is located between the flexor carpi ulnaris and the flexor sublimis digitorum. The ulnar nerve is found at the inner side of the former muscle. The incision is carried through the integument and fascia between these muscles, and the artery tied. vVouNDS OF THE Palmar Aeoh are difficult to manage, owing to the numerous anastomoses of the arteries. The haemorrhage may persist after ligation of the ulnar, radial, and brachial arteries. Some surgeons keep a compress on the wound for two or three days, and, if this does not succeed, ligate the vessels in the forearm or arm. "When compression fails, the bleeding vessels should be tied in the wound, if possible. Ligation of the femoral artery is commonly performed in the lower portion of " Scarpa's space." The integu- ment and fascia are divided at the inner mai'gin of the Sartorius muscle. After the sheath is opened, the femoral vein will bo found at the inner side of the artery. The ligature is carried around from within outward. After ligation of the femoral artery, the limb should be encased in a thick roll of cotton, to keep up its nor- mal temperature, until the collateral circulation is estab- UBued. iu\ ' 1 ti .. ' 'U ro EMERGENCIES, AND HOW TO TREAT THEM. Ligation of the pojiliteal artery. — This vessel is rarely tied except for wounds which involve its walls. In the upper third of the artery the operation is performed by cutting the integument and fascia, at the edge of the semi- membranous. The muscle is drawn inward and the artery exposed. The popliteal vein is external, ai.^ superficial to tlie artery, and the internal popliteal nerve external and superficial to the vein. In the lower third, the incision is made in the medir,n line, immediately behind the joint. The deep fascia is here very thick, and there is considerable cellular tissue around the vessels, which requires some time and trouble to clear away, so as to bring them into view. When this has been done the limb is flexed, and tlie needle passed around the artery from without inward. The anterior tibial artery is usually tied in its lower portion above the ankle-joint. The artery is here found between the tibialis anticus and extensor proprius poiiicis, and is covered by the integument and fascia. Thcoe .' ^.ttei* are incised — the tendons separated, and the artery exposed. The nerve is in this situation superficial to the r. icry. The vense comites are separated from pi,ch side of the vessel, and the ligature applied in the usual manner. Posterior tibial. — It is extremely difficult to reach this artery in its middle third, because of its depth from the surface. The operation is performed by extending the foot, making an incision at the inner border of the tibia about three inches in length, ''/hen the integument and fascia have been cut, the 'dije of the gastrocnemius muscle is turned aside, and the soleus detached from the tibia by cuttins: its fibres on a director. The fascia underneath this WOUNDS OF ARTERIES AND VEINS. n muscle is next divided, and the artery exposed from three- quarters of an inch to an inch from the inner border of the tibia. The tibial nerve in this region is situated on the outside of the artery, and should be separated from the vessel before tying. The vessel is sometimes tied as it passes around the ankle, by making a curved incision midway between the internal malleolus and the heel. The integument and superficial fascia having been divided, the needle is passed from with- out inward, as in the previous case. WouNDE OF Veins, Entrance or Air. — Fatal haemor- rhage takes place in a short time when large veins, as the jugular or vena mnominata, are wounded, unless immediate assistance is rendered, and the wound closed by ligation or pressure. In wounds of small veins the danger from haemor- rhage is slight. Wounds of veins may be followed by phlebitis or by the entrance of air. The latter complication occurs particularly in the veins of tlie upper extremity and neck, during opera- tions for the removal of tumors. The air enters the open- ing in the vein with a loud hiss, and the patient, in many cases, expires instantly. If only a small quantity of air enter, there is a tendency to syncope, difficult breathing, and con- vulsive n.ovements of the body, which may last for several hours before a fatal termination is produced. In the majority of cases su :lden death ensues. A number of explanations have been offered to account for the suddenness of death in this accident. Bell thought it due to the action of air upon the medulla oblongata. Moore ascribed it to irregular action of the valves of the m 'I i'A M % ■Cvl 'if'i.i H'i -■ti ■■'H If li 78 EMERGENCIES, AND HOW TO TREAT THEM. Bili'il'i! ' heart from the presence of air ; * others, again, ascribed it to the impossibility of a frothy liquid passing through the lungs. In the absence of any accepted theory, I would suggest the following : la the great majority of cases the accident occurs in removing tumors from the neck or axillary region. These tumors by their pressure empty the veins upon which they lie. As the knife of the surgeon passes into the vein, and the weight of the tumor is removed, air rushes in to fill up the vacuum, and the heart ceases. When it is consid- ered that the pressure of the atmosphere is equal to fifteen pounds to the square inch, and the force-pump action of the heart only thirteen pounds and a half to the square inch, it will be seen that the column of air by its own direct press- ure is sufficient to overcome and paralyze the muscular force of the heart. The stoppage is instantaneous. Subse- quent pressure on the wound fails to do good, because of the presence of air in the heart, which cannot be disposed of with sufficient rapidity to enable the organ to recover itself. The distention of the right side of the heart, which is usually found after death, is accounted for on these grounds. Whan only a small portion of air enters, and pressure is made on the wounded vein, there is sometimes recovery. Whenever operations are performed about the neck or axilla, every vein in the vicinity of the surgeon's knife should be closed by assistants. Both before and after the removal of the tumor, this precautionary measure is called for. Treatment. — Immediate eflfbrts to restore the respiratory movements, and with them the action of the heart, should * Holmes's Surgerf, article Wounds of Veins. WOUNDS OF ARTERIES AND VEINS. 73 be made. Marshall Hall's or Sylvester's methods of arti- ficial respiration can be tried. Stimulant enemata and friction of the surface are always necessary. Galvanism may also be tried. In mild cases, brandy and ammonia may be given by the stomach. Hot plates over the epi- gastric and precordial regions are also serviceable. w m IS*! !l ■ '^'- i^f m iil Ml ' I V li ! i I 1 1 iiii CHAPTER VI. POISONED WOUNDS. Diesectiiig WounUs. — IIydroi)bobiu.— Snake-Bites.— Insect-Bites. Dissecting Wounds. — During the process of putrefaction a poison is generated wliich is capable of exciting inflamma- tion in healthy tissues, and of reproducing itself in the cir- culation, giving rise to serious constitutional disturbances. The poison is introduced by cutting or puncturing the flesh with the knife used during the progress of jyost-mortem ex- aminations, or in the anatomical investigations of the dis- secting-room. "Wounds of the most serious character may be made by a piece of broken rib or other rough bone. When putrefaction is much advanced, the system is less likely to be infected. It is an established fact that "wounds inflicted in the dissecting-room, when decomposition is near- ly at its maximum, are comparatively hannless, while those inflicted in a ^ostrmortem examination often destroy life. Whether the material injected in the arteries of subjects about to be dissected modifies the poison or not, is a subject for future investigation. The disease with which the patient died has much to do with the severity of the disease in the wounded person. Puerperal fever, erysipelas, pyceraia, typhus, etc., are pecu- POISONED WOUNDS. m liarly daiigcroud. They seldom fail to proiliiec either locul or constitutional pois< dng. On the other luind, parturient women are sometimes infected by the poison of the dissect- ing-room carried on the hands of a physician. Erysipelas, piieiperal fever, etc., are not unfrequently developed in this manner. Debilitated states of the system arc favorable to the in- fection. The influence of the poison is more strongly mani- fested in every case where the constitution is b"'.^w nar. In merely local poisoning, the wound sli* "'s 1 3 ten- dency to heal, closing for a day or two and tl.\ r^ bi euking out afresh. Around the wound the integum ^': is thick- ened, and of a dus\y hue. There is an ex ;dation from the cut surface, of a sero-purulent character, i .-s condition of the wound may last for weeks, and even months, healing partially for a time, then breaking out and assuming its original unhealthy appearance. In another variety the wound, after a lapse of twenty-four or thirty-six hours, becomes hot and painful. A small quan- tity of sanious fetid pus exudes from the surface. The sur- rounding integument is red and swollen. In a short time, small red lines may be noticed running up the arm, indicat- ing the extension of inflammatory action to the lymphatic vessels {angeioleucitis). The arm is swollen and painful. The axillary glands enlarge and often suppurate. Abscesses may form and burrow in the cellular tissues of the arm and chest. The skin is hot and dry, the pulse rapid, and urine scanty and high-colored. "When the abscesses open and dis- charge, great prostration ensues, which may destroy the life of the patient or leave him a helpless invalid for months. The third class of cases rarely recover. The patient, If r y < I m I III ? 76 EMERGENCIES, AND DOW TO TREAT TUEM. 1 1 J ™ II within a period ratiging from twenty-four to forty-eight hours after the wound is received, is seized witli violent chills. These are succeeded by unniistakahlo evidences of blood- poisoning. The pulse becomes rapid and very small, the countenance anxious, and tongue brown and dry. The in- tegument is of a tiiwny color, and may be jaundiced. There is profuse perspiration. Meanwhile, the wound becomes very painful ; the tissues around it are thickened and infil- trated with pus. Abscesses are not confined to the injured tissue, but may shoNv themselves in any part. The lym- phatics are involved as in the preceding case. Delirium sots in, and ie soon followed by death. In severe cases, death may occur within forty-eight hours after the infliction of the injury. Treatment. — In wounds of this character, proper pre- cautions should be immediately resorted to in order to pre- vent the retention of the poison and its subsequent entrance into the circulation. The wound should be washed by hold- ing it under a stream of water for a few seconds. The lips are then applied and the virus removed by suction. Tiiere is no necessity for the application of caustics. The treatment of cases where there is only local poison- ing resolves itself into stimulation of the wound by means of carbolic-acid or nitrate-of-silver solutions, and maintain- ing the health of the patient at a proper standard, by fresh air, good food, and tonic medicines. In those cases where acute inflammation appears in the wound and extends to neighboring tissues, the wound should be enlarged and cleansed of accumulations of pus with a strong solution of carbolic acid. A poultice of linseed-meal and charcoal may be then applied to the wound, and, if POISONED WOUNDS. 77 necessary, to tlio wliolo limb. Puintlnf; the inflaiiiod lym- phatic vesselo with iodine haa been reconmiended. Opium is freely given to relieve pain and to produce elecp. Easily-digested nutriment, such as beet-tea and chieken-broth, is to bo administered ad libitum. Stimu- lants are sometimes necessary. The treatment for the third variety is similar, with the addition of stimulants used freely, and largo doses of quinine. IlYDKoriiOBiA. — Phobodipson, rubies, canine madness, lyssa, and a variety of other terms, have been used to desig- nate this malady. It has been known from tlie earliest his- torical periods. Tlie disease attacks man and many of the lower animals. Dogs, cats, and wolves, are most sulgjct to its ravages. Cows, goats, pigs, and horses, are occasionally afflicted. It occurs at all seasons of the year, without refer- ence to climate or temperature, appearing in the winter season as well as in " dog-days." The nature of the poison is unknown. It is transmitted from one animal to another by means of the salivary secretions introduced through wounds inflicted by the teeth. Other secretions in the body are said to be harmless and unable to transmit the disease. . The period between the inoculation and the develop- ment of the disease is subject to considerable variation. Generally it appears between one and two months. Cases have been recorded (hardly with sufficient authority, how- ever, to establish them as facts) where tiie disease remained latent for twelve or fifteen months. Billroth mentions an old superstition which attaches great importance to the number nine, and gives the disease a tendency to develop on the ninth day, ninth week, or ninth month, succeeding the injury. \ ft'' i hi ■ f ! { w \ h I ; i ■- -it ' I', It 78 EMRnOKN'CIEfl, AND HOW TO TREAT TIIEM. Ilabies in tlio ihv^ U divided by Virchow into tliroo stages : 1. The nieliinchulio; 2. Furiotis; nnd 3. I'uralytic. The luiiinul aftVicted losoa itfi appcjtito — slirinks from water and ordinary food — endeavors to hide in his kennel, and can witli great dilliculty bo coaxed out. The licad droops, and the eyes are bloodshot and heavy. There is great thirst, and water is not refused. In the second stage the animal yelps or howls, and runa wildly about, biting at every thing. The tongue hangs from the mouth, and the eyes are congested and wild. In the third stage emaciation is apparent and rapidly progresses, great exhaustion supervenes. Little effort is made to move, and the saliva dribbles from the mouth. In walking, both hind-legs are dragged on the ground as if paralyzed. Death ensues in from four to eight days from the commencement of the disease. IlYDuopnoniA in man has many of the characteristics just described. A person bitten by a mad dog is usually on the watch for some manifestation of the disease. The wound may heal readilv, but the dread remains. If the cicatrix begins to inflame and is painful, and other signs appear which show that his fears are about to be realized, the depression of spirits and anguish are intensified. All cases are pre- ceded and accompanied by this terror. It is one of the char- acteristics of hydrophobia. As the disease progresses, the skin becomes hot and dry, the pulse rapid, and lacking strength. There is much thirst. In two or three days from the first manifestation of the disease the muscles of the throat, and especially those con- cerned in deglutition, become stiff and sore. Attempts at - 'fi POISONED worsDa 79 BWiillowiiig nro fullowod by spasmodic coiitrn^tion of ilio.^o niuscloa, and of those concorncd in res[)iration. These con- vuUivo inovoniciits increase in frcquciicy, cxt-ited by the Buuillest provocation. Shimming doi»rs, cold currents of uir, pouring water from one vessel to another, or changing the bedclothes, brings them on. In some cases there are general convulsions. Tliirst is intense, and the unfortunate patient does not relievo it for fear of choking or renewing the spasms. Sometijues there are small jmstules under the tongue (Marschetti). The patient's countenance exprcf^ses all his terror. The eyes are staring and bloodshot. A thick saliva is constantlv thrown from the mouth. The voice is husky. As the end approaches, the skin becomes cold and clammy, the pulse almost imperceptible, and the respira- tory movements irregular. A convulsion may terminate life by involving the muscles of respiration, or tlie patient may die gradually from exhaustion. After death, the fauces, throat, and lungs, are dark-colored and congested. In some cases, there are congestion of the cord and effusion into the ventricles of the brain. There is nothing definite in any of the lesions to indicate the Bpecific action of the virus. Strange as it may seem, hydrophobia is sometimes imitated for mercenary purposes. A case of this kind Avas admitted to "Ward 9, Bellevue Hospital, in the winter of 18G7. The pat nt stated that, when seven years of age (ho was then twein ;-five), he was bitten by a mad dog. One year after- ward, ■ ymptoms of hydrophobia manifested themselves. He recovered from that attack, but exactly one month afterward at " the full of the moon," he was affer*ted in a similar manner. This peculiar tendency to a monthly ro- IP m \ 1 Ml a . ! l' iiii 'l:t 111! i,lll 80 EMERGENCIES, AND HOW TO TREAT THEM. currence kept up for two or tliree years, and then ceased up to within two years of his first appearance. At that time they again commenced, and had continued at irregular in- tervals until his admission to the hospital. While in the reception-room, awaiting transference to the ward, an orderly approached him with some water, which immediately threw him into a convulsion. He writhed violently on the floor^ throwing the arms and legs about in every direction. The saliva collected in the form of foam around his mouth, and he howled and yelped like a " mad dog." The convulsion lasted for two minutes. At its ter- mination he seemed to be quite exhausted, but was able to walk to the ward. Shortly after his admission, and while in a convulsion, he was seen by Dr. Flint, who advised the application of hot water to the skin. The patient did not wait for the remedy, but recovered immediately. Finally, after a close questioning, he confessed the fraud, and admitted that for many years he had practised the game successfully, making considerable capital out of it. This man's story was told with such an appearance of candor, that it was hard to doubt at least his own faith in the reality of the disease. Treatment. — A wound inflicted by a dog suspected of madness should be washed and sucked as in ordinary dis- secting wounds, and afterward thoroughly cauterized Complete excision of the part is better, in most cases, than destroying the tissues by cauterization. Previous to the washing and excision, some recommend that a ligature be placed tightly around the limb, above the wound, in order to prevent absorption of the poison. On the arm or leg the •i I if POISONED WOUNDS. 81 i procedure is useless, because the circulation through the deep veins cannot be completely stopped. If placed on the fingers or toes, it may answer. In the bitten parts the ex- cision should extend some distance into the healthy tissue, and the wound be subsequently cauterized. The actual cau- tery is the best, but the most painful. When the disease is fully developed bnt little can be ac- complished. Stimulants can be given in large quantities by enema, and other liquids in like manner. Opiates and anaesthetics should always be administered to relieve the pain and distress, and decrease the convulsive movements. As the wound has again become inflamed and painful, hot di: infecting poultices, sprinkled with laudanum, will be serviceable. Free discharge should be kept up continu- ally. Snake-Bites. — Among the principal venomous reptiles may be enumerated the whip-cord snake, cobra de capello, rattlesnake, viper, and adder. The bites of the first two pro- duce a fatal result more quickly than the others. Rattle- snake-bites stand next in order of virulence. Yiper and adder bites are fatal only to very young animals, or to hildren of tendei* years. In the more deadly classes the symptoms following a bite, and the action of the poison, are the same. Eattle3nake-bit33 are not uncommon in the Southern and Western States, and the mortality attending them is very great. The venom of this reptile is contained in a small sac situated at the base of the shar^^> tooth or fang. The tooth ia channelled throughout its centre to make a place of exit for the poison. When the tooth is inserted into the tissues, the -as i 'H m ' ■ ' » !. m \ 62 EMERGENCIES, AND HOW TO TREAT THEM. poiBon-sac is compressed, and the venom ejected into the wound. The person bitten is overcome, either immediately or after the lapse of a few minutes, by a feeling of faintness and great depression. The pulse becomes feeble, rapid, and in- termittent. The pupils are dilated ; there is some pain over the abdomen, vomiting, and sometimes purging. Delirium is present in most cases. The extremities and surface of the body are cold and clammy, respiration is catching and diffi- cult. Coma comes on, grows rapidly deeper, and terminates in death. The wound, shortly after the bite, swells rapidl} . In one case it assumes a dark-red color, in another a bluish- black. A few patches of a light color may be intermixed. There is a sharp, intense pain in the wound, which extends up the limb, generally in the course of the principal serves. Inflammation extends to the neighboring tissues, and, if the patient live long enough, diffuse suppuration may occur, and abscesses form throughout the limb. Rattlesnake-bites produce death in from five to ten hours. The ^ost-mortem appearances show nothing of the special effects of the poison. Sometimes there is congestion of the brain, with serous effusion underneath the arachnoid and into the ventricles. There may also be congestion of the lungs and mucous membrane of the stomach and intes- tines. The blood remains fluid in the cavities of the heart in many cases. Treatment. — The wound should be treated in precisely the same manner as a wound produced by the bite of a mad dog ; that is, the part should be washed, sucked, excised, or cauterized. POISONED WOUNDS. 88 A vast number of internal remedies have been proposed. Bilron's antidote is one which has been strenuously advo- cated. Dr. "VV. A. Hammond, after a series of experiments, came to the conclusion that it was a remedy of great efficacy. Its formula is as follows : 5. Potassii iodidi Hydrg. bichloridi Bromii gr. IV. 3iv. ? 'It I '• I f m From ten to twenty drops of this mixture are given every half-hour, until an amelioration of the symptoms is pro- duced. Arsenic is another remedy highly spoken of. Guaco, Virginia snakeroot, and other medicines of vegetable origin, have also acquired temporary reputation as antidotes. The the most efficacious treatment is to administer large doses of oarbonntft of ammonia repeatedly in conjunction with enemaca of whiskey or brandy. The ammonia can be ad- ministered in ten or twenty gi'ain doses every half-hour. Friction to the surface, with hot pieces of flannel dipped in alcohol, is also beneficial. The poisoned wounds produced by scorpions, tarantulas, centipedes, and other members of this class, are rarely at- tended with destruction of life. Scorpions have an elongated body and a slender tail, the latter six-jointed. In the last joint there is a sharp sting, which communicates with poison follicles. Scorpions are found in all tropical climates. The largest scorpions are the most venomous. The tarantula, a species of spider which inhabits South- ern Europe, was at one time held in great terror on account )}.'■' m 41 m \ • ! i.'i 84 EMERGENCIES, AND HOW TO TREAT THEM. vmiW of its reputed deadly iuflueneo. The stories of its ravages are, however, not founded on fact. Centipedes are less dangerous than either of the pre- ceding varieties. The most venomous grow to a length of six inches. A number of poison-claws project from the body. As the insect crawls over the surface, these are in- serted into the integument, and the virus introduced. Some writers deny the existence of any 'fecial poison in members of this class. The constitutional symptoms following the bites of these insects are exhibited in the form of headache, vertigo, dim- ness of vision, and sometimes febrile excitement. Tlie wound, in some cases, is not inflamed ; in others, it becomes reci and painful, and the inflammation spreads to other parts of the extremity injured, ending in difi'use suppuration. Treatment. — ^When the wound is cleansed, it should be sponged thoroughly with a strong solution of ammonia, and afterward covered with cloths moistened with the same sub- stance. Brandy may be given internally in conjunction with ammonia. lit!:; 11 i|\,,f CHAPTER VII. «l EXTRACTION OF FOREIGN BODIES. Foreign Bodies in tlie Larynx, Trachea, Bronchial Tubes, Pharynx, CEsopL* ttgus. Eyes, Nose, Ears, Urethra, Bladder, and Kectum. — Tracheotomy. — Laryngotoniy Larynjjotomy. — (Esophagotomy. FoKEiGK Bodies in the Aik-passages. — Foreign bodies are usually lodged in that portion of the air-passages known as the larynx. This organ is situated in the median line of the neck, between the trachea and base of the tongue. The .nterior margin of its superior opening is guarded by a car- tilage called the epiglottis. During the act of deglutition, the epiglottis closes the aperture in the larynx, and prevents the entrance of food as it passes over on its way to the oesophagus. It is raised during the respiratory movements for the free ingress and egress of air. The trachea commences opposite the fifth . ical, and bifurcates about the third dorsal vertebra into right and left bronchus. The ri^-ht bronchus is shorter an the left. Its orifice lies directlv under the tracheal cai' so that for- eign bodies which pass below the trachea di p in and effect a lodgment. The endeavor to talk, laugh, or respire, with food or other substances in the mouth, is often followed by the entrance of some portion into the f>ir-passages. In talk- ing or laughing, the air is passing out of the lungs, and the epiglottis is raised. Heavy substances contrimed in the ■«. 86 EMERGENCIES, AND HOW TO TREAT TUEM. I ill iii; mouth during theso acta, readily roll backward, notwitli- Btanding the outward current. Taking a sudden inepiration while eating is more dangerous, as the current of air pass- ing downward is liable to sweep a portion of the food along with it. Vomiting, while in a state of intoxication, is apt to be attended with the entrance of half-digested parjcles of food into the larynx. It is not unusual for worms to find their way into the larynx during sleep, or for bronchial glands to become detached and carried upward, producing Berious and even fatal results. The presence of a foreign body in the pharynx, or oesophagus, may induce spasm of the glottis, and lead to the erroneous supposition that it has found lodgment in the air-passage. The introduction of a probang will settle the difficulty. Children are more often subjected to this accident than adults are. The habit of carrying in the mouth ])ead8, marbles, or pennies, is very prevalent among them. As an instance of the dangerous results attending it, thg following incident, which occurred in Bellevue Hospital, may be of interest : "While engaged in amputating the great-toe of a little girl, who was under the influence of chloroform, she sud- denly ceased to breathe ; the face assumed a purple hue, and death seemed imminent. Apprehending that the chloro- form was the cause of the difficulty, I commenced artificial respiration. While I compressed the chest, my assistant introduced his finger into the mouth to clear the throat of nmcus, and draw forward the tongue. In so doing he found a copper coin completely closing the superior aperture of the larynx. The removal was soon followed by a renewal of the respiratory movements, and disappearance of all the i 'U EXTRACTION OF FOREIGN BODIES. 8T alarming symptoms. The child had been playing with the penny, and had placed it in her mouth previous to my arrival in the ward, and, when insensibility was induced by the ana33thetic, it fell back into the larynx. Foreign bodies may lodge in the upper part of the larynx — in the ventricle between the vocal cords, or in the trachea and bronchial tubes. The symptoms differ with the location of the material, and the length of time it has remained. The size of the foreign l)ody bears no special relation to the severity of the symptoms, unless, indeed, it is so large as to completely block up the canal. A light substance capable of being moved up and down with the respiratory movements occasions greater distress ^'i lU one which is sta- tionary. "When the material lodges in ^iie larynx, whether large or small, it produces a spasm of the laryngeal muscles which close the glottis, and thus prevents the passage of air. The patient struggles for breath, the lips and cheeks become livid and swollen, the eyes protrude from their sockets^ convulsive movements of the limbs accompany the agonizing efforts to breathe, and the patient dies at once, or receive^ temporary relief from a relaxation of the spasms. The cur- rent of air which now enters, either passes the obstruction, or carries it f^irther down into the trachea. Once in this organ, the intense suffocative symptoms become less marked and continuous. There is more or less difficulty of re' ^i ra- tion all the time, pain over the point where the foreign body is lodged, and a distressing cough. The countenance has an extremely anxious expression ; the pulse is rapid. Severe dyspnoea occurs now only at intervals. "Whenever the substance is forced up into the larynx, violent efforts at 1 n I .. , ..f.- V i ■ i\ '^^B^m ' wSmW r ii 88 EMERGENCIES, AND DOW TO TREAT TIIEM. expulsion again ensue, with the same paroxysm as char- acterized the first stage. When the foreign body reaches one of the bronchi, the hmg on the corresponding side gives but little respiratory murmur on auscultation, and over the opposite lung there are exaggerated respiration and increased resonance on per- cussion. The presence of a foreign body in any part of the air- passages gives rise to symptoms like those mentioned above — they only differ in degree. After a day or two has elapsed we have more pain — the cough is increased, the pulse becomes accelerated, the countenance retains its anx- ious expression, the voice is husky, and general febrile ac- tion is developed. Thei*e are also the special signs of in- flammation in the part occupied by the irritating material. Death may occur instantaneously in the Jirst ^eriod^ from asphyxia or injury to the brain, from extravasation of blood following the violent eiForts to respire. In the second period death is induced by bronchitis or laryngitis. If weeks and months elapse before its expulsion, abscesses may form, and the patient succumbs to exhaustion. Treatment. — A violent blow on the back, if given im- mediately after the accident occurs, will assist the natural efforts of the patient in ejecting the foreign body. After it has passed the larynx, this procedure alone will be of little avail. If the first attempt fails, the body is to be inverted and held up by assistants, while the physician strikes with the open hand between the shoulders, at the same time moving the patient rapidly from side to side. If this method induces violent suffocatve paroxysms, it must tt»* be repeated. Should the urgent symptoms continue, which '..,.f EXTRACTION OF FOREIGN BODIES. 80 ^. ' ' they are liable to do, laryngotomy or tracheotomy must be performed without delay. The acute sensibility of the larynx hinders the irritating material from passing the glottis, which closes spasmodically every time it reaches that point, and, unless an opening is made lower down to give it exit, death may soon ensue. Some surgeons advise the administration of emetics, but such j)ractice is worse than useless. Tracheotomy is preferred above other operations by some praetitlonerfi,^ especially for children ; but, if circura- Btanees admits Uvyngotomy should be first performed. It possesses many advantages worthy of attention : 1. The parts are more accessible at all periods of life. 2. It is performed with greater rapidity, and conse- quently is peculiarly applicable to cases requiring instant S. There is no danger of wounding important vessels, >i I i M- ;i' 90 EMERGENCIES, AND UOW TO TREAT TUEM. artery is avoided. Tho nporturc thus made in tlio larynx is now widened by a dilator or ordinary forcei)8, and the patient turned oi\ his chest. If the ojioning be too small, the incinion may l>o carried down tlirough tho cricoid carti- lage and upper ring of tho trachea. The ejection of tho foreign body often occurs as soon as the operation U completed, but, if this desirable result do not follow, and tho substance be within reach, along-curved forceps may bo carefully introduced to remove the obstruc- tion. AVhen the passages are entirely cleared, tho edges of the wound must be approximated and allowed to heal. Tracheotomy requires greater care and skill in its per- formance than laryngotomy. The trachea, especially in children, is deeply seated, and covered by important plex- uses of veins and close proximity to large arteries. The parts to be avoided in the operation are : 1. Tho anterior jugular veins. 2. The isthmus of tlio thyroid gland which lies on the second and third rings of the trachea ; and 3. The inferior thyroid veins. It is always safe to administer chloroform to a child before commencing the operation. It renders material assistance to the surgeon, by relieving spasm and keeping the patient from struggling. Should it be considered advis- able to dispense with the anassthetic, the child's body must be enveloped in a sheet, which will keep the limbs motion- less. The head is thrown back in the former case, and the larynx held by an assistant. An incision is made through the integument directly in the median line, beginning a short distance below the cricoid cartilage, and continued down from one and a half to two inches. By keeping exactly in tlie median line the anterior jugular veins are i 'I EXTRACTION OF FOREIGN DODIES. 91 avoiJud. Theso vesseliJ are pushed nsidc, and tlic incisjlun carried tliroujijh tlio fascia, which covers the stcrno-hyoid and stcrno-thyi'oid murfclcB. Tlieso miiacles are separated, and the inferior thyroid plexus of veins is reached. Tlio handle of the scalpel is now to be carefully used in getting them out of the way without laceration. A tenaculum is inserted into the trachea to draw it forward. The knife is introduced hetween the rings, and two or three of them divided from helow upward. The cut-ends are held apart by ligature or widened by dilators, and the patient is placed in a supine posture, and, if the obstruction still "emaiiis and is within reach, it nmst bo removed with the forfrps. When these operations are performed for other patho- logical conditions, as laryngeal inttanimations, tumors of the larynx, a3dema glottidis, croup, etc., a jurved tube is intro- duced through the opening, and allowed to remain until the difficulty which called for the operation is removed. When the operation is concluded and the tube inserted, the patient must be carefully watched for a day or two, and the tube kept clear of blood and mucus. The old form of trachea-tube necessitated the u^e of a feather in order to keep it clean ; but the variety now employed has a second tube fitting closely inside the first, which can be removed and cleaned at pleasure without disturbing the patient. Foreign Bodies in the Pharynx and CEsoimiaous. — The pharynx is that part of the alimentary canal which extends from the base of the skull to the fifth cervical vertebra, where it becomes continuous with the oosophagus. It lies behind the nose, mouth, and larynx, in the order mentioned from above downward. Its widest part is opposite the hyoid bone, its narrowest portion is where it joins the iliiS m '"n 11 \l' I f' i I, ..:': hi i ri f ' i I'll ! ! I , ; i i m i m IMAGE EVALUATION TEST TARGET (MT-S) // 4 <. V.^^ .^^ ^z' f/. fc ^ 1.0 I.I ■- IIIM ■ 50 ^^ lllllil M 1.8 |l.?5 11.4 111.6 ■->/ !^ Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 92 EMERGENCIES, AND HOW TO TREAT THEM. m-f' CEsophagus. The food passes into it from the month, and is carried down into the oesophagus by contraction of the pharyngeal muscles. The oesophagus commences opposite the cricoid carti- lage, to which it is attached by muscular fibres, and termi- nates in the cardiac extremity of the stomach, on a level with the ninth dorsal vertebra. In the neck it lies behind the trachea. It measures nine inches in length, and is the nar- rowest portion of the alimentary canal; the most contracted parts are at its origin, and as it passes through the dia- phragm to connect with the stomach. Various foreign bodies have lodged in the oesophagus and pharynx — among the most frequent of which are bulky articles of diet, such as meat, potatoes, beans, apples, etc., and metallic substances, such as pennies, needles, pins, and nails, and even bones, false teeth. India-rubber, and pieces of glass have been found. The symptoms depend in some degree on the location and character of the foreign body. When of large size, it is apt to stop at the lower por- tion of the pharynx, and by its pressure on the larynx cause spasm of the glottis and consequent suiFocative paroxysms. Should it pass below this point, the pressure on the trachea may still obstruct the entrance of air. After the foreign body fully enters the oesophagus, it generally reaches the lower constricted portion at the cardiac orifice before it again lodges. Small bodies, such as pins or needles, pierce the mucous membrane, and cause more pain and irritation than other varieties. If they stop at the lower anterior part of the pharynx, spasmodic closure of the glottis is induced, often to a grea*:er extent than when bodies of a large size press on the same part. Irregular sharp substances in the pharynx EXTRACTION OP FOREIGN BODIES. 93 or upper end of the oesophagus cause nausea and vomit- ing. In the average of cases there are pain at the point of lodgment or over the episternal notch, and difficulty of swallowing. The patient is often extremely nervous, and complains of general distress in the throat. Treatment. — In all cases of simple obstruction of the pharynx or oesophagus, the first endeavor should be to ascer- tain the character of the material swallowed and its point of lodgment. The first point can be ascertained from the patient or friends ; the second by an examination with the finger, elastic bougie, or probang, and by the seat of the pain. The latter symptom, however, is not reliable, for in many instances the pain remains after the foreign body has been swallowed or vomited. The patient's statements, therefore, cannot be implicitly relied on. In examining the pharynx, an ordinary laryngoscope may be used with advantage. "When the tongue is fully depressed, and the light thrown in, the patient should then take a deep inspiration, which will separate the pillars of the fauces, and allow inspection. If the obstruction is in the pharynx or upper part of the oesophagus, it should be removed if possible. If below the level of the episternal notch, and not too large or sharp, it may be pushed down into the stomach. Particles of food may generally be treated in this manner when below the pomt named, or when it is difficult to extract them. The use of dilute mineral acids will soften a piece of bone so that it will go down {Hall). Force must not be employed in removing needles, pins, or other sharp articles, for fear of piercing, or lacerating the * - I i d'k : N if '''If 13'' iii. .::|i iliii:li;5;;' EMERGENCIES, AND HOW TO TREAT THEM. mucous membrane, and the important neighboring parts. Obstructions in the upper portion of the pharynx maj be extracted with the finger, or when farther down with curved forceps adapted to the purpose. Among the instruments that are used for pushing foreign bodies into the stomach the jpro^ang is the best. It consists of a thin strip of whalebone with a piece of sponge attached firmly to one end. It is carefully introduced and moved slowly downward, until the foreign body is reached and dis- lodged. Elastic bougies or catheters are used in the same manner. When needles or pins become impacted in the canal, an elastic catheter having a skein of silk fastened in the eye may be introduced until it passes below the obstruc- tion ; it is then drawn up, entangling the needle or pin in the meshes of the silk (Gray)* A very ingenious instrument has recently been em- ployed by surgeons in this city, for the removal of foreign bodies. It consists of a gum catheter, from which the end has been cut, a thin piece of whalebone several inches longer than the catheter, and a number of bristles. The whale- bone is made to slide readily up and down inside the catheter. The bristles are attached by an extremity to the end of the whaleb'ine, which protrudes from the catheter ; the other is fastened around the open end of the catheter. "When the whalebone is pushed out through the catheter as far as possible, the bristles sunound the whalebone very closely and compactly. The instrument in this condition is then carried below the obstruction, and the catheter firmly held, while the whalebone is drawn up within it. This causes the bristles to double up in the centre, and protrude * Article Foreign Bodies, Holmes's Surgery, vol. ii., page 826, EXTRACTION OF FOREIGN BODIES. 95 all around in such a manner, that when the instrament is withdrawn it carries the foreign body with it. When foreign bodies are not removed, they produce ulceration and suppuration of the parts pressed upon, and other organs become involved. If milder methods fail, we must resort to c^ophagotomy. The operation should be performed on the side occupied by the foreign body, or, if this cannot be determined, the left side must be selected, because, in the neck, the oesophagus inclines to the left of tlie median line, and is therefore more easily reached. After the patier*^ is fully under the influence of an antes- thetic, the shoulders are raised, the head turned to one side, and an incision is ii?ade along the inner border of the sterno- mastoid muscle, commencing on a level with the upper border of the thyroid cartilage, and extending down about four inches, cutting through the integument and platysma- myoides muscle. The omo-hyoid muscle is then exposed, and must be either cut or pushed aside. The sheath of the carotid vessels comes next in view, and is drawn outward and retained by an assistant while the thyroid gland and trachea are moved slightly inward. A bougie is now passed down the throat, and protruded below so as to bring the oesophagvs fully to view in the wound. An opening is then made, through which the foreign body is extracted. The patient should be fed daily through a tube for two or three weeks after the operation, in order to give the oesophageal wound time to heal. FoEEiGN Bodies in the Nose. — Children of tender years are particularly liable to this accident. It is of frequent 1 j- I 96 EMERGENCIES, AND HOW TO TREAT THEM. S. ••' i occurrence, but happily there is more inconvenience than danger attending it. Peas and beans in the nasal cavities are specially trouble- some ; they enlarge in size by their absorption of moistare, and by an increase of pressure cause greater irritation. Peas and beans have been known to sprout in the nasal cavities after having remained there for several days, giv- ing rise to serious inflammation of the mucous membrane and spongy bones. Treatment. — Having by careful examination determined which nostril the obstruction is in, snuff or other sternutatory may be introduced into the opposite nostril, in order to in- duce sneezing. This procedure will probably dislodge the foreign body. In place of this, a stream of water, carried into the nostril by means of " Thudicum's nasal douche," may wash out the material. When simple measures like the foregoing are found useless, the forceps must be em- ployed. The long curved forceps used for the extraction of polypi may be tried. The instrument is passed up carefully to the foreign body, closed upon it and drawn down. In all cases care should be taken that the substance is not forced back through the posterior nares into the throat, or that the efforts at extraction are not carried to such a length at one sitting as to fatigue the child, or cause inflammation in the organ. Foreign Bodies in the Ear. — The length of the ex- ternal auditory canal is about one inch and a quarter, and at its inner extremity is the merabrani tympani, a delicate membrane which separates the middle from the external ear. Across the middle ear are stretched three small bones connected externally with the membrani tympani, EXTRACTION OF FOREIGN BODIES. 97 and, through the foramen ovale, on the inner wall with the internal ear. Foreign bodies in the external ear, in consequence of their close proximity to important and delicate structures, may produce grave and even fatal results. The inflamma- tion usually excited by their pressure may extend to the mem- brani tympani, destroying it and causing deafness. It may pass on to the middle ear, involving the temporal bone, giving rise to caries and abscess, and may even reach the brain, exciting fatal meningitis or abscess in the middle lobe of the cerebrum. Sometimes efforts at extraction cause permanent deafness by rupturing the tympauum. Grains of wheat, corn, seeds, and also insects, such as bugs or fleas, have been found in the auditory canal. In- sects cause great irritation, but their removal is not attended with diflBculty. Accumulations of wax of any great quan- tity may cause distress. If the body is large, there is considerable pain and singing in the ear, and more or less deafness is experienced. If it is allowed to remain in the canal, there will be in the course of twenty-fonr to forty-eight hours a discharge from the meatus, which soon becomes purulent and mixed with blood. Small substances do not excite inflammation so rapidly, but are often as difficult to extract as large bodies. Insects create an itching in the canal, and a loud rattling or grating noise, excessively annoying to a nervous individ- ual. Treatment. — Insects are removed by closing up the ex- ternal meatus, or as much of the canal as possible, and pre- venting the admission of air. This is best done with a 7 *'' L - r. '.» I v- 98 EMERGENCIES, AND HOW TO TREAT THEM. ^1 -I Hi piece of " cotton-wool," thoroughly saturated with a strong solution of common salt or vinegar, and sufficiently large to plug the orifice completely. After its introduction turn the patient on the affected side, and allow the hand to press firmly on the ear. In a few minutes the noise and irrita- tion will cease, and, if the plug at this time be withdrawn, the insect will probably be found partially embedded in its substance. To remove small bodies, a stream of water may be thrown gently into the canal, or a scoop and bent probe may be used. The scoop should be introduced into the ujpper part of the canal, so that, in pressing on the foreign body, the edge of the instrument will recede, instead of pressing against the membrani tympani, as it undoubtedly would if inserted below. Great care must be observed in the employ- ment of tliese instruments, and verv little force should be exerted through them. If it is found impossible to remove the obstruction by these means, the canal must be syringed gently twice each day with warm water, until all inflammatory symptoms have subsided. In the majority of cases the foreign body will come away in the purulent discharge. Foreign Bodies abound the Eye. — Sand, broken eye- lashes, cinders, etc., often lodge under one of the lids, usually the upper lid. If these substances remain, inflammation of the conjunctiva will be established, and ulceration set up around them. Treatment. — Hairs which have become fixed in the con- junctiva should be extracted with forceps. To do this, the lid is everted, and the eye cleansed of any effusion which may have collected around the hair; the latter is then readily EXTRACTION OF FOREIQN BODIES. 09 e to the ireBS rita- iwn, n its rown ay be ♦ part y,the eesing luld if nploy- ttld be jion by e each ptoma body removed. For the extraction of dirt, sand, etc., the follow- ing Bimple proceeding will answer : Grasp the upper lid between the thumb and forefinger, lift it from the eyeball and draw it forcibly down, outside of the lower lid. "When stretched as far as possible, allow it to slide slowly back to its natural position, touching its fellow as it goes up, then wipe the edges with a handkerchief so as to remove the foreign body from the lashes. The operation can be repeated three or four times, or ottener, without injury. Some use a small scoop made from wire, which is moved around under the eyelid from one canthus to the other. Foreign Bodies in the Ukethba. and Bladder. — In many cases this occurrence depends on unnatural or uncon- trolled desires which seek relief in local irritation and excite- ment. The most astounding means are resorted to for this purpose. Slate-pencils, hair-pins, knitting-needles, wire, pieces of wood, leather strips, straw, tobacco-pipes, etc., are among the long list of articles which have been extracted from these organs. Prof. James R. "Wood has in his collection a thick leather thong, with a large knot at its extremity, which a patient of his was in the habit of introducing into the urethra. On one occasion the knot passed beyond the sphincter muscle, and was forcibly held. It had to be removed by an operation. However, there are other means by which foreign bodies become lodged in the urethra and bladder. In the dilata- tion of a stricture with elastic bougies, or while using a catheter, the instrument may break, and the pieces remain impacted. After remaining a certain length of time in the bladder, :.f ■ J' LOO EMERGENCIES, AND HOW TO TREAT TDEM. foreign bodies become encrusted with various salts, and grow larger by deposit. Such an occurrence is attended with all the symptoms and dangers of stone. In the urethra they may cause inflammation and sloughing of the mucous mem- brane, and subsequent stricture. Treatment. — Extraction is necessary in all cases. When impacted in the male urethra, the removal may be effected by a forceps adapted to the canal. If this fail, urethrotomy mast be performed. Foreign bodies in the male bladder are sometimes broken up with a lithotrite; but in most cases perineal section {see page 61), or some of the opera- tions for stone, are usually made. Substances may be taken from the female bladder with a forceps. The urethra in females is very short and easily dilated, so that the introduc- tion of a forceps or other instrument is accomplished with- out difficulty. Foreign Bodies in the Rectum is a rare accident. Fall- ing on the rung of a chair, or on fence-spokes, may result in a portion of these materials entering the rectum. The prin- cipal danger is from laceration of the bowel, uterus, or bladder. Death usually follows rupture of the latter o^gan. The treatment consists in keeping the bowels quiet, relieving pain by opiates and warm fomentations to the abdomen and anus. If the mucous membrane is torn to any extent, and the injury will admit of it, the parts may be drawn together with sutures. CHAPTER YIII. BURNS AND SCALDS. f arietiet of Deformities produced bj Bums. — Spontaneous Combustion.— CImh siflcation of Burns.— Constitutional Symptoms, — Duodenal Ulcers. — CauiM of Death, etc.— Effects of Cold.— Frost-Blte. There are few accidents which combine so many un- natural elements as bums and scalds. In none do we wit- ness so much agony or such poor results from treatment. Burns are to be dreaded in their remote results, as well as in their immediate consequences. Recovery in many cases is accompanied by hideous deformity. Severe facial bums not unfrequently leave the face twisted and distorted to such a degree as to almost destroy its semblance to humanity. The cheeks may be stretched to one side, the angles of the mouth widely separated, or the lower jaw drawn toward the shoulder, by a cicatrice of the neck. Bums of the neck may bend the head sideways, or draw it down on the chest. Where the arms or hands are burned, the cicatrices bend the joints out of place, and impair their movements. Thus the fingers may be doubled up and clinched, or the forearm flexed or strongly pronated. Some- times the eyelids are fastened to the cheek, or drawn upward on the forehead. In the latter case the eyeballs cannot be covered or protected from irritating particles of dust ; great distress results in this condition, from want of sleep. A case h; s\\ 102 EMEROEXCIES, AND DOW TO TREAT TIIEH. I I'M'' I of this kind came under ray care at Bullevuc, in a female patient whu Butlercd frum a severe burn of the forehead and arm. The upper eyelid was drawn up on the forehead, and fastened above the superciliary ridge. The suffering for want of sloop was considerable. Even opiates failed to bring relief. Ordinary covering for the eye only produced irritation. Finally, as there was no integument near from which to manufacture a new lid, I dissected the old one from its attachment on the forehead, and drew it down. It was retained in its position, until the healing process became complete, by means of a fine silver wire passed through, near the free margin of the lid, carried down across the end of the nose, and fastened at the back part of the head to the other end of the wire from the opposite side. This unusual operation answered the purpose admirably. Being retained in its position for several weeks, the cicatrice was prevented from contracting so as to uncover the eye, and leave it with- out protection. Sleep was procured for the patient ; most of the hideous deformity removed, and the old lid performed its duty once more. Many cases of burning arise from carelessness in the use of kerosene and other explosive oils in tenement-houses. This class of burns has attained a magnitude, in point of numbers, which is truly alarming. The columns of our morn- ing journals are seldom without the history of a victim. These accidents usually arise from filling lamps near alight, or from pouring kerosene on kindling-wood to make a brighter flame. Sometimes they are occasioned by careless- ness in shutting off gas. The material escapes until the apartment is filled, and upon the entrance of a person with a light an explosion takes place, and frightful burns result. i;i iiiii: BURNS AND SCALDS. 103 Recovery from such burns is rare, owing to tlio extent of surface injured. Dangerous bums nro also produced by the contact of melted metals with the body. They burrow into the flesh, and cauHe great destruction of tissue, and fearful scars. Melted sugar, hot mash, boiling water, etc., when applied to the body, are not characterized by the same deep eschars which attend scalds with other substances. Their effect is superficial, but, as they sometimes extend over a greater sur- face of the body, they are usually as fatal as burns from flame. The appalling phenomena of spontaneous comhusticm may be mentioned in this connection. Several cases of it are recordei by reliable observers. It takes place in persons who imbibe the worst varieties of ardent spirits. There is much diversity of opinion respecting this curious accident. Some hold that the system becomes so thoroughly impreg- nated with alcohol as to make ignition possible through the medium of the breath ; or, that combustible gases are gen- erated internally, which take fire and destroy independently of external influences. The majority of investigators, how- ever, believe that the combustion commences on the outside of the body. Thus, a person completely stupefied from alcohol may fall or lie down in the vicinity of a fire, and the flame may be communicated to his clothing. His helpless- ness, and the body being loaded with fat and alcohol, fur- nish all the materials for rapid combustion, and the un- fortunate creature soon becomes a blackened, fetid mass. In ordinary burns the danger to life varies with the seat and extent of the tissue destroyed. Burns of the thoracic or abdominal walls are attended with the greatest danger, on account of the proximity of important viscera. i\ I I 104 EMERGENCIES, AND HOW TO TREAT THEM. A. superficial bum, involving a large integumental area, is apt to prove fatal. Localized deep eschars are not par- ticularly serious, unless important nerves or vessels are destroyed. When the air-passages, pharynx, or oesophagus, are in- jured from hot liquids or steam, the prognosis is always bad. The mortality from burns is always greater in childhood than in adults. The delicate and susceptible nervous sys- tem of the child succumbs to a burn, which would, compar- atively, be of little consequence to an adult. In persons of tender years these accidents usually terminate in convul- sions. Dupuytren divides burns into six classes. Other urgeons have increased the number. For our present purposes four degrees of burns will be sufficient : The Jirsi includes all burns which redden the cutis and produce slight vesication. The second includes all cases where the true skin is either partially or completely destroyed, and bullro or eschars of a brown color result. The third class includes all which extend through the subcutaneous cellular tissue into tlu muscular substance. The fourth includes those in which all the tissues of a limb are more or less involved in the destructive process. "We usually find, in burns, the first two degrees combined in the part afiected. Where boiling water is spilled on the surface, the tissue is not broken up as when flame is ap- parent ; with the worst cases the true skin is merely deprived of its cutis and reddened. Our classification, therefore, does not apply to this variety. T)ie immediate symptoms accompanying severe buma BURNS AND SCALDS. 105 may be divided into three stages, each differing in a marked degree, and giving rise to different indications for treatment. The immediate symptoms accompanying the first stage of severe burns are those of collapse. The pulse is small and feeble. The extremities are cold and clammy. There are great thirat, M'itli difficulty in swallo^ving {dysphagia)^ and nausea and vomiting. The patient's countenance is shrunk- en, and has an expression of anxiety. Chills and rigors are present. The most prominent symptom is the intense agonizing pain. The pain is probably more acute than in any other form of injury, and oftentimes only relieved by death. This stage lasts from twenty-four to forty-eight hours, and the greatest number of fatal cases occur in it. A post-moi'tem examination of persons who die in the first stage reveals great congestion of the brain and its mem- branes, serous effusion into the ventricles, and on the surface of brain. There is also marked congestion of all the inter- nal oro^ans. The second stage or period of reaction is recognized by an increase in the temperature of the body, and a rapid pulse. The skin feels hot to the touch, and the tongue is brown and dry ; the dryness being particularly apparent in the centre. There is intense pain in the head {cej>halalgia)^ and sometimes delirium. Vomiting may also be present in this stage. Tlie dangers in the second stage arise from inflammatory affections of different viscera. Meningitis is liable to occur. Pneumonia or bronchitis stands next in order of frequency. Inflammatior of the intestines, giving rise to ulceration, is not uncommon. The inflammation usually commences in the upper portion of the small in- testines. The peculiar duodenal ulcer which accompanies 'M m II iii " T ^Kn't 1 Mil:' sKPi . ■. m^ 1 : I 1 ■11 f k '■ llli I V ^ I 't%i 106 EMERGENCIES, AND HOW TO TREAT THEM. Bovoro Imrns may take place in this period, altliougli it ia inure frequently seen in the tliiril. This ulcer is situated at the upper portion of the duodenum near the pylorus. Bowman supposes it to be caused by the extra labor thrown on the intestinal glands in consequence of suppressed cu- taneous pccrction. It is recognized by pain in the right hypoohondrium, loose and sometimes bloody evacuations from the bowela. Usually it appears on the tenth day, but it may connnence as early as the fourth. The duratioTi of this stage varies from one to two weeks. IXxo post-mortem appearances are principally those belong- ing to diHeront intlannnations. If meningitis have super- vened, the arachnoid will be found opaque, and studded with flakes or patches of lymph. The membrane is raised by effusion of serum into the meshes of the pia mater. The brain is congested, and the ventricles contain serum. The lungs may present various stages of pneumonia, or be simply engorged. There is congestion throughout the in- testinal canal, but especially in the duodenum, and there may be ulceration. A diminution in the febrile symptoms, and the cota- menoement of suppuration, usher in the third stage. In severe cases, the patient's condition is similar to that of the lii-st stage. If the suppuration bo excessive, death soon en- sues from exhaustion. The pathological changes are much the same as in the preceding stage, with the exception that the brain and its membranes are not so often the seat of inflammatory clianges, and ulcers are more frequently found. The most common causes of death in each period are, in the fii*st stage, collapse from injury to the nervous system BURNS AND SCALDa 107 and coma duo to cerebral congestion. Second stage, in- tlaininatory disorders, as meningitis, pneumonia, peritonitis, etc. Third stage, exhaustion from excessive suppuration, hicinorrhage, or peritonitis from perforation of an ulcer, and thoracic inilaniniation. The constitutional treatment varies in each period. In the first stage the intolerable pain should bo relieved by opiates, and the patient roused from his prostration and collapse by the free use of stimulants. And it must bo borne in mind that, "when excessive pain exists, the system can bear double doses of narcotic medicines. Two or three grains of opium may bo given to adults at short intervals, and increased if necessary. Morphia is best administered in solution, and, of the two liquid preparations employed, Magcndio's is the best. From twenty to thirty drops may be given by the mouth, or by hypodermic injection. If the preparations of opium fail, hydrate of chloral in half- drachm doses, or ancesthetic inhalations, may be tried. Do not let the unfortunate patient suffer, but relieve him at all hazards. In conjunction with narcotics, brandy may be given by mouth or rectum. Hot bottles applied to the extremities will be found of service. As soon as heat of the skin and increased frequency of the pulse indicate reaction, diminish the quantity of stimulants. In the second stage there is an entire change in the con- dition of the patient. Inflammation is present in some of the viscera. The treatment will of course vary with the organ involved. Should the pain continue, opiates must be administered. Stimulants may be kept up and their action carefully watched. Antiphlogistic measures are not re* :i 108 EMERGENCIES, AND HOW TO TREAT THEM. quired. Beef-tea, broths, and other light, nouriBhing diet, are always beneficial, and cannot be dispensed with. In the third stage there is great exhaustion, and efforts must be made to sustain the rapidly-failing vitality of the patient. Brandy, with or without ammonia, should be ad- ministered freely in conjunction witli quinine. This valu- able drug may always be employed in the treatment. Five grains every three or four hours will be sufficient. Beef- tea, raw-scraped beef, eggs, oysters, and other nutritious articles, are also essential. Tliey may be given in all cases. If the stomach be too irritable to receive the medicine, diet, or stimulants, they can be safely given by infection. There are three important rules to be remembered in the local treatment of burns : 1. Exclude atmospheric air. 2. Only remove the dressings when they become loosened by the discharges. 3. Prevent the contraction of cicatrices. In simple burns which do not involve the true skin, very little treatment is necessary. The part may be kept wet by cloths dipped in water or sweet-oil. When the true skin is partially or completely destroyed, a thick layer of flour may be placed over the burned surface, and covered by cotton. Lint or cotton, dipped in a mixture consisting of equal parts of linseed-oil and lime-water {carron-oiT)^ can be used instead of the flour. Some envelop the burnt part in cotton saturated with sweet-oil alone, and others apply a solution of nitrate of silver first, then cover the lint with cotton. I have seen the best results from the employment of flour and carron-oil, and prefer them over all others. Whatever dressing is employed, it should not be disturbed until separated by the exudation underneath, or unless foul odors arise. In changing, every particle should be carefully BURNS AND SCALDS.— EFFECTS OF COLD. 109 removed, and the parts thoroughly washed with some dis- infectant liquid, sue! an 3> Acidi cnrbolici ....... 3J« Aquflo ........ fl. I vi\j. M* This solution may also be sprinkled on the dressings and bedclothes. When granulations grow above the surface, the sore will not heal; applications of nitrate of silver and strapping with adhesive plaster will then be required. During cicatrization, the great tendency to contraction and deformity must be counteracted by splints or band- ages, and parts supported in their normal position until the healing process is completed. The hideous deformi- ties which arise from the contractions of cicatrices are sometimes remedied by surgical procedures. No special rules can be laid down for those operations, as each one has its own separate requirements, and the common-sense of the surgeon must alone be the guide. EFFECTS OF COLD. — FBOST-BITES. Cold is a valuable therapeuticalagent in many diseases. Cold shower-baths or ordinary cold-water baths have a stim- ulating effect on the system, invigorating both the mental and physical forces. A dry cold atmosphere is also an efficient agent in maintaining the vital powers at a normal standard, and in destroying or keeping in abeyance inju- rious miasm. Exposure of the body to intense cold results in a local or general loss of vitality. It produces a feeling of depres- sion, a disturbance of the mental faculties, and a great desire to sleep, which, if indulged in, soon increases until a r- -f r I 110 EMERGENCIES, AND HOW TO TREAT THEM. state of profound coma is reached whicli may end in deatli. The desire to sleep is beyond the control of the sufferer, and it is here that the great danger liea. If the power of re- sistance, or an appreciation of the danger were felt, the person exposed might be enabled to resist until assistance was obtained. "When the coma is developed, it is almost impossible to arouse the patient. The comatose condition is brought about by congestion of the brain. The intense cold propels the blood from the surface to tlie internal organs. The functions of the brain, in common with those of other organs, are interfered with by the pressure of the accumulated blood, and insensi- bility supervenes. It is also probable that an accumulation of carbonic acid takes place in the blood owing to the diminished respiratory movements, and through its narcotic effect assists in producing the coma. Fatigue and intem- perance are two great auxiliaries in making the system sus- ceptible to the effects of cold. Persons who have been overworked, or who have imbibed freely of alcoholic bev- erages, succumb readily to cold. Temperate men resist long exposure to a low temperature. TliC condition of the atmosphere modifies the effect of cold. Thus a much lower temperature can be borne when the atmosphere is still than when the wind is blowing. When a breeze exists, the warm stratum of air nearest the body is removed rapidly, and cold air takes its place ; there is consequently more heat abstracted from the body than in the former condition. Air is a bad conductor of heat, and these warm strata afford a certain amount ot protection, and lessen the demand for a higher temperature. Wlien only a portion of the body is exposed to the cold, FROST-BITES. Ill as the eyea, ears, nose, etc., there is a local loss of vitality. The part becomes pale and bloodless, and is devoid of sen- sation. If the vitality is only partially destroyed, a condi- tion arises whicli is known as frost-bite ; where the exposure has been long continued, and the life of the part totally de- stroyed, gangrene rapidly ensues. Little or no pain is ex- perienceu until recovery begins, and the circulation is renewed. The pain is intense, and always the forerunner of more or less inflammation. The parts become red, swollen, and hot, and the cuticle peels oif. Resolution may occur in a day or two, or the inflammation may continue until sloughing ov gangrene takes place. Extreme degrees of cold and heat have analogous effects. In both the vitality is destroyed, and in both there are suboe- quent inflammation and sloughing of tissue, with constitu- tional disturbance. Treatment. — A person suffering from frost-bite should be placed in a cold room. The part frozen may then be rubbed with snow, or ice-water poured on it, until sensation begins to return. The occurrence of stinging pain, with a change in color, is a signal to stop all rubbing or other measure which might excite inflammation. Cloths M^et with ice-water may then be applied to the part. If the inflam- mation extend to the deeper tissues and suppuration occur, the cloths can be wet in a solution of carbolic acid and ice- water, and the application continued. When gangrene sets in, amputation is generally necessary. In cases where the constitutional effects of cold call for treatment, general stimulation is necessary. Brandy and ammonia are to be given internally, while the body should bo briskly rubbed with the hands and warm flannel. \\i 1 ' \\ lao EMERGENCIES, AND HOW TO TREAT THEM. from retinal apoplexy several months previous to tlie ex- travasations in the brain which ended his life. When the attack is sudden, the patient falls to the ground insensible. The face presents a congested appear- ance ; one pupil may be dilated and the other contracteply four or five drops of the mixture to the back of tljc tongue. This can be done by moistening the end of a pen- cil or pen-handle with the oil, and wiping it on the back of that organ. It is not well to use the croton-oil undiluted, on account of its irritating properties. The dose should bo repeated in three-quarters of an hour, if free evacuations from the bowels do not follow. If preferred, elaterium may be administered in quarter-grain doses every hour until a like effect is produced. In connection with the internal medication, profuse sweating should be produced by means of hot-air baths. Bottles of hot water and warm blankets, applied to the surfixce, answer the same purpose. The sweating may be kept up for a considerable time without injury, but the action of cathartics must be guarded, espe- cially if the constitution be much weakened. In ordinary cases, this treatment should be persevered in until con- sciousness is restored. Prof. A. L. Loomis has lately em- ployed morphia in ursemic coma. He administers it hy- podermically, and with good success. Subsequently the action of the skin may be kept up by warm baths and mild diaphoretics. Tonics and nourishing diet are also necessary. To sustain the action of the kidneys, and at the same time to support the strength, the following may be given in tea- spoonful doses four or five times a day: 9. Ilydrg. bichloiidi . Tinct. cinclioiiaB coiiip. gr.J. fl. I iv. M, The internal administration of benzoic acid was at one time proposed as an antidote for the poison of urea ; ex- periments, however, did not warrant a continuance of its LOSS OF CONSCIOUSNESS. 127 use. When urtemic coma is the result of acute inflamum- tion of the kidneys, the treatment varies. In addition to the ordinary remedies, the application of wet or dry cupa over these organs is required, and is generally followed by great results. Rum Coslv. — When large quantities of alcohol are taken into the system, a state of insensibility is induced which in certain particulars resembles the other varieties of como. The comatose or " dead drunk " patient lies insensible, breathing heavily. The respiration has more of the char- acter of a snore than of a true stertor. The pupils are regular and act to light. Sometimes they are dilated. In the early part of the coma the pulse is soft and in- creased in frequency, but afterward becomes slower. The breath usually smells strongly of alcohol. Too much re- liance, however, mast not be placed on this sign until the history of the case is examined into, for, in cases of sudden insensibility, by-standers are in the habit of administering stimulants. The patient usually has been drinking freely for some time, and the stupor appears gradually, preceded by a staggering gait, and other signs of drunkenness. Coma due to compression of the brain may be excluded, if there is no paralysis or irregularity of the pupils, or complete coma. From ursemic coma it is diagnosed by the absence of oedema of the eyelids and lower extremities, of albumen or casts in the urine, or urinous odor in the perspiration Besides, ura^mic coma is profound, w^hile coma from rum is only partial. If the patient had a convulsion previous to the coma, and no signs of Bright's disease present, the case might readily be mistaken for true epilepsy. Our main reliance under such circumstances must be the • Mi ^i\ ikt.i M ' i i 1; i li 128 EMERGENCIES, AND UOW TO TREAT TIIKM. history of the case and the surroundings of the patient. If the tongue hti not been bitten, and tlicro is a history of a spree, we may then exclude epilepsy. Treatment. — If an emetic of mustard can be admin- istered, and the stomach emptied, much good will result. Subsequent applications of cold water to the licad and chest will be beneficial. Hysterical Coma is one of the manifestations of the hydra-headed nervous affection hysteria, a disease peculiar to nervous women. Scientific investigation has not yet reached the morbid changes which occasion the disease. Its real nature is still in the dark. We know that it is charac- terized by a morbid sensitiveness, a tendency to imitate dis- ease, and that it is to a certain extent under the control of the will, but farther we cannot go. The patient imagines she has a disease, but the practised eye detects the counterfeit. She may simulate paralysis, and remain in bed for months. All the pains, aches, and diseases, which " flesh is heir to," may be represented and imitated without limit, and yet these nnfortunates cannot bo charged with fraud. The case of a young ijysterical patient, who Vvas a*-, one time in "Ward 24, Belle vue Hospital, furnished an excellent example of this class. On her admission, she was placed near a patient in the last stages of Bright's disease. In a few hours afterward, I found her suiFering from nearly every prominent symptom exhibited bv her dving neighbor. The condition lasted for a few days, when the ambitious young woman developed the signs of peritonitis, and managed to keep them up for two or three weeks. Subsequently, she passed to the care of another house-physician, and I lost sight of her. In an- It r ir «ii'- LOSS OF CONSCIOUSNESa 129 other ward of the samo hospital was a young Irish girl who BufTerod from retention of urine. The catlioter was regular- ly employed for several days before the real nature of the disease was discovered. Her will, or her disease, enabled licr to remain three days without passing water. At the end of that period slie relieved herself naturally, and continued to do so afterward. The same patient afterward developed paralysis of tho lower extremities, which lasted several months. Temporary recovery took place during a thunder- storm. Tho noise alarmed her so that she forgot her paraly- sis and sprung out of bed. It returned again in a milder form, but gradually wore away. When discharged from the hospital, she was entirely cured. Hysterical coma is a comparatively rare manifestation of the disease. It is often preceded by general excitability, and by spells of violent laughter and crying witliout assign- able cause. There is often a sense of choking {globus hys' teriGua), duo to contractions of the oesophagus, from below upward. It gives a feeling as if a ball were rising in the throat. Previous to the coma there may have been a con- vulsion, but it is not always an accompaniment. The patient, during the attack, lies motionless, and to all appearance unconscious. The breathing is natural. There is no lividity or other unnatural condition of the face. An examination of the eyes will show that the patient sees all that is passing around her, and that the pupils act to light. The pulse is natural in all respects. The absence of stertorous breathing, insensibility, and irregularity in the pupils, suffices to show that there is no compression of the brain or other serious affections. Treatment. — For hysterical coma, the cold douche is the 9 :'. . Mi ;-li ■U> •U'' L30 EMERGENCIES, AND UOW TO TREAT THEM. best known remedy. Two or three pitchers of cold water, poured from a hci^^ht upon the face, will generally suffice to brin^ about a recovery. The after-treutmeut consists in developing self-control, sustaining the genurul health with fresh air and good food, the removal of any existing disease of the generative apparatus, and the administration of anti* spasmodics, as musk, valerian, assafoetida, etc. Epilkptio Coma follows an epileptic convulsion. The insensibility is never complete. Blood may collect on the lips. There is laceration of the tongue. The sudden oc- currence of the convulsion when the patient is in good health otherwise, and the complete recovery when the attack has passed away, servo to distinguish this disease in all cases. {See article on Epileptic Convulsions.) Treatment. — Epileptic coma does not require treatment. To prevent a recurrence of the convulsion, bromide of po- tassium can be given. Ten grains, four times a day, will be enough for an adult. CONCUSSION OF THE BRAIN. Concussion of the brain may be defined as a shaking to- gether of the contents of the cranial cavity, with more or less contusion of the brain-substance, and attended by par- tial or complete unconsciousness. The injury may be pro- duced by direct blows upon the head, or by jumping from a height and alighting on the heels, the force in the latter case being transmitted through the spinal column. In some cases the most careful examination of the brain after death fails to detect signs of contusion. In the major- ity, however, minute points of extravasation, discoloration, LOSS OF CONSCIOUSNESS. 131 and softening of einnll jurtiona of the nerve-eubstnnce, are found. Millnr, ^Voo(l, and otherfl, divide concussion into three stages : 1. That of insensibility; 2. Reaction; and 3. Ex- cessive reaction or inflammation. The symptoms attending the first stage vary with the amount of concussion. In typ- ical cases, the patient falls unconscious after receiving the injury. The skin is pale and cold, and the pulse small and rapid. Kespiration is natural or sighing. The pupils aro contracted, or one may be contracted and the other dilated. The sphincter muscles are not often interfered with. In the second stage, the patient vomits and shows evi- dences of returning consciousness. Tlio pulwe becomes stronger, warmth returns to the body, and slight color to tlio lips and cheeks. If this reaction be excessive, showing a tendency to inflammation, the third stage is ushered in. The skin becomes dry and hot, and there is considerable headache. The pulse rises, and is firmer than during the preceding stages. Finally, if the case progresses unfavor- ably, all the signs of meningitis are manifested, such as in- tolerance of light, intense headache, contracted pupils, sub- sultus tendinum, delirium, and finally coma. The difieren- tial diagnosis between compression of the brain and con- cussion has already been given. In many instances, the concussion is extremely slight, lasting but a few moments. This is the case where the pa- tient is merely stunned, and the efiect soon passes away. In other case?, the concussion is so great as to cause instant death. Treatment. — If there be collapse, hot bottles and blank- ets are to be applied to the extremities, and the circulation n » .'J i ' \ r i. 1 r lI ill 132 EMERGENCIES, AND HOW TO TREAT THEM. Btimulated by friction with the hands. Diluted eiiemata of brandy and ammonia are also serviceable. All stimulating efforts must cease as soon as reaction returns. Should in- flammation set in, the ordinary antiphlogistic treatment, previously referred to, will be necessary. CHAPTER XI. LOSS OF coif SCI 0{rSJ!^£SS-iCoifTa(vm). SYNCOPE. Syncope from Hremorrhago.— Thrombi in the Pulmonary Vein. — Antemia.— • Mental Emotion. — Blows on the EpigastriuiQ. — Collapse. The normal performance of every function depends on an adequate supply of healthy blood. The delicate ma- chinery ceases when the'proportion to each part is not com- mensurate with its demands. The continuous pulsatory movements of the heart propel the blood into the vessels which carry it to all parts of the body. A partial or complete cessation of the action pro- duces a condition known as syncope, or fainting. This is characterized by unconsciousness, and by suspension of the powers of volition. The regular contractions of the heart depend upon several conditions: 1. A sufficient and regular supply of blood, which exercises a stimulating eflPect on its fibres ; 2. A normal proportion of the necessary ingredients in the circulating fluid ; 3. A healthy state of the brain and of the nerves and sympathetic ganglia which supply the heart ; 4. A special irritability possessed by the muscular fibres, which causes its contractions to continue even when all connection m Hi' i mi 'lit '' A f m 'I mi 1 1 hi ,1 184 KMKRGENCIES, AND IIOW TO TREAT THEM. i t:; with tho body lias been sovorcd, and the oxtmnoous rouitcs of stinudatiou roiuovod. Thin innato power is, for want of a bettor name, dononii- natod irritability. Of its nature wo are totally ignorant. In cold-blooded aninials it ib particularly noticonblo. Any morbid change, wliicli directly or indirectly disturbs the con- ditions spoken of, is liable to induce syncope. Syncope is produced by excessive lu\unorrha. This, however, when noi, too prolon<};ed, is rather of benefit than otherwise. Tho cessation in tho movements of the heart allows tho blood to coagulate in the bleeding vessels, and prevents tho possibility of luvmorrhnge when the cireuhi- tion is renewed. Thronibi in tho pulmonary vein causes fatal syncope by preventing the blood from passing through the lungs to the left side of tho heart, and by pr»jducing ilistention of the right auricle and ventricle. Syncope arising from a deficiency in the ordinary stimu- lating ingredients of tho blood is witnessed sometimes in nnivmia, and in chlorosis. In these dise.ises the watery portions of tho blood aro inci uased, tho red corpuscles are diminished, tho circulation being at all times exceedingly feeble. In leucocytluv3n)ia, where there is a very great excess of white corpuscles, and in phthisis, where there is much general deterioration of tlio blood, sudilen failure of the heart's action is likely to occur after rapid exertion. Syncope likewise results from mental emotions, such as sudden joy, anger, grief, etc. These act in some pecidiar and unknown manner upon tho nerves of tho heart, sus- pending their influence. In some cases the emotion baa been so great as to destroy life. LOSS OF CONSCIOUSNESS. 135 Anoomia of the brain and concussion arc attended witb Byncopo. IJlows on the opigaatrium may injure the solar l)lexu3, and cause a fatal reflex paralysis of the heart. The cases of sudden death from drinking cold water while per- spiring ai'e similarly accounted for. Sed}),tive9 may induce syncope if the doses are large or too frequently repeated. The majority of sedatives, such as tobacco, colchicmn, antimony, prussic pcid, etc., act by di- minishing the nerve-force. Some consider that digitalis acts on the heart as a tonic, and not as a sedative. It is hard to harmonize Vv ith this theory the authenticated cases of syncope, or collapse, following its use in the usual medicinal doses. Chloroform, wlion administered to debilitated individuals, may act directly upon the nerves of tlio heart, and cause paralysis of that organ. Chloroform usually kills by acting through the lungs and producing asphyxia, or through the brain, causing coma. Severe burns, crushed limbs, surgical operations, etc., are sometimes followed by sudden partial suspension of tiie functions of the nervous system, and diminished action of the heart, ttWcL h commonly known a^ shock or collapse. Although in many essential points resembUng ordinary syn- cope, there are import.int diiferences which distinguish them. The duration of syncope is more brief. The pa- tient either dies suddenly or recovers rapidly. Collapse is prolonged. Syncope is attended with unconsciousness and loss of voluntary motion. In collapse the patient is not completely insensible, the mind is to a certain extent clear, and the power of voluntary movement remains. Other varieties of syncope arise from disease of the heart or its coverings. Among them are fatty degeneration ■•n " r .^:■■ i ;Hi: 186 EMEUGENCIES, AND HOW TO TREAT TIIEM. of the muscular fibres, angina pectoris, and pericarditis, with cflfusion. Persons of delicate frame and sensitive nervous organiza- tions are most subject to syncope. Women are alfected more frequently than men. Feeble women, with uterine disorders, will faint from slight injury, or any unusual mental excitement. The symptoms of syncope are clearly marked. The patient is conscious of a sinking sensation in the epigastric region, and about the heart. There are dizziness, dimness of vision, and ringing in the ears {tinnitus auriitm). The features are pinched, and the lips and cheeks are pale and cold. The pulse, at first small and fluttering, is at last im- perceptible. An impulse can scarcely be recognized in the preecordial region. There is also partial or complete uncon- sciousness. Respiratory movements may cease altogether, or a spasmodic, irregular sighing is present. The attack lasts from a few seconds to two or three minutes. It is very rarely prolonged beyond two minutes. Resuscitation would not be possible if the heart's pulsations were absent for five minutes ( Walsh). Recovery is announced by attempts at swallowing, by sighing, movements of the body, restoration of warmth and color to the cheeks, and a return of the radial pulse. In some cases the attack may terminate with nausea and vomiting. Although in most cases syncope is easy of recognition mistakes are sometimes made and erroneous opinions given. It is therefore well to consider the morbid states for which it may be mistaken. There is a class of persons called malingerers^ who, from LOSS OF CONSCIOUSNESS. 137 from sordid or other motives, feign various forms of illness, and Byncope is sometimes simulated. Prostitutes or disorderij characters, in order to escape detention in the station-house, or a subsequent visit to Blackwell's Island, work on the sympathies of the police official, until a carriage is ordered, and they are conducted to the hospital. Once there, unless the doctor in attendance is particularly disgusted with the performance, the patient will likely be dischargad the next day without trouble. These cases are read'iy recognized by the fact that the pulse is beating with its accustomed fulness and regularity, that the temperature of the body is normal, and that an announcement of an intention to draw blood from the arm, or shave the head and apply ice, is fol- lowed by an avowal of tlie patient that she is much better, and will not require further treatment. Ordinary syncope is readily distinguished from hysterical stupor by the fact that the patient has not lost conscious- ness, nor is the action of the heart or pulse cpecially altered. Poisoning from carbonic acid gives a dark, livid color to the countenance, the insensibility is continuous, and the pulse can be felt in the wrist. Poisoning from urea, or Bright's disease, is diagnosed by the accompanying dropsi- cal swelling of the lower limbs, urinous odor, and the pres- ence of casts and albumen in the urine. A person in a state of deep syncope may be considered dead, but if the characteristic signs of death are understood, little difficulty will be experienced in making a correct diagnosis. {See article on Asphyxia, page 147.) Treatment. — In mild cases, where the patient is only partially unconscious, stimulating inhalations of eau-de- cologne, vapor of ammonia, sprinkling the head and face Vi t ^1 188 EMERGEXCIES, AND HOW TO TREAT THEM. with cold water, or placing the patient in a cold draujjjht of air, will suffice to restore sensibility.* Where there is complete unconsciousness, more urgent measures will be necessary. In all cases, the patient should be placed in the recumbent position, with the head lower than the shoulders. This is done in order that the blood flowing toward the cerebrum may have the assistance of gravitation, and also to accelerate the current travelling from the lower extremities toward the heart. All super- fluous clothing should be removed from the chest and throat. Collars, neck-tier>, and other articles which constrict the neck, hinder recovery. The stimulating inhalations of am- monia, etc., are of little avail in complete syncope, for there is scarcely any resj)iratory movement; the nostrils, how- ever, may be moistened with the liquid. Cold water, thrown violently in the face, or sprinkled forcibly on the chest, striking the palms of the hands, and rubbing them rapidly, are efiicacious in all cases. An efficient remedy is to dip a plate in hot water and place it over the epigastric or precordial regions ; either place will answer. All these methods maj be combined in the treatment of individual cases. Should they fail, galvanism may be carefully tried. Too much is worse thiin too little. One pole of the battery may be placed at the upper part of the spinal column, and the other moved up and down over the sternum and prse- eordia. The poles may also be applied abng the course of the spinal accessory nerve. The action of the heart has in some cases been renewed by exciting the spinal accessory and the four upper cervical nerves ( Valentin). The treatment of syncope resulting from excessive haem- orrhage haf neeu discussed in a preceding chapter. CHAPTER XIT. iv' i ! lisem- ASPHYXIA. Beipirfttory Apparatus.— Effects of Non-a6rntion of Blood.— Strangulation.— Com* pression of Thorax. — Inhalation of Poisonous Gases.— Signs of Death.— Drowning. The pathological changes arising from defective aeration will be better understood if we glance briefly at the pro- cesses which regulate the supply of oxygen, and the elimi- nation of carbonic acid. To describe in detail these impor- tant phenomena would lead us beyond the prescribed limit of this work. We must confine our attention to such as have a special bearing upon the morbid actions in question. The respiratory apparatus comprises the larynx, trachea, bronchi, and lungs. The lungs, the heart, and great vessels, are contained within the cavity of the thorax or chest. A large, flat muscle, called the diaphragm, forms the floor of this cavity and separates it from the abdomen. Each lung is composed of bronchial tubes, air-cells, vessels, and nerves. The bronchial tubes commence at the termination of the trachea. They divide and subdivide, becoming emaller as they pass in, until they terminate with a diameter of -^ of an inch in the intercellular passages or bronchioles. Around these passages and terminal bronchi, the air-cells are clus- tered in a manner similar to the arrangement of " leaves on a ■ it ■ D. i'i ) ' i uo EMERGENCIES, AND HOW TO TREAT THEM. tree-branch." These cells measure from -^ to ^^ of an inch each in diameter. They are formed of a delicate layer of mucous membrane, closely attached to which are minute plexuses from the pulmonary artery and veins, and to unite the whole there is a quantity of yellow elastic tissue. According to the calculation of M. Eocheaux, there are 17,790 air-cells connected with each terminal bronchus, and in the lungs, 600,000,000. Prof. Dalton, of this city, esti- mates the amount of surface thus exposed to the action of the air, at 1,400 square feet. The capillary vessels of the pulmo- nary artery and pulmonary veins distributed in delicate meshes on the walls of the air-cells are the channels through which the blood-changes are eflfected. The venous blood, loaded with carbonic acid, is carried by the pulmonary ar- teries from the right siue of the heart to the lungs, where it gives up its load of impurity. The capillaries of the pul- monary veins, which originate in the walls of the air-cells, take up the renovated blood with its load of oxygen, and carry it to the left side of the heart, whence it is propelled to all parts of the body. The interchange of gases and aeration of the blood are effected during the respiratory movements of inspiration and expiration. During inspiration, the diaphragm con- tracts and increases the vertical diameter of the chest, while the ribs are elevated and separated by the actioi of the other inspiratory muscles, thereby mating the lateral diameters greater. A vacuum is thus formed, and the ai^ rushes in. Following immediately is an expiratory move- ment, in which the air is forced out : 1. By the relaxation of the diaphragm, which is pushed upward by the abdom- inal organs resuming their original positions ; 2. The ribs )od are iration n cou- ch est, ioi' of ateral lie aK move- xation bdom- le rib3 ASPHYXIA. 141 are drawn together by the external intcrcostals ; and 3. The lungs, which are extremely elastic, contract and force the air out of the cells. After the air enters the bronchial tubes, a diffusion of gases takes place, and the impure air below i)aB8e8 upward, while the oxygen continues on to the air-cells. After reaching the cells, the oxygen passes by en- dosmosis through to the blood, and is carried off by the cor- puscular elements of the circulatory fluid which have pre- viously given up their carbonic acid. Allowing that twenty respiratory movements take place in a miimte, the air in the lungs will be necessarily changed 1,200 times in the course of an hour. About 17 cubic feet of oxygen are consumed in 2-1 hours, and during the same period from 300 to 400 cubic feet of atmospheric air are supplied to the lungs. Oxygen gas is an essential requirement of a healthy organism. It exerts a remarkable influence rpon both vegetable and animal life. Eight-ninths of the whole mass of w^ater, one-third of the earth's substance, and one-flfth of the atmosphere, are composed of oxygen : no element is more abundant or more important. Repair and decay are closely linked in the animal econom}'. Death is a necessary accompaniment of life. Molecular disorganization, elaboration, and growth of new material, proceed simultaneously. In health the growth keeps pace with loss, in disease waste prepor derates. Dur- ing the physiological interchange of mate ial new sub- stances of a poisonous nature are generated, and are removed by the different emunctories. Should the avenues of escape be closed, life is speedily terminated. For instance, the kidneys eliminate an excrementitious substance called urea, which is formed by the decay of nitrogenized tissue. When ; 1 , I ; p-g^n- iiti! II U2 EMERGKXCIES, AND HOW TO TREAT TIIEM. those orgniis ceaso to abstract tlild material from the Mood, it at'cii Ululates and pi'oduccs convulsions, coma, and final])' death. Carbonic acid, which is specially under considera- tion in this connection, is another product of retrograde metamorphosis. A7hen tiirough disease or accident it is retained, and the blood imperfectly aerated, all the nutri- tive processes are retarded, or entireW stopped. Tiio vitality of the body necessarily fails to approximate to a healthy standard, and latent germs of disease are impelled to an inordinate and even fatal growth. The large mortality in our tenement-houses is sufficient evidence of this truth. Human beings arc crowded together in these dens, in a stifling atmosphere, unfit to supply the wanta of the system. A family of six and seven will some- times be cramped in one or two small rooms, scarcely large enough to accommodate a single person. But it is not alone the evil of a diminished quantity of jxygen that tliese people have to contend with ; tlie surrounding atmosphere is rendered doubly poisonous by the animal exhalations which naturally accumulate and occasion cholera, typhus fever, and other pestilences. In these homes of the poor, these monuments to the grasping spirit of the nineteenth century, death reaps a rich and continuous harvest. And all this must endure until the strong arm of the law compels avaricious landlords to construct houses properly ventilated, and fit for human habitation. As an example of the effects of imperfect ventilation, the suffocation of a large number of persons in the famous oi rather infamous " Black Hole of Calcutta," will be remem- bered. One hundred and fifty persons were confined for a single night in a room eighteen feet square, having but one V : -/I ASPHYXIA. 143 Birmll window. In tlio inoniing only seventeen were alivo. Aa anollier exnmjilo of the evilu attendin*; inijierfect ventila- tion, we niav mention tlio destruction of lite which occurred on an Irish steamer some }'ear9 ago while crossing the Channel. During a storm the captain compelled one hun- dred and fifty of the passengers to go below, and afterward closely fastened down the hatchways. Seventy persons perished before the hatchways were removed. The violent storm prevented their outcries from being heard, otherwise their horrible fate might have been averted. Similar occurrences, but on a smaller scale, are fre- quently brought to our notice. They generally arise from design or neglect. The condition resulting from a complete cessation of the respiratory movements is usually known as usphyxta or ap7t,a>a. The word asphyxia^ derived from two Greek words Bignifying pulselessness, does not define the condition. Ap- ncea indicates the prominent features of the morbid pro- cess with greater accuracy ; but, as asphyxia is the word in general use, it will be adhered to in the present chapter. The first eflfect of obstructing the entrance of air is a re- tardation of the current of blood in the capillary vessels of the lungs and general system. The blood accumulates and moves slowly through ♦aem. Should the ingress of air be still further prevented, this state of congestion ends in com- plete stagnation or stoppage of the circulation. Unaciated blood cannot pass through the capillaries. Prof. Austin Flint, Jr., considers the want of oxygen in the tissues, and the accompanying capillary congestion, as the starting-point of suffocation or asphyxia ; and that the obstruction in the capillaries throws the blood ffi ' f ' 1 1 ^ n;' i'. ;■ ■ IE" . ' j s « ■ I I: ■ ; /, ■ 1, j , 1 . i i 1 'A • f;' 1 144 EMERGENCIES, AND UOW TO TREAT THEM. ^:^i back on tho lioart, antl overpowers it, so tlmt it entirely coascfl. Some cotirtider thivt tlio conf^estion of tho lungs is alono tlio cause of death ; others, that tlio blood going to tho brain, loaded with carbonic acid, destroys tho activity of tho cerebrum, and through it acts upon tho heart and the nerves supplying that organ. "Where so many phenomena exist, involving difterent vital parts, it is almost impossible to separate tiiem, and definitely say which is tho cause of death. To repeat, defec- tive aeration causes tho rapid increase of carbonic acid, and induces capillary congestion in every part of the system ; this congestion demands more labor from the heart, and the con- gestion of the lungs increases the difficult respiration, and makes it more labored. Tho blood, whicli is loaded with carbonic acid, necessarily obtunds nervous sensibility, and, acting through the cardiac nerves upon the heart, combines with the other morbid influences in weakening the contrac- tions of that organ, and bringing about a fatal termination. The morbid appearances after death vary but little with. the cause of the asphyxia. In the majority of cases there is a similarity in the changes. The face generally is of a dark, livid color ; froth or foam, streaked with blood, sur- rounds the mouth. The eyes protrude. In suffocation from hanging, the tongue is swollen and pushed out between the lips Rigor mortis appears soon after death. The lungs are heavy and dark, and contain a large quantity of black blood. The air-cells and smaller bronchial tubes are filled with a sanious, frothy fluid. Blood is absent from the left side of the heart and arteries. This latter peculiarity is due to the elasticity of the walls of the arteries forcing ont the ASniYXIA. 145 blood. It itf not confined cspociully to deuth from suH'oeii- tion, but occurs in otlior fornw. The nuriclo and ventricle on tlio left side of tlio heart are distended with dark blood, and all the blood in the body IB blacker than under ordinary circuinstanccB. This id caused by the abL,enco of oxygen, which gives the circulat- ing fluid a red color. In the liver, kidneys, and spleen, there is generally more or less congestion. There are vari- ous opinions advanced respecting the conditions of the brain. Some modern investigators {Acl'ennan, Dondus) endeavored to show that anffimia of the brain is more com- mon than congestion. This idea, however, is not sustained by facts, or accepted by many in the profession. The cerebral vessels, except in rare cases, are engorged with blood. Having now dwelt on the ])hysiology of respiration, and the pathological changes which depend upon the defective aeration of the blood and total cessation of the respiratory act, we now come to the various forms of asphyxia and their treatment. Strangulation. — This term is generally applied to that variety of asphyxia caused by external compression ; but any mechanical occlusion of the trachea or larynx, whether external or internal, belongs under the same head. The strangulation produced by clasping the throat tight- ly with the arm or hands is the common method employed by garroters. In suicidal attempts, handkerchiefs or ropes are generally used, and the rope is resorted to in most civil- ized countries in judicial strangulation. All cases of hang- ing, however, do not terminate by asphyxia. The neck is usually broken by the fall, and death results from pressure 10 •|: 1 t m ! !• !: I! i J , 146 EMERGENCIES, AND HOW TO TREAT THEM. on the upper part of the spinal cord, and congestion of the brain. The greatest number of strangulated patients who come under the care of the surgeon are those of attempted sui- cides, and every stage of asphyxia, from a slight suffocation to complete stoppage of respiration, may be found among them. The symptoms arising Irnm mechanical occlusion of the air-passages are common in a greater or less degree to all other varieties of asphyxia. They are usually so well mar^:ed as to preclude a possibility of mistake. At the same lime, the history of the patient should always be in- quired into. The patient's countenance presents an anxious expression, and is of a livid color, which, in extreme cases, is almost black. The lips are swollen and somewhat evert- ed, the eyes bloodshot and prominent, the vessels of the head and neck are enlarged to double their ordinary size. There is an intolerable feeling of discoi ifort and oppression over the chest, and intense desire for air. The respiratory movements become rapid, but after a time they are slow and prolonged. There is a momentary increase in the pul- sations of the heart. As the asphyxia progresses, the move- ments diminish in force, until they are totally lost. In the beginning, the patient suffers from giddiness, ringing in the 2.\r {thmitiLS aurium), and great general distress. The agony gives way where asphyxia results from immersion in water, and is succeeded by pleasant visions and dreams. In some recorded cases, these sensations are said to have been so en- trancing as to cause the resuscitated patient to curse his attendai'its for bringing him back to renewed torture. These dreams are followed by insensibility ; the pulse is usually ASPHYXU. 147 abseut, but the action of the heart may still be made out with a stethoscope. So long as an impulse is detected, there is chance of recovery. In asphyxia resulting from violence, there is often an ac- companying condition of syncope. This may resemble death to such an extent as to prevent the continuance of treatment. However, if the points of difference between death and simple insensibility are appreciated, there will be little diflSculty. "When life ceases, the pupils are dilated, the cornea is flattened, and the eyes fixed. There are congestion of the cutaneous capillaries, especially in the most dependent por- tions of the body, and blusness under the finger-nails. (In true asphyxia this congestion is not a sign of much impor- tance.) All respiratory movements have ceased, and no moisture will appear on a looking-glass held over the mouth or nose. The pulsations of the heart cannot be made out with the ear or stethoscope. Another test has been proposed lately by a French gen- tleman, -eho states that, if a bright steel needle be inserted into the dead body, it will become tarnished ; if introduced into the living body, it will come out perfectly clean. If a prepp.ration of Calabar bean is applied to the eye while life is present, the pupil will contract ; if ueath has taken place, no effect will be produced. A muscular rigidity {rigor mortis) ensues soon after death, and a peculiar, oflensive odor is emitted. Treatment.— The, treatment of strangulation from for- eign bodies in the air-passages has been considered in a pre- vious chapter. When strangulation results from external compression of the throat, a careful examination should bo instituted to ascertain the amount of local injury. Lacera- I r l\: I' < u-^ 148 EMERGENCIES, AND HOW TO TREAT THEM. tion or fracture of the larynx or rings of the trachea may cause pieces of cartilage to prctrude on the internal surface. Such obstructions must be removed, in order to render the treatment effectual. All superfluous clothing should be re- moved from the chest and neck, and the mouth and throat cleared of mucus. Artificial respiration, either by Mar- shall's, Hall's, or Sylvester's methods, must then be tried. The manner of employing these methods is hereafter fully explained. It is at times necessary to perform tracheotomy {see Tracheotomy), and to fill the lungs by forcing in air with a bellows, or with the mouth applied to the opening. In addition to artificial respiration, the surface of the body should be briskly rubbed to keep up the circulation, and stimulants administered through the rectum. 7is in cases of hanging there is congestion of the brain, a few ounces of blood can be taken from the arm with benefit. Compression of the Thoracic "VYalls producos suffoca- tion by preventing the expansion of the lungs and admis- sion of air. It usually occurs from jamming, or by being crushed beneath embankments or masses of building mate- rial. In the former case the sufferer is usually very much frightened. The arms are thrown involuntarily above the head, leaving the chest exposed to the pressure of the crowd. Persons in large crowds can, with ordinary pre- cautions, protect the chest by keeping the arms and elbows close to the side of the chest, flexing the forearm, and bringing it in front, thus making the hands meet in the median line. Unless extraordinary pressure is made, this method will allow of sufficient respiratory movement to eustain life. The notorious resurrectionist and murderer, Burke, usU' ,(• ASPHTXIA. 149 ally destroyed his victims by compressing tlie thoracic walls. With this variety of asphyxia there may be more or lesa bruising and laceration of the chest-walls, but the general pymptoms and treatment are the same as given above. Suffocation from Indalation of Gases. — The inha- lation of nitrogen or hydrogen occasions the same changes and symptoms as are witnessed in other forms of asphyxia. Nitrogen exists in large qaantitieo in atmospheric air. When inhaled in a. pure state, it destroys life with greater rapidity than other gaseous bodies. The inhalation of sulphuretted hydrogen, carbonic acid, carbonic oxide, carburetted hydrogen, etc., should be treated under the head of poisons. As death in these cases, however, is usually attributed to asphyxia, and as the treatment if« the same, they will be considered in this section. Sulphuretted hydrogen is a product of the decomposition of animal matter. It is found in sewers, old drains, and stagnant pools. The foul odor of " rotten eggs " is due to tliis gas. "When inhaled, it proves rapidly fatal. Accord- ing to Flenard, one part in a hundred and fifty of atmos- pheric air will kill a horse. Men can bear larger propor- tions. Small quantities of s'llphurettcd hydrogen, inhaled in a diluted form, give rise to nausea, vomiting, pains in" the abdomen and extremities, vertigo, and a semi-paralytic condition of the extremities. In large quantities, it pro- duces rapid insensibility, convulsions, and death. The body exhales the characteristic odor of the gas. After death the mouth and fauces are coated with a dark-brown f) 160 EMERGENCIES, AND HOW TO TREAT THEM. mucus. The muscles and all the internal organs are dark- colored, and the blood is fluid. Carbonio acid, or di-oxide of carbon, is found in large quantities in the bottom of wells, coal-mines, and in all dark, damp situations, where organic matter is in a state of decomposition. In coal-mines it is usually known as " choke-damp," and death is often caused by its inhalation. This f^Tibstance also results from the physiological decay of living bouies. An atmosphere containing one-tenth of carbonic acid will produce death. Its effect on the system is that of a narcotic poison, although, when death results from its in- halations, it is commonly said to cause suffocation, or as- phyxia. The symptoms attending its inhalation, with one or two exceptions, resemble those occurring in ordinary asphyxia. There is at first marked loss of muscular power, with ten- dency to sleep, and the countenance assumes a leaden hue. After death tlie eyes remain bright for some time, and sev- eral hours elapse before rigor mortis sets in. Charcoal-vapor consists of carbonic acid, carburetted hydrogen, free nitrogen, and atmospheric air. This vapor is often used as a means of self-murder. In France it is frequently employed for this purpose. Suicides burn the charcoal on a brazier, in a close room, where all the crevices for the admission of air are shut off. The vapor at first creates a sensation of extreme languor and general weak- ness. This is soon follo.ved by complete insensibility. In some of these cases the countenance is pale, and the jaws are usually fixed. After death the heart is empty, or a little black blood may occupy its right ventricle. ASPHYXIA. 151 Coal-vapor. — The materials arising from the ordinary combustion of coal are sulphurous acid, carbonic acid, sul- phuretted hydrogen, and carburetted hydrogen. It is im- possible to inhale this vapor under ordinary circumstances. It possesses such irritatin;^ qualities that, unless a person u stupefied with alcohol or other narcotics, he will escape be- fore a sufficient amount is taken in to destroy life. Occa- sionally, persons are suffocated in holds or cabins of vessels from this vapor. A sad instance occurred recently in New- York harbor. Five seamen shut themselves in the forecastle, where a brazier* of coal was burning, and in the morning were found dead. Coal-gas. — This substance is employed for illuminating purposes. It consists principally of light carburetted hydro- gen, carbonic oxide, olefiant gas, hydrogen, nitrogen, etc. Its odorous principle is due to vapor of naphtha. Carbonic oxide is supposed to be its principal poisonous ingredient. If the atmosphere of a room becomes impregnated with twelve per cent, of the gas, a lighted candle introduced will cause an explosion. Accidents arising from coal-gas arc generally the result of carelessness or ignorance. Neglect- ing to turn the gas off, and leakage in the pipes, are the common causes. The effects produced by its inhalation dif- fer from other varieties. There are more or less vertigo, nausea, and vomiting, a semi-paralytic condition of the muscles, and convulsions ending often in death. After death the blood is sometimes of a light-red color. Treatment. — In all these varieties of suffocation, inhala- tion of oxygen gas will bring about speedy relief. Where respiration has ceased, it must bo restored by artificial methods. If necessary, oxygen may be forced into the ■1, : ■■ '«,l! ,11 * L52 EMERGENCIES, AND HOW TO TREAT THEM. lungs in tlio manner previously mentioned. Cold water, poured on the surface of tlio body, is likewise beneficial. DROWNING. The length of time that persons can remain under water, and afterward be resuscitated, varies according to the cir- cumstances attending each individual case. When timid persons become accidentally submerged, they throw up tlie arms, open the mouth to shriek, and consequently fill the lungs with water and strangulate at once. If presence of mind is not lost, the arms kept under water, and the res- piratory movements controlled until the head comes above the surface, life may be prolonged a considerable period. Again, should the submerged individual faint, the chances of resuscitation are good even when several minutes have been spent without air. The fit of syncope is attended with a stoppage of respiration and of the heart's action, and, the demand for oxygen being diminished, the system does not feel the loss as it would under other circumstances. Occa- sionally, life is destroyed after an immersion of one minute, while in other instances persons remain under water for two and even three minutes without receiving injury. Thus sponge and pearl divers, who spend a great part of their working-hours under water, remain deprived of air for two or three minutes with but little discomfort. Marac relates the case of a Gennan woman who was tied up in a bag with a cock and cat, and thrown into the water as a punishment for child-murder. She was submerged fifteen minutes, and, when removed from the bag and exposed to the air, imme- diately recovered. Such a prolongation of life without air can only be accounted for on the supposition that the woman ' ,' ., ■VI ■ ASPHYXIA. 153 fainted on being ininiersed, and that the state of syncope lasted until she was brought to the surface. A coranutteo of the lloyal Chirurgical Society, London, instituted a series of experiments to ascertain the length of time animals could sustain life without a supply of oxygen. A brief siatoment of the principal results will bo of interest. It was ascertained that, when the entrance of air was pro- vented by submursion, death was more rapid than when the trachea was thoroughly closed with a plug. When the trachea was simply plugged, the respiratory movements con- tinued from three to four minutes and a half, and the action of the heart was perceptible from six to seven minutes and a half. As a rule, the heart's action continued two or three minutes after respiration ceased. "When animals were kept under water one minute and thirty seconds, death followed, even when the animal was taken out alive. No efforts were made in any of these cases to restore life. If respiration had been artificially produced, they would have probably recovered. The striking difference in the period of death in the two classes is explained by the fact that, in simple plugging of the trachea, sufiicient air remained in the lungs to maintain life for a short time, while in the other, water found its way into the lungs and displaced the air which might otherwise have been reserved for aeration. Some contend that water does not enter the lungs of the drowned, but the results o£ post-mortem examinations do not confirm this statement. Water, sea-weed, and other extraneous matter, have been found in the bronchial tubes in the major- ity of cases. It is true that at times there is not the slight- est trace of water. This circumstance is, however, excep- tional. The remarkable power of absorption possessed by fi '■ 164 EMERGENCIES, AND HOW TO TREAT THEM. i^"H the lungs may account for the rapid disappearance of the liquid. As human beings, when drowning, alternistely sink below, and rise again to the surface of the water, occasion- ally giving them opportunity to obtain a fresh supply of air, we cannot definitely determine the maximum of time they can remain under water and yet recover afterward. The experiments qaoted are not proper criteria to judge by in the majority of drowning cases. Waen submersior is con- tinuous, however, fivt minutes is the longest period after which lire may be restored. There Ib a peculiar condition, known as secondary asphyxia, which occurs at ti les in per- sons who have been restored by artificial lespiration. It shows itself generally within lbr*y-eight hours after respira- tion has been fully established. When the symptoms seem favorable, and all anxiety removed, the patient is suddenly seized with urgent dyspnoea, the chest expands imperfectly and irretj, ularly, the patient struggles for breath, and in a short time all the worst features of asphyxia return. Death soon supervenes, unless immediate relief 'a afforded by arti- ficial respiration. The cause of this change is not well un- derstood. It is probably due to congestion of the lungs, induced by some active movements on the part of the pa- tient. The exercise sends more blood to these organs than they, in their weakened condition, can provide for. Exces- sive and laborious respiration immediately follows. The ap- pearances presented in asphyxia resulting from immersion varv somewhat from other kinds. The livid discoloration of the face and fulness of the blood-vessels are not so dis- tinctly marked. There are more general pallor and coldness of the surface. Rigor mortis or post-Tnortein, contractlone of the muscles appear very soon after death. ASPHYXIA. 155 Treatment. — There are four special rcquisilxjs in the treatment of drowned persons : 1. Artificial respiration / 2 Warmth; 3. Friction; 4. Stimulation. All these are employed together, but the first is generally relied on. Strip the patient of clothing, and envelop the body as fai as possible in warm blankets. Then clear the mouth and throat of water, mucus," or other substance which might pre- vent the ingress of aii'.* To do this perfectly, cover the index-finger closely with a handicerchief, and carry it in as far as possible, and sweep it around the pharynx and upper part of the larynx. The cloth takes up more of the moisture than the finger alone would. The tongue is now drawn out at; far as possible. Unless the organ is pulled forward with considerable degree of force, the ary teno-epiglottidean folds at the upper border of the larynx will close the aperture suflScieutly to inter- fere with the admission of air. This is a point of consider- able importance in all cases where artificial respiration is resorted to, and cannot be too strongly insisted upon. A forceps attached co the extremity of the tongue, or a towel wrapped around its end, and grasped with the thumb and forefinger, will make traction easy. Having cleansed the air-passages, we try some of the methods of artificial respira- tion. vVhen the immersion has been short, and the patient 0'o\v partially asj^ hyxiated, simple compression of the lower half of the thorax and upper ])art of the abdomen will answer. The hands are applied on 'jacli side of the chest- walls, the fingers reaching as high as the nipple, and firm * Some advise C'lspension of the drowned person by the limbs, in order to facilitate the escape of water from the lungs ; but this is an unnecessary pro cedure. Ip ' '' 15U KMKIKJHNl'IKS, AND HOW TO TIIKAT TIlKM. .» j' propHuro tinulo to dimiiilsli tlio avity of the cliofit. Tho IimikIb aro then lilted Tor a low bucoikIh, iiiiil tliu iMUtrt iillt>\vi»(l to rertuino tlioir imtuml position. Thirt is \pan8ion a certain amount of frchh air pas^^cs in. Thirt intiM'chungo gives moro oxygen to tho blood, and relii'vert it of carltonio acid, Htimuhili'S tho circulation, and through it tho ncrvo-muscular a[>pavaturt, and limilly restores all tlio functiona of life. In novero eawes, either Marshall llaU'a ov Hylvcsti'r'a method of artificial respira- ti»tn is to bo prelerred. Tho latter U m'n\ to be sniicrior, as it onablea more air to ]>asrt tnit of and enter thu chest. Tho prelimitiary 8tep^<, hjicIi aa cloaring tho thr-jat and drawin" out the tongue, aro tho HMinu. In Marshall Ilaird nu>lliod tho patient in placed on llm nldo, with tho arm t(»\vard tho pt»Hterh>r plane of the body. Tho body is then n)lle(l alowly over on tho face, whilo tho handa of tho surgeon attheaamo time aro pressed ilrmly on tho back ami t*idca of tho chest, diminishing its cavity. When thia movement la coinplott'(| tho ]Mitient is turncil on his back, and tho cheat-walla re- sumo their original position ; theao movements aro to bo kept up until natural respiration is resunu'd. Tho principal elVect to bo produced in all cases is a renewal c»f tho air in tho lungs. In Sylvester's method tlio j)alient is placed in tho recmnbent position, with tho head and chest somewhat raised. The operator stands at tho head of tho patient and grasps both arn\rt wildway between tho elbow and wrist- joint, uuning them gradually to a vertical position so aa to make them nearly meet alH>vo tho head. They aro held in AsrnYxiA. 157 fliifl pohitioii for :i nioinont, ftniglottidcan folds are reduplications of mucous membrane which loosely cover the cuneiform cartilages. Large, irregular pouches, which are here developed by tlie inMltration of serum, hang over the laryngeal aperUire. Tliese bags are forced in with each inspiration, making the opening still smaller, and seriously obstructing the ingress of air. (Edema Glottidis occurs more frequently in adults than in children ; the reasons for this are — 1. That in early life the mucous membrane of the larynx adheres more intimately to the adjacent tissues. An exudation of any kind from the blood-vessels would therefore appear on the free surface of the membrane, and not on its attached portion ; 2. The (EDEMA QLOTTIDia 173 disoagcB wliicli occoBion ocdoina aro moro coinniuu in ad- vunced life than in youth. The alFection doponds on conditions which give riso to exudations of scrum in other parts of the body, such as obstructions to the circulation ; inflamniations, lack of tonicity in tho vascular walls, or a watery condition of the blood. It is not unusual during tho progress of all chronic kidney-diseases, erysipelas, small-pox, continued fevers, etc. It is in most cases an attendant of acute and chronic inflammation of the larynx ; it may arise, however, as an independent affection. "When it proceeds from inflammation, Virchow applies to it the term collateral oedema. The inflammatory stasia ofl'ers an obstruction to the circulation in the diseased part, increases the pressure in the blood-vessels, so that the watery portions exude in the areolar tissue. Exceptionally, it has been known to occur in thoracic aneurism, and in quinsy sore-throat, and pharyngitis from extension of the inflammation. Whether occurring alone, or in connection with local or constitu- tional disease?, the symptoms of oedema glottidis are dis- tinctly marked. The patient complains of great difiiculty in breathing, which seems to proceed from an obstruction located in the throat, and he coughs violently in order to eject it. If the epiglottis be involved to any extent, there will be pain in the act of swallowing. The difficult respira- tion rapidly increases. Exi, '^me distress is apparent. The l)atient grasps the throat violently, in vain endeavors to relieve himself, and begs and prays for help. The respira- tion is hard and rasping in character. The voice is usually husky, but it may be clear if no inflammation is present. More difficulty is experienced during inspiration than with M li; I'M t' I i 174 EMERGENCIES, AND HOW TO TREAT THEM. )' i expiration, owing to the fact that the pendulous bags of serum at the edge of the larynx are forced down by the current of air, and almost completely close up the canal. The expiratory act will be found comparatively free. If laryngeal inflammation be present, both inspiration and expiration will be difficult. On examination of the throat the epiglottis may be seen enlarged and prominent, and, if the finger be carefully inserted, the puffy, oedematous swelling is readily felt. If the symptoms are not relieved, the patient soon dies asphyxiated. The duration of oedema glottidis is variable. It may destroy life in a few moments, or it mav last for hours before a fatal termination. Treatment. — There is no time for vacillation in these cases. Some measure for relief must be instituted without delay. Should the affection be complicated with laryngitis, and the dyspnoea not very urgent, a brisk cathartic may be given, and leeches may be applied to the top of the sternum, and at the sides of the neck. Leeches should never be applied directly to the larynx in inflammation, as a great deal of local cedema generally follows the bite. In the majority of cases this kmd of treatment will not pvail much; operative measures have to be resorted to. Local scarification, as employed by Dr. Buck, of this city, is highly recommended. In performing this operation, a curved bistoury, covered almost to the point with adhesive plaster, is used, The forennji,er of the left hand is passed down to the back of the tongue until the swelling is reached. The kuife is tlien introduced, following the finger as a guide, and the bags of serum are punctured. Great care must be taken not to wound any part but the oedematous I .' (EDEMA GLOTTIDIS. 175 atrictwre, or the flowing of blood into the larnyx may chote the patient before the oedema is removed. Scarification is sometimes rendered extremely diflBcnlt, because of the efforts at vomiting induced by the irritation of the finger in the throat. In such cases perseverance ceases to be a virtue, ^nd tracheotomy or laryngotomy should at once be performed {see pa'jes 89, 90). Either of theee operations may be performed in all serious cases. V'l a n CHAPTER XYI. CONVULSIONS. Infantile Convulsions. — Convulsions ft-om Urromic Poisoning, Cerebral £xtrav»« sation, Hysteria, Alcohol, Epilepsy, Tetanus. Syno7iymes. — Eclampsia, Fits, Falling-Sickness, Spasms. A convulsion is an involuntary contraction jf one or more muscles, with or without loss of consciousness. The sensorial and intellectual faculties are seldom aifected ex- cept in general convulsions. The muscular contractions may be either tonic or clonic. In the former the spasm is continuous, in the latter each contraction is followed by relaxation. The spasmodic movements succeed each other v;ith rapidity. Tonic contractions appertain especially to tetanus. The clonic variety is peculiar to epilepsy and all other classes of convulsions. Convulsions depend either on an irritation transmitted from the periphery to the nerve-centres, or on an abnormal irritability, arising directly in the nerve-centres, which calls forth excessive and irregular action in the motor nerves. According to Longet, sensations coming from the pe- riphery to tlie brain are converted into motor impulses through the tuber annulare. Irritation of this ganglion, whether proceeding from ex- ternal sources or acting through the blood, wi^l excite irreg- ular muscular movements throughout the body. CONVULSIONS, 177 ConTulsions are merely symptomatic j)lieiiomena, repre- senting diverse pathological conditions ; the sigiuticance of a convulsion, therefore, depends upon its cause : it may be the premonition of deaMi, or only the result of hidigestion. Convulsions may occur at ^ny age, but they are most fre- quent during infancy. The rapidly-developing delicate tissues of the child pos- sess a susceptibility which intensifies every irritation, and slight causes will excite irregular action and disarrange the nervous system. As children advance in years this sensi- bility decreases, and consequently they are less liable to convulsive attacks. In adult life, except under the form of epilepsy, they are comparatively rare. Infantile convulsions usually occur during tlse ilist den- tition and early part of tliat period. The first few months after birth give the greatest percentage of cases. Convul- sions in utero have been recorded by some observers. Children whose parents have been subject to eclamptic attacks are more liable than others to the affection. Causes insignificant in themselves develop this liereditary ten- dency. A debilitated state of the system is a predisposing 3ause. Those who have soft skulls from rachitis suff*er fre- quently from convulsions. As exciting causes may be enu- merated : indigestion, worms in the alimentary canal, teeth- ing, burns, scalds, eruptions, foreign bodies penetrating the integuments, the application of mustard-poultices, and blis- ters, fright, affections of the brain, such as meningitis, con- gestion, tumors ; exanthematous disorders ; degenerations of the kidneys, pneumonia, bronchitis, etc. The attack in many instances can be traced to indiges- tion, solid food in the alimentary canal, uuhealtliy milk, and 12 178 EMERGENCIES, AND HOW TO TREAT THEM. pi Mil • ( I m arrow-root, or other articles partially cooked, and reroaiuiiig unacted upon by the digestive fluid. An irritation is con- sequently produced, whicli is carried by the sensory nerves to the brain, and convulsions follow. Worms in the ali- mentary canal have a direct irritating action upon the mu- cous membrane of the intestines. They also diminisli the digestive functions, and lower the vitality of the system ; hence both cause?, acting toge'.her, may excite the abnormal muscular movements. During the first dentition, convulsions are remarkably frequent. In fact, the grent majority of diseased peculiar to infancy develop during the evolution of the teeth. At this time the swollen and tender gums give rise to constant irritation. The child becomes fretful and feverish, and if there happen to be a very slight predisposition to convulsive attacks we may depend upon their occurrence. Convulsions proceeding from the reflex irritation of teething are said to be more serious than other varieties, and paralysis is not an uncommon sequence. Irritating applications to the integument, in the form of blisters or mustard-poultices, are attended with danger. Great care sliould be exercised in their application. A blis- ter scarcely two inches square may cause alarming attacks. Diseases of tlie brain in children are usually marked during some part of their course by convulsions. In acute hydrocephalus they occur in the later stages of the disease — exceptionally they appear in the first stage. M'.;.;/ of the narcotic medicines cause convulsions, Poison ii 'J. 1:-',' 3tramonium-seeds is not uncommon. The only reliable vejt of this occurrence is the presence of ihe seed'- in ^Iv: uuxildV vomited. CONVULSIONS. 179 Convulsive movements mav affect all the muscles of the bodv, involuntary as well as voluntary, or he Ihnited to a single muscle, or to one set of muscles; one side of tlie hody may alone he convulsed, or alternate convulsions of each side, or of different limbs, may take place. In the affection known as inward convulsions the dia- phragm, the muscles of the abdomen and thorax, and oc- casionally the muscles of the larynx, are involved. The symptoms of eclampsia can conveniently be divided into premonitory and immediate. The premonitory signs, however, are not always present. For a variable length of time preceding the fit, the child may be feverish and restless. The sleep is disturbed, and muscular twitchings are observed. If teething, tlie child moans, moves its head about, and the jaws are worked from side to side. If undigested food or worms are present, there will be a tympanitic abdomen, and eructations of gas from the intestinal canal. In brain-affections, the abdomen is flattened; there may be vomiting, projectile in character, and without nausea. There is pain in the head, and, when carried rapidly from one place to another, the child screams violently. The convulsive movements commence suddenly. The child cries sharply, and falls. The muscles for a moment become rigid. The corners of the mouth are drawn down, the eyes are either fixed or oscillating, generally the former. There may be either convergent or divergent strabisnms. Respiration ceases. The child's face, which -was at first pale, becomes livid, the veins of the face and neck are turgid and filled with blood, and a gurgling noise is heard in the thront. The rigid condition of the muscles, or tonic !<^3\|uii*e an importance which they do nut possess (;>sr»>^ infantile life. In many cases they indicate the ■[X'esoHce of constitutional lesions, which may bring about a fatal termination in a short period. An extended dc'Scri]^>tion of the diseases which give rise to these convulsions is, with the limited space at command, inad- missible. All the prominent features of ea^-h condition, and especially the different signs which lead to a correct diag- nosis, will, ho>wever, be fully considered. Thc-.c points of difference cannot be too closely observed, and they should be studied more carefully than the points of resemblance. These c-onvulsions may be classed under five separate heads : 1. Tbose which arise from the retention of urea in til© Wood in disease of the kidneys^, viz., ursemic convulsions ; •^. Convukions which characterize epilei)«y ; 3. Those Ssing from affections of the brain, sn';h as extravasations oL blood in its substance, or upon its surface ; 4. Hysterical p 111 184 EMERGENCIES, ASD UOW TO TREAT TIIEVf. convulsions, and 5. Convulsions tlue to the excessive use of alcohol. 1. Uii.KMio Convulsions. — la the chapter on urannic coma, the source and character of the poison {urea) which accumulates in the blood in Bri<;ht's disease of the kidneys were fully considered. It is said to act on the base of the brain and medulla like any other irritant, calling forth irregular and violent muscular movements. These convulsions may also bo due to oedema of the brain-substance, which exists in common with oidema of other parts in Bright's disease {Rohertu). The pressure of the ell'used serum empties the arteries, and diminishes the amount of blood in the organ. Preceding the commencement of the convulsion, the patient complains of headache, dimness of vision, dizziness and other symptoms referable to the nervous system. The stomach is irritable, and the bowels are usually relaxed. The countenance has a pale, waxy appearance. There is Gideraa under the eyes. Pressure on the lower limbs may leave a pit or indentation under the finger, showing the presence of ajdema. Coma may or may not occur before the paroxysm. The urine may be scanty, and of a high color. It must not, however, be forgotten that ursemic convul- sions, occurring with the small contracted kidney, may have none of these characteristic symptoms of diseased kidney preceding them. The paroxysm appears suddenly. The body and extremi- ties become violently convulsed. Spasmodic contractions of the clonic variety succeed each other rapidly. The face becomes livid, the eyes are glassy and fixed, or may oscillate I I CONVULSIONS. 185 from Bido to side {iiystagmus). The pu[)ils arc coTitructid or diluted, usually the latter. Froth, mixed Bometimes with Mood, collects around the mouth, and in exceptional cases the tongue may bo bitten. There is a strong urinous odor emanating from the perspiration. "When the convulsions cease, the patient sinks into a deep eoma, which usually endb in death. There may be only one convulsion, or the convulsions may succeed each other at short intervals for several hours. The points of ditlerencc which distinguish a uvcemic convulsion from epilepsy, or from apo])lectic convul- sions, require careful investigation. In ureemic convulsions both sides of the body are equally aft'ected by the spasmodic movements. lu epilepsy one side is convulsed more violently than the other. There are few exc .^/tions to this rule. In urcemia -we find oedema of the face and extremities, and urinous odor to the perspiration, vhicli are generally absent in cerebral extravasation and in epilepsy. A chemical and microscopical examination of the urine will probably show, in ursemia, albumen, and fatty, granular, or hyaline casts, while in epilepsy and cerebral extravasation they are usually absent. In one case we have an antecedent history of Bright's disease of the kidneys ; in epilepsy a history of previous convulsions, with perfect health during the intervals. The tongue is generally bitten in true epilepsy, rarely in a urajmic convulsion. Following the latter, there is deep coma ; in tlie former merely a deep sleep, from which the patient may be aroused. In cerebral extravasation there is paralysis with irregularity of the pupils, which is not present in uraemia. In the former also there is sometimes rigidity of the muscles following the attack ; in the latter, this is rarely manifested. The treat- IMAGE EVALUATION TEST TARGET (MT-3) /. \^ W6 1.0 l.i 1.25 ■- IIIIM ■ 50 ""' M ■^ i^ III 22 1^ lii lis 11= U IIIIII.6 V vl ^c*l ^ ^». 'roathotono8\ contractions of one side give a lateral inclination, c&Wed jpleurosihotonos. When tetanus is once fully established, a breeze, the creak- ing of a door, and other slight causes, suffice to excite a con- vulsion. Tonic spasm of the respiratory muscles generally kil'9, the patient dying from asphyxia. Treatment. — Ancesthetics, opiates, chloral, or assafoetida, can be administered in large quantities. CHAPTER XVII* SUSPENDED F(ETAL ANIMATION. PreiBure on Umbilical Cord.— It^jury to Brain.— Eupturo of Umbilical Cord.-* Asphyxia.— Syncope. — CongoBticn of Brain. DuBiNO the progress of labor the child is subject to many accidents which may supend for a time tlie functions of life or completely destroy it. Thus, the umbilical cord may be pressed upon by the head in its passage through the straits of the pelvis ; the cord may be wound around the neck ; the air-passages filled with mucus so that the child's blood remains unaerated, and a condition of asphyxia in- duced. Profuse hcemorrhage, due to rupture of the cord or to separation of the placenta, occasions another variety of sus- pended foetal animation known as syncope. The head may be compressed in the maternal passages, or by instruments, with such severity as to cause congestion of the brain. Of these three conditions asphyxia is most commonly met with. The child in this, as in the former cases, is born apparently lifeless. The face is swollen and of a dark-blue color, and the lips are livid and everted. The extremities and general surface may present a similar appearance. Respiratory movements are absent, or there may be a slight gasp, repeated at long intervals. The pulsations of "■ill fl m\ 196 EMERGENCIES, AND nOW TO TREAT THEM. the heart are extremely feeble ; as long as any movement can be diatinguished, there is hope of rcBuscitation. A favorable result is scarcely ever obtained when the heart has entirely ceased its action. In cases where the asphyxia is produced suddenly, lividity may to a certain extent be absent, but this is rare. In the second variety, or the state of syncope, the child is pale and cold. The lips are colorless. Ilespiratory move- ments are sighing in character or absent. The extremities are limber and flaccid. The pulse cannot be detected at the wrist, but weak pulsatory movements of tlio heart may be heard with a stethoscope. When congestion of the brain exists there is some li- vidity about the head and face, but the color is not so dark as in asphyxia, and the capillaries of the extremities do not present the same blueness. Treatinent, — In all cases exertions to restore life should be made so long as the faintest movement of the heart can be detected. Life has been restored after an liour's labor, and it is not uncommon for a child to remain for half an hour without breathing, and yet be finally restored. Even when respiration has been established the treatment should be continued until the child cries vigorously. In the first variety, where asphyxia exists, the child may be plunged alternately into warm and cold water to excite respiration through the sensory nerves of the cutaneous surface. Slapping the body at the same time with the flat of the hand is also beneficial. In mild cases this method alone will answer. Should they fail, artificial respiration by Sylvester's method (see chapter on Asphyxia), or inflating the lungs by insufflation, must be tried. In doing this the SUSPENDED F(ETAL ANIMATION. 107 mouth and throat of tho patient must be cleared of mu- CUB, the larynx pressed against the spinal cohimn to pre- vent air from entering the cesophagus, while the physician, with his lips applied to those of the child, blows steadily into the lungs until they are expanded ; when this is done pressure is made on the lateral walls of the thorax to force the air out. Again they are inflated and again compressed until the respiratory movements are naturally performed. Sylvester's method is preferred above all others. The chief raquirement in the condition of syncope is to furnish more blood to the child. This is accomplished by "stripping" the cord from the placenta toward the child's abdomen, i. e., pressing the blood along the vessels to the child. Friction and warmth to the surface are also neces- sary. In the congestive variety the umbilical cord is cut at once and allowed to bleed freely for a few minutes, while the surface is rubbed and respiratory movements assisted by alternate pressure and relaxation on the thoracic walls. 11 u n. CHAPTER XVIII. COMPLICATIONS OF LABOR, ETC. Bupture of tho Uterus.— Prolapse of the FuniB.— Short Cord.— Irregular Pre- Bout«tio".8. — Application of tlio Ttuiipon. Rupture of the Uteuus.— Among tho serious accidents to which parturient women are exposed there is no* one more serious than rupture of the uterus. It is one of the worst complications of labor. The prognosis in all cases is bad. This accident is of more frequent occurrence in mul- tipara, or those who have passed through several labors. Women in labor with the first child are not liable to it. The successive enlargements of the uterus diminish tho strength and firiiiuess of its walls, and develop a tendency to rupture. Rupture of the uterus may occur at any period of utero- gestation, but usually it takes place during tlie second stage of labor. At this period the resistance to the uterine con- traction reaches its maximum. The head of the child en- gages against the bony walls of the pelvis with considera- ble force. If, now, tho liuea ilio-pectinea be abnormally prominent and labor delayed, tho contractions force the neck of the uterus against this part, and laceration results. In nine cases out of ten the rupture starts at the neck, but it may commence in other portions of the uterine walls. COMPLICATIONS OP LABOR, ETC. :li^^'^:: 199 Abnormal thinness of the uterine walls, and fatty de- generation of the uterine fibres, are liable to cause rupture, if there is the slightest over-distontion or obstruction to the free passage of the head. Great distention from multiple foeti or monsters, even where the uterine walls are of normal thickness and structure, is an exciting cause. Deformities of the pelvis, by obstructing the passage of the child, and increasing the internal pressure on the walk of the uterus, introduction of the hand or instruments into the uterus, are not uncommon causes. Eupture of the uterus may also arise from blows on the abdomen, or from violent straining efforts. The dangers from rupture of the uterus are shock or collapse, hcemorrhage, peritonitis, or metro-peritonitis, and strangulation of intestines. The principal and immediate danger arises from hcem- orrhage. The flow of blood from dilated vessels of the uterus may put an end to life in a few moments. If the contractions of the uterus continue after the accident, there will be less danger of bleeding. In connection with the eft'ects of loss of blood on the system, there is more or less danger from shock. In all injuries to internal organs this peculiar sudden loss of vitality is present. Sometimes the loss of blood is slight, but the shock is so great that the patient never rallies. When immediate danger from hremorrhage and shock has passed, peritonitis or metritis is apt to 8n])(,'rvcnc. If tlie inflammation of the peritonreum be of any great extent, if it involve more than that portion covering the uterus, a fatal tennination may be expected. After the rupture has occurred, a portion of intestine 200 EMERGENCIES, AND HOW TO TREAT THEM. V I ] ■■ m i may pass througli the opening, and be tightly strangulated by the contracting uterine walls. If this complication have not been recognized by the hand in the uterus, it will soon manifest itself by violent vomiting, at first of the contents of the stomach, and then of fecal matter, and by obstinate constipation, pain and tenderness over the abdomen, and finally collapse. At the time of rupture the woman shrieks loudly, and complains of an agonizing pain in the hypogastric region. If the physician be near the bedside, a distinct " tea^ " may be heard. There is a gush of blood from the vagina, and the presenting portion of the child immediately recedes. In many cases the child can be felt in the abdominal cavity outside of the contracting uterus. The patient's coun- tenance becomes excessively anxious and pallid. The pulse is rapid and very feeble. In severe cases the patient may succumb at once. If the patient survives the combined efiects of shock and haemorrhage, there is still very little chance of escaping metro-peritonitis or other complications of the accident. Treatment. — In every case the child should be delivered at once. If the head is within reach, the forceps can be used, or version performed to efiect that object. When the child has passed completely out of the uterine cavity. Prof. T. G. Thomas, of this city, recommends the performance of gastrotomy, and abstracting the child through the open- ing in the abdomen. He believes that the danger to the mother's life from the operation is not so great as when the child is taken out through the natural passage, because in this latter case some portions of the intestine are almost certain to be caught in the opening and strangulated ; and COMPLICATIONS OF LABOR, ETC. 201 also that an opening in the abdomen, besides obviating ihis danger, gives an opportunity to clean the cavity of all blood or portions of placenta which would excite peritonitis. Other authorities recommend the introduction of the hand in all cases without exception, and the delivery of the child through the natural opening. In so doing, great care should be taken to prevent portions of the intestine from being dragged through the hole in the uterus. Stimulants are to be freely administered to counteract the effects of the collapse; styptics, to prevent hcemor- rhage, and opiates in quantities sufficient to relieve pain, are always necessary. Peolapse of the Funis. — "WTien the umbilical cord enters the vagina in advance of the child's body, it is said to be prolapsed. If labor proceeds under such circum- stances, the cord is compressed against the walls of the pelvis, and the aerated blood coming from the placenta cannot reach the child. If this pressure is maintained for many minutes, the child dies asphyxiated. Prolapse of the funis occurs once in every two hundred and fifty cases {Thomas). It is caused by unusual length of the cord, sudden escape of liquor amnii, excessive quantity of liquor amnii, transverse presentations, and obliquity of the uterus. If the membranes have ruptured, the cord can be recog- nized by its isolation from surrounding structures, and the rapidity of its pulsations. The pulsations are synchronous with the movements of the foetal heart. Treatment. — If a diagnosis is made before tlie head is engaged in the superior strait, the patient should be placed on her chest and knees ; the hand of the attendant should 202 ElIERGENCIES, AND HOW TO TREAT TEEM. •I ^H^^ : i ■Hi H ■ '' ^Hb H |, H ^^^^^H ■ ' ' 1 H ■;■ • H ] ^^^B 1 ^J^hK 1 iHli then be inserted into the vagina, and the cord grasped and gradually returned to the uterus at the point where it made its exit. These efforts should be made while the uterine fibres are relaxed. The cord is retained inside the cervix by the finger of the physician until the uterus is firmly con- tracted. The woman should remain on her chest and knees until the head of the child is engaged in the superior strait. This method of replacing a prolapsed cord has super- seded all others. It was first introduced by Prof. T. G. Thomas, of this city. If the child's head passes the superior strait before the prolapsus has been discoveret], the forceps must be applied, and the labor completed without delay. Short Cord. — ^The length of the umbilical cord is sub- ject to considerable variation. Schneider reports a case in which the cord measured over three yards, and Cazeaux speaks of one which was only nine inches in length. It usually measures from eighteen to twenty-four inches. A short cord retards the progress of labor. It may also give rise to hsEmorrhage by causing premature separation of the placenta, or rupture of the cord. When the cord is shortened by winding around the child's body, similar con- sequences may ensue. A short cord cannot be recognized until the commence- ment of labor. At this time the fundus of the uterus will be found depressed or " dimpled " with each contraction. The cervix is soft and dilated, but there is no advance in the labor. If the index-finger is applied to the child's head it will be found to recede during the relaxation of the uterine fibres. Haemorrhage more or less profuse may also be present. (See Placenta Prsevia.) -1 m COMPLICATIONS OF LABOR, ETC. 203 Treatment. — If tlie labor has not progressed beyond the first stage, the membranes should be ruptured, so as to bring the uterus in more immediate contact with the body of the child, and thus increase its power of ex- pulsion (Cazeaux). When the child's head has passed beyond the cervix, and is prevented from advancing farther by the short cord, the delivery must be terminated with the forceps. Some obstetricians advise the performance of version as soon as the cervix is dilatable. Ieeegulab Presentations and PosmoNS. — In ordinary cases of vertex presentations the occiput rotates anteriorly under the pubes. Exceptionally, it rotates in a contrary direction into the hollow of the sacrum. In this position the head can only be delivered by extreme flexion. In some instances the efforts of Nature are sufficient to termi- nate the labor ; the majority of cases, however, require the aid of the forceps. When the patient is fully anoesthetized and in position, the male blade of the forceps, which is usually held in the left hand of the operator, is introduced on the left side of the vagina, and applied to the right of the child's head, ilie female blade is introduced on the right vaginal wall, and passed up to the left side of the head. When tlie for- ceps are locked, the handles should be raised toward the pubes, in order to produce greater flexion of the head. At the same time traction is made, and the head brought down to the vulva. When the head reaches this point, some obstetricians prefer to remove the forceps, and let the labor proceed naturally. Presentations of the Arm or Leo, together with the il ;tnii 'f • m't f-r-! 204 EMERGENCIES, AND HOW TO TREAT THEM. • i t head, may eft'ectually impede the progresB of labor. As soon as discovered, eflfbrts should be made to return the pro- truding limbs to the cavity of the uterus. Sometimes the presenting parts are so firmly wedged in the pelvic cavity, that they cannot be replaced ; in such cases embryotomy or craniotomy must be performed. In Transverse Presentations it is not unusual for the arm and shoulder to present at the superior strait. The arm should be replaced and the head brought down {cephalic version). If the head cannot be brought to the superior strait, one of the lower limbs may be seized and the child delivered by podalio version. In the performance of ver- sion the following rules must be observed : 1. Oil the lach of the hand and fingers only ; 2. Introduce the hand during the relaxation of the uterine fibres ; 3. Introduce the hand, which when in the cavity of the uterus will have itb palmar surface in relation with the anterior portion of the child's body; 4. Do not rupture the membranes until the hand has reached the part of the child to be brought down ; 5. The necessary manipulations in the uterine cavity should be made between the pains. Face Presentations occur once in two hundred and fifty labors {Thomas). The most frequent position is the " right mento-iliac transverse." In natural labors the chin is car- ried forward under the pubes and is finally delivered by a process of flexion. Should the chin rotate posteriorly into the hollow of the sacrum, the longest diameter of the child's head (occipito-mental) is brought in relation with the antero-posterior diameter of the pelvis. The former measures five inches and a quarter, the latter four inches and a quarter. It is impossible, therefore, for the labor /' COMPLICATIONS OF LABOR, ETC. 205 to terminate naturally. Operative procedures are always necessary. Treatment. — If a diagnosis is made before the head is engaged, the face-presentation may be converted into one of the vertex by flexing the head. If this cannot be done, an attempt should be made to change the position of the f>ioe and rotate the chin under the pubes. Either the hand of the physician or the vectis may be employed for this pur- pose. When the movement of rotation cannot be accom- plished, the perinceum may be incised and the child delivered by means of forceps. This method is recommended by Dr. Taylor. Other authorities advise craniotomy when milder measures fail. Application of tub Tampon. — The tampon is employed for the suppression of hasmorrhage occurring in abortion, placenta praevia, ulceration and laceration of the vaginal walls, etc. It should not be resorted to in jfost-jpartum haemorrhage. The tampon may be made of sponge, picked lint, cot- ton. India-rubber bags filled with water or ice, or a surgi- cal roller-bandage. The latter was first employed in tam- poning by Prof. I. E. Taylor. He claims that the bandage is more readily introduced and removed than any other ma- terial. Any of the substances employed may be wet in astrin- gent solutions previous to their introduction. The operation is performed with or without a speculum. The patient should be placed in the recumbent posture and the thighs flexed on the abdomen and abducted. A speculum is then introduced into the vagina, and the lint or other materials passed up and packed tightly around and upon the cervix, I 206 EMERGENCIES, AND HOW TO TREAT THEM. increasing the quantity until the vagina is completely filled. A T-bandage is afterward employed to maintain the tam- pon in position. The tampon should be changed at the end of twenty-four or thirty-six hours. When the patient desires to micturate, a portion of the plug at the entrance of the vagina must be removed. At this point the plug presses on the urethral canal, and its removal is necessary before the urine can pass through. CUAPTER XIX. RETENTION OF URINE.— DISLOCATION OF THE NECK.-INJVRISH FROM LIGHTNINO.-COLIC. f. *- Re^'ention of Urine. — Retention of urine may arise from spasmodic contraction of the muscular fibres of the neck of the bladder, organic stricture of the urethra, en- larged prostate, stone in the bladder, paralysis of the blad- der, abscesses in the perinteum, fracture of the pubic bones, with laceration of the urethra, and injuries to the spinal cord. Retention which is produced by spasm of the muscular fibres accompanies exposure to cold, or acute inflammation of the urethra. It occurs suddenly, and is not connected with chronic disease of the genitals. There is pain in the perinceum and hypogastric region. If the bladder is dis- tended with urine, a large area of dulness will be found on percussing along the pubes. Febrile excitement is also pros ent if the retention follows inflammation. The patient is readily relieved by the application of hot fomentations over the hypogastrium and genitals, hot baths, and by the internal administration of opium. Leeches to the perinseum are useful in some cases. In retention from organic stricture the patient will have fl i: 208 EMERGENCIES, AND UOV TO TREAT TUEM. ' had, for a variable period previous to the attack, great diffi- culty in micturition, a small, twisted stream of urine, and some decree of pain. An exploration with sounds or bougies will show an obstruction at some point between the meatus and membranous portion of the urethra. If the stricture cannot be dilated rapidly, and if the condition of the patient will not permit of urethrotomy, the distended bladder may be temporarily relieved ])y punctur- ing through the rectum. At the base of the bladder there is a space uncovered by peritontcum, which is bounded on each side by the vesiculoo seminalis, behind by the recto- vesical fold of the peritonreum and in front by the prostate gland. Tlie operation at this point is performed by insert- ing the left index-finger into the rectum and carrying it half an inch or an inch beyond the prostate, and then in- troducing a large, curved trochar (using the finger as a guide) and plunging it into the bladder at that point. The stylet is then removed, and the urine escapes through the canula. If fluctuation cannot be detecte«i by the finger, the operation should net be performed. Retention from enlarged prostate occurs in advanced life. The hypertrophied gland may be felt by a rectal examina- tion. If the ordinary large curved prostatic catheter can- not be passed over the obstruction, an instrument \<^ith a shorter curve may be forced through the enlarged lobe into the bladder, or the bladder may be opened through the rec- tum in the manner previously described. i Habitual distention of the bladder may induce a semi- paralytic condition of the walls of the organ and produce retention. This condition occurs not unfrequently in females whose opportunities for emptying the bladder are often re- J DISLOCATION OF THE NECK— INJURIES FROM LIGHTENING. 209 fitriutod. It is relieved by frequent introduction of tlie catheter, cold hip-baths, and tonics. When retention arises from injuries to the spinal cord the bladder should be emptied twice each day by means of a catheter, and thoroughly washed after the urine is evacuated. Dislocation of tue Neck. — This accident is usually fatal. In death from hanging the transverse ligament is ruptured, the axis is dislocated from the atlas, and the odontoid process of the former bone presses upon the upper portion of the cord. Death in such a case is almost instantaneous. Partial dislocations of the cervical vertebra lower down are sometimes recovered from. In these cases, the head is turned to one side, and there may be slight paralyses below the point of injury. Treatment. — The surgeon grasps the head of the patient, while an assistant steadies the shoulders. Extension is then carefully made, while the head is rotated toward its normal situation. Perfect rest for a few days is afterward necessary. Injuries from LionTNiNG. — The effects of lightning on the system vary in character. In some instances death is instantaneous, in others there is more or less extensive charring of the tissues, paralysis of the extremities, loss of sight, sjjeech, and hearing, and heemorrhage from the mucous canals. Bums produced by lightning are apt to run a protracted course, and are accompanied by extensive suppuration. Paralysis is rarely recovered from. Boudin speaks oi cases where persons injured by lightning had images of surrounding objects depicted on the body and 14 210 EMERQENCIES, AND DOW TO TREAT THEM. !!: i clothes. Similar curious occurrences Imvo been recorded by otlier observers. The symptoms presented by a patient suflferiiig from a lightning-stroke are coldness of the extremities, sighing res* piration, absence of radial pulse, and insensibility. After death the ordinary rigor mortis is not witnessed, and the blood is said to be more fluid than in death from other causes. The treatment consists in friction to the surface, artifi- cial respiration, and the administration of stimulants. Colic. — Spasmodic contraction of the muscular walls of the intestines is generally attended with great pain. It is occasioned by cold, or over-indulgence in indigestible food. It is characterized by paroxysms of intense pain over the abdomen ; vomiting is sometimes associated with it. The pain is distinguished from that accompanying infiamma* tion by the fact that it is relieved on pressure. An injection of one or two quarts of very warm water and an opiate will cure it. The following prescription answers in many cases : Q . Rismuthi snbnitratia Morpliioo snlphatig Ft. pulv. X. 3j. gr.j. M. One powder should be given every hour until tlie patient is relieved. Mustard or hot flax-seed poultices may also be applied over the abdomen. {See Lead Colic.) CHAPTER XX. TOXIVOLOOY. NARCOTIO POISONS. Op'um, BoUndonna, Ilyosoyiitnus, Aconite, Tolmcco, Strnmonlum, ClilorofonB| llouilovk, Lobulia, Wooruru, Kthor, Alcoliol, oto. Opium is obtuined from tho unripo cai>8ules of the Papa- ver somniferutn, or poppy. The juice of tlio capsules is tho portion used. The plant is cultivated in India, Persia, Europe, and in this country. It has been eini)loyed as a medicine from the time of Hippocrates to the present day, and stands unrivalled as a remedy for the alleviation of pain. In Tu-^key and China the drug is habitually smoked and chewed. In the western parts of Europe and in this country the habit of smoking and eating opium is not un- common. It engenders exaltation of ideas, and general buoyancy of spirits. Some of the brightest lights of the literary world have fnllen victims to this vile habit of opium-eating. The well-known case of Fitz-IIugh Ludlow is familiar to most American readers, and in England the celebrated Coleridge and De Quincy were victims to the drug. The quantity of opium necessary to cause death varies with circumstances. Quantities which would destroy life m f; ';/ .^f\ 212 EMERGENCIES, AND HOW TO TREAT TUEM. in ordinary cases are eaten with perfect impunity by persona accustomed to its daily use. Enough lias been taken at a dose to destroy a dozen lives. Ilerdouin mentions the case of a woman with cancer of the uterus who took laudanum by pints. De Quincy was in the habit of taking nine ounces daily. I have known two cases average daily from four to six ounces. The amount which will destroy life depends also on the age of the person. Infants can bear but a very minute quantity. One drop of laudanum has been known to kill a child. Children are extremely susceptible to its influence. The smallest quantity known to have destroyed the life of an adult is two drachms of laudanum (Skae). In the majority of cases larger quantities are required. Opium kills in from four to twelve hours. Some animals are scarcely affected by the drug. On apep I't exerts no perceptible effect. In one instance five., hundred grains were given to one of inose animals without injury. Tests. — Perchloride of iron gives a red precipitate with solutions of opium which contain meconic acid. Kitric acid gives a red precipitate with morphia, the principal alkaloid of opium. The symptoms manifested in persons addicted to opium- eating are readily recognized. Tiie face is sallow, pinched, and parchment-like. The e^^es are sunken and glassy. When they arc deprived of the drug there is an unsteady, trembling gait, great depression of spirits, and intense mental and physical agony. "While under treatment pa- tients endeavor by every conceivable means to obtain a dose. even getting down on their knees, begging piteously for it. ,7 NARCOTIC POISONS. 213 But in such cases it is rarely expedient to satisfy their cravings. " Tapering off," as they call it, will not result in cure. The appetite for the drug remains bo long as they are allowed to taste and experience its intoxicating effects. Large doses of bromide of potassium will do mich in these cases to diminish the craving. The effects of poisonous doses of opium appear in from thirty minutes to two hours from its administration. Liquid preparations of opium, and the salts of morphia, act very rapidly. The patient trembles, becomes giddy, drowpy, and unable to resist the tendency to sleep. Gradually the- stupor deepens, until there is perfect insensibility. The pupils are contracted, eyes rd face congested; the pulse, at first rapid and small, h now slow and feeble. A marked diminution in the number of respiratory movements is discernible. From twenty per minute they run down to twelve, or even eight. The breathing is stertorous. A profuse perspiration breaks out on the surfaces. As coma deepens, and death approaches, the extremities become cold, and the sphincters relaxed. Occasionally the odor of opium may be noticed in the breath, and in such a case the diagnosis is materially assisted. The following singular case of opium-poisoning in con- junction with cholera illustrates the characteristic effects of the drug : A colored woman was admitted, in the summer of 1866, to the pavilion attached to Bellevue Hospital ; she was suffer- ing from a bad attack of Asiatic cholera, and when brought to the ward was fast approaching a state of collapse. Inquiring into her history, she stated that the attack came on four hours previous, and while at the station-house half an hour 'i -y 1 214 EMERGENCIES, AND HOW TO TREAT THEM. before her admission a policeman had given her a table- spoonful of pure laudanum. As there were no symptoms to corroborate her story, I did not credit it and left her. In about three-tjuarters of an hour the nurse in charge informed me thai the patient was insensible, and could not be roused to take her medicine. I went down immediately and found the patient as the nurse had stated, in a comatose condition. The pupils were contracted, respiration down to eight per minute. Pulse slow and small. Injections of brandy and ammonia, and strong coffee, were ordered. The body was properly stripped, and flagellation applied with twisted towels. After two hours of this treatment signs of con- sciousness appeared. The patient was then lifted from the bed and rapidly marched up and down the ward, supported by her nurses until she was fully restored. Five hours were spent in bringing this woman to a state of consciousness. The treatment for opium-poisoning, and the opium it- . self, seemed to exert a curative effect on the cholera, and the patient was discharged three days after her admission, cursi. Treatment. — If the patient is seen soon after the poi- son has been taken, the stomach should be emptied by a stomach-pump or emetics. Twenty grains of zinc, or ipecac, a tablespoonful of mustard or common salt, will suffice to eject the poison. These medicines should be fol- lowed by copious drauglits of warm water to keep up the vomiting. As soon as the stomach is emptied, belladonna, * the physiological antidote for opium, may be tried. The active principle of belladonna {airopia) may be given by hypodermic injections. A solution of one grain to the ounce is made, and fifteen or twenty minims injected, and NARCOTIC POISONS. 215 repeated, if necessary. Strong coffee is another antidote. In all cases the antidotes should be accompanied by stimu- lants. Brandy and ammonia may be frequently given by the moutli or rectum. Flagellation of the surface by the hands or towels, and causing the patient to walk about, are important aids to restoration. The use of the Faradic current will be of service in all cases. The electrodes may be applied over the phrenic nerve and diaphragm, and over the frontal bone. BELLADONNA. The leaves and root of Atropa helladcnna, or deadly nightshade, are largely employed for medicinal purposes. All parts of the plant possess poisonous qualities. The leave? and berries are frequently eaten by children, and with deleterious effects. Thirty-six berries have produced death in a child. An infusion made from two drachms of the leaves has killed an adult. Atropia, the active principle of the plant, given in two-grain dofes, has proved fatal. The first symptoms of poisoning are dryness of the throat, constriction of the tauces, difficult deglutition, indis- tinct vision {a}nll(/qpia), or double vision {dijplopia), head- ache, staggering, and confusion of ideas, stammering, etc. The pupils are widely dilated, face suffused-, lips livid, and pulse rapid and intermittent. Delirium and deep coma soon supervene, followed rapidly by death. In a few cases there are convulsions. After death putrefaction rapidly ensues. Large purple spots form on the body. There may be signs of inflamma- tion in the stomach and intestines. II ;; 216 EMERGENCIES, AND HOW TO TREAT THEM. I: b -.■' k Treatment. — An emetic should be administered without delay, and repeated until the stomach is completely emptied. This should be followed by stimulation, friction to the extremities, and warmth. Some recommend opium as an antidote. It has been successful in one or two cases. Runge advocates the use of lime-water in large quantities as a neutralizer of the poison. Bouchard has employed the ioduretted iodide of potassium with benefit. All the strong alteratives are said to possess more or less remedial power ; but experiments have not proved their efficacy. Brardy by enema, arid opium by hypodermic injection, in conjunction with large doses of lime-water, constitute the most reliable remedies that have yet been fixed upon. If the coma appear rapidly and without convulsive move- ments, electricity may be used with benefit, and cold water may be poured on the chest and face. HEMLOCK. There are five varieties of hemlock which possess poison- ous properties, viz., Conium maculatum^ Clctita virosa, (Enanthe 0}'ocaia, Phellandrium aquaticum, and ^thusa cynapium. Conium maculatum, or spotted hemlock, is much used for medicinal purposes. It was a preparation of this drug whic^ caused the death of the philosopher Socrates. All parts of the plant are poisonous. To inhale the air in the vicinity of this plant in the hot months of summer is said ■ to be followed by slight narcotism. Its poisonous efifects are manifested within half an hour after entering the stomach, and death results in from one to three hours. The symptoms are dryness of the throat, muscular trem- ors, dizziness, difficult deglutition, and a feeling of great NARCOTIC POISONS. 217 rt'o cases. prostration and faintness. The limbs are rendered power- less, sometimes being completely paralyzed. The pupils are dilated, the pulse is rapid and small. Deep insensi- bility rapidly supervenes, and there may be convulsions preceding the fatal termination. The roots of Cicuta virosa, or water-hemlock, are fiome- times mistaken for parsnips, and eaten in large quantities. The symptoms of poisoning resemble those of the preceding variety, with the addition of vomiting, and pain in the epi- gastrium ; convulsions are also more frequent. The leaves and roots of the (Enanthe crocata are more deadly than any other species of hemlock. The plant grows at the sides of ditches and other moist places ; it resembles celery. When taken internally, it always produces violent and protracted convulsions, in conjunction with the symptoms previously enumerated {Taylor). jEthvsa cynapium, or fool's parsley, does not kill so rapidly as the other varieties. It resembles ordinary pars- ley, and is sometimes eaten by mistake. The symptoms commence by intense pain in the abdomen, followed by vomiting and purging, and a tendency to coma. Treatment. — Empty the stomach of its contents, and use diffusible stimulants in large quantities. If there are much pain and vomiting, bromide of potassium, in ten-grain doses, may be given at short intervals. IIYOSCYAMUS. Hyoscyamus niger, or henbane, is a European plant, cultivated in this country. The leaves and seeds are largely employed in medicine. All parts of the plant are poisonous. 218 EMERGENCIES, AND HOW TO TREAT THEM m i! .1 M The seeds are more powerful than other parts. Its alkaloid {hyo8cyamia) is a deadly poison taken in minute quantities. Animals, such as horses, goats, cows, etc., are exempt from its injurious influences, and eat it without receiving harm. Dogs and cats are soon killed by it. Poisonous doses of the seeds or leaves are followed rapidly by dilatation of the pupils, dimness of vision, mus- cular twitchings, inability to articulate plainly, and a ten- dency to sleep. In a later stage there are vomiting and purging, abdominal pain, delirium, convulsive movements of the extremities, small, intermittent pulse, and coma, which is often followed by death. A post-mortem examination shows evidences of inflam- matory action in the stomach and intestines, and in a few cases congestion of the brain. Treatment. — Common charcoal has been strongh' recom- mended as an antidote by Dr. Gar. The substance lapidly absorbs the alkaloid upon which the poisonous properties of the plant depend, and prevents its peculiar action. Solu- tions of caustic alkalies are said to neutralize the poison. In every case stimulants should be employed, as in the other varieties of poisoning. ACONrrE. This drug is obtained from the leaves and root of the Aconitum napellus (monk's-hood, or wolfsbane). Prepara- tions of the leaves and root are used in medicine. The root is said to have ten times greater strength than the leaves. The plant has been mistaken for horseradish. In small doses it acts as an arterial sedative, diminishing the heart's action, and lowering the pulse. It difiers from all other NARCOTIC POISONS. 219 [kaloid ntities. )t from ; harm. )llowed 1, mus- l a ten- ng and '^ementa 1 coma, inflam- n a few ,' recom- lapidly rties of Solu- poison. be otlier of the 'repara- the root leaves, small heart's 11 other narcotic medicines in producing a peculiar numbness and tingling sensation in the mouth and fauces. Cases of poisoning generally result from careless over- dosing with the tincture of the root. Thirty drops of Flem- ming's tincture have caused death, but there are instances of a drachm or two having been taken by mistake without fatal results. The active principle (aconitla) is one of tlie most active poisons known ; one-twelfth of a grain has proved fatal. Poisonous doses produce immediately the characteristic numbness and tingling of the mouth and fauces. The same feeling is experienced in the extremities. There are sore- throat, pain over the stomach, and vomiting. The pulse is extremely weak and comj)ressible. The pupils are in some cases dilated, at others contracted. As in poisoning by other narcotics, there are dimness of vision, vertigo, great prostration, general loss of sensibility, delirium, and coma. Death is said to take place from syncope, asphyxia, and coma. Treatment. — Emetics are first employed. Complete evacuation of the stomach is sometimes all that is required. Brandy in tablespoonful doses, given in ice-water every half-hour, is a useful method of stimulation. Preparations of nux-vomica are said to neutralize the action of aconitia. The tincture of nux-vomica has been used with apparent benefit. It may be given in ten-drop doses, every fifteen minutes, until the alarming symptoms have subsided. TOBACCO. This plant was first discovered in America by the Spaniards. The English are indebted to Sir "Walter Ra- 220 EMERGENCIES, AND HOW' TO TREAT THEM. h If'; m 1 leigli for furnishing them with the " weed." Tlie leaves are employed medicinally as poultices to painful swellings^ and for their emetic properties. Fivo grains of the powder will produce emesis. In the form of snuff it has been employed by keepers of immoral houses to drug their vic- tims. A teaspoonful of snuff in a glass of ale will give rise to delirium, vomiting and purging, and fuintness. The active principle {nicoiia) is a deadly poison. One drop will kill a rabbit {Taylor). It causes death in two or three minutes. The effects produced in persons of nervous temperament by long-continued use of tobacco are well marked. An examination of the heart shows that it is intennittent in its action, and its pulsations more rapid than normal. The pulse is weak. Shortness of breath and palpitation of the heart are complained of in going up-stairs. Sh'ght excite- ment induces great tremulousness. There is often impair- ment of the mental faculties, such as defective memory, etc. The countenance has a sallow aspect. Some impairment of the digestive functions is almost always present. The effects of large quantities of tobacco on the system are well known to smokers and chewers. Early efforts in acquiring the habit are characterized by poisonous symp- toms. There are intense nausea and vomiting. The nausea is said to resemble that occurring in sea-sickness. Vertigo, muscular weakness, and intense prostration verging on syn- cope, are also present. Later the extremities become cold and clammy, and convulsions sometimes precede death. Treatment. — Hot bottles and blankets should be applied to the body. Brandy by enema is always required if the liquid cannot be retained on the stomach. Sub-nitrate of ii\ NARCOTIO FOISONS. 221 bismuth in ten-grain doses, continued with onc-fiftccnth of a grain of morphia, will do much to allay the distressing nausea. DIQITALia Is a product of the Diyitalia purpurea, or purple fox- glove. It exerts a powerful sedative effect upon the licart, acts on the kidneys as a diuretic, and on the brain as a nar- cotic. Some ascribe its influence in diminishing the pulsa- tions of the heart in febrile diseases to a stimulating effect on the heart's fibres, which gives them renewed vigor. It is dangerous on account of its accumulative efiV'ct. It may be administered for several days without apparent action of any kind, when suddenly the patient is prostrated with all the symptoms characterizing poisoning by this drug. The alkaloid digitalia,yfhen. boiled with suli)huric acid, is changed into glucose, or grape-sugar {Kinsman). The symptoms produced by poisonous doses are loss of strength, feeble and fluttering pulse, faintness, nausea and vomiting, and stupor. The body is bathed in cold perspira- tion, the pupils are dilated, the breathing is sighing and irregular, and convulsions are sometimes presenti Treatment. — Ammonia, given internally in frequently- repeated doses, is an admirable remedy, when the patient is in a state of syncope. The medicine should also be applied to the nostrils. Brandy internally, and warmth to the sur- face, are followed by good results. STRAMONIUM. The common name of the plant is thorn-apple, or Jamestown weed. It grows all over this country, particu- larly along the roadsides and in moist grounds. All parts of 222 EMERGENCIES, AND UOW TO TREAT TIIKM. I! the plant aro poisonous. Tlio seeds are not unfn'f|nontiy eaten by cliililfen. These seeds are recoj^nized by their dark, abnost bbick color, their flat, roughened surface, and kidney-shape. The drug is much used in asthnui and other spasmodic atfections. Cigarettes made of the leaves aro smoked by asthmatics with great relief. The active prin- ciple {daturia), given in small doses, proves rapidly fatal. The symptoms of poisoning are dryness of the throat, thirst, delirium, convulsive movements, swelling of the face, dilatation of the pupil, suffusion of the eyes, small, rapid pulse, hurried breathing, and hot skin. In some cases there are pain over the stomach, and vomiting. Convulsions are nearly always present, and are liable to be mistaken for those arising from uraemia or epilepsy. On examination of the vomited matters, the seeds of stramonium will probably be discovered, which will make the diagno&is clear. Treatment. — Opium, stimulan "> and alkaline medicines are employed in the same manner as after poisoning by belladonna. LOBELIA INFLATA lo ii-'ed in medicines as an emetic and antispasmodic. The common name is Indian tobacco. It is often adminis- tered by quacks who style themselves " vegetable doctors," and is sometimes given in dangerous doses. Taylor recites several cases where death resulted from improper quantities administered by those men. In large doses it induces excessive vomiting and purging, pain in the bowels, contraction of the pupil?!, delirium, coma, convulsions, and death. The j>ost-mortem appearances consist in congestion of ii NARCOTIC POISONS. 223 the membranes of tlio brain, and evidences of inflaniniution of the stomacli and intestinal canal. The treatment is confined to stimulants, and counter- irritation over tlio stomacli. C00CULU8 INDI0U8 Contains a peculiar active principle, called j)ict'o(oxia, tc which its poisonous character is due. The drug is some- times given to certain kinds of fish in India to render their capture an easy matter. The seeds are small, and about the size of a pin-head. The active principle is said by Glover to produce the same class of convulsive movements witnessed after lesions of the corpora quadrigemina and cerebellum, viz., tonic spasms, and wheeling and backward movements of the body. The symptoms and treatment are the same as in other varieties. MU8HR00M8. This plant is eaten in largo quantities in all parts of the civilized world. There are numerous varieties of the jdant, some harmless in their nature, and others highly poisonous. Strangely enough, many which are regarded as deleterious in one part of the world are eaten with impunity in others. Mushrooms which are considered dangerous in England and in this country, are used as food in Russia; and some which are eaten in England are thought poisonous at Home. The poisonous mushrooms may be recognized, according to Chrystosln and M. Richaud, by their dark color, acid, bitter taste, pungent odor, and by the fact that they gener ally grow in damp, dark places 224 EMKHOKNCIES, AND IIOW TO THKAT TIIEM. When a poirtonous mushroom ia taken internally, it causes extreme muwculur weakness, vortip), mental Inilluci- natiuns, stupor, and in a few instances violent vomiting and ]>urging. liecovery is not unfrequont, even when lurgo quantities liavo been eaten. I'rcatinent. — Tho stomach and bowels should ho acted upon by emetics and cathartics, whoro vonjitiiij^ anst8 for zinc are ammonia, ferrocyanide of potas- sinm, ana sn.phuretted hydrogen, all of which give a white precipitate. In poisoning from white vitriol, there are nausea and vomiting, pain in the abdomen, followed by all the signs of collapse. When the chloride is the poisoning agent, the pain and collapse are greater ; there are lividity of the sur- face, vertigo, and dimness of vision. In the evacuations from the stomach, shreds of mucous membrane are found. The Btumncli, after death, is dark-colored ; the mucous membrane thickened, congested, and perhaps ulcerated. 252 EMERGENCIES, AND HOW TO TREAT TUEM. Treatment. — Wl-.ito of egg, boaten up with milk and water, followed by infusions of astringent medicines, is the chief remedy for poisoning from the sulphate. In poisonirg from the chloride, emetics should first bo given; the albumen in milk can bo administered when tho stomach has been emptied. NITKATE OP SILVEB. This substance is a corrosive poison. It has powerful escluirotic properties, duo to its affinity for the albumen of the tissues. In poisonous doses, it produces intense pain, vomiting, and purging. Mucus, blood, and shreds of mucous mem- brane, are found in the excavations. If these are allowed to stand, they become dark from exposure to air. Common salt (chloride of soditim) throws down a white precipitate with solutions of nitrate of silver, and it is also given as an antidote. Mucilaginous drinks should be ad- ministered ad libitum. riiospnoKrs. Phosphorus is largely employed in the manufacture of lucifer matches. It is seldom used for medicinal purposes. Children are frequently poisoned by sucking the ends of matches, or drinking water in which they have been soaked. In match-factories, chronic poisoning from inhalation of phosphorus-vapor is of common occurrence. The symp- toms of acute poisoning from phosphorus are peculiar in not developing for some hours after the poison has been taken. A small amount, one-tenth of a grain, has caused death. Phosphorus is recognized by its peculiar odor, and its luminous appearance in the dark. METALLIC POISOyS. 253 Chronic poisoning usuftUy manifests itself firnt by or(li« nary dyspeptio symptoms ; euch os loss of appetite, feel- ing of weight and hoat in the epigastrium, and by prostru' tion. There are also nausea, diarrhoea, rcstleesneHS, inability to sleep, pains in the bones, and febrile excitement, which is worse toward night. If the exposure to the poisonous vapor have been of long duration, necrosis of the lower jaw, low grauiiluxy, IVO. uru'tnin, 1^1. epilepsy, 1H7. hyre Uleediiig). Hiomorrliagio diitthesis, 13. Hujmorrholds, bleeding from, 27. Haut-mal (sets Kpilc.psy). Heart, wounds of, 50. llunuituriu, 85. Hemloclc, poisoning by, 216. Hemiplegia, 120. Henbane, poisoning by, 217. llernia, strangulatou, 112. Hospital cases, 5, 9, 10, 11, 62, 79, 85, 102, Ua, 213. Hysteria, 128, 102. Hydrophobia in animals, 78. in man, 78. Hydrochloric acid, poisoning by, 257. Hydrocyanic acid, poisoning by, 227 loo in htemorrliago, 10. Ileus {see Hernial. Infantile convulsions, 177. Inguinal hernia, 115. Inhalation of oxygen {see Asphyxia). Innominata artttry, ligation of, CO. Insolation {see Sunstroke;. Insect bites, 83. Intercostal vessels, bleeding from, 64. pressure on, 54. Internal mammary artery, ligation of, 54. Joints, wounds of, 62. Jugular veins, relations of, 67. Kidneys, disease of, as causes of com» and convulsions {see Coma), hojinorrhago fiom, 35. Laceration of perina?um, 60. Larynx, wounds of, 47. foreign bodies m, 8tj. Laryngotomy, 89. Laryngismus stridulus, 169. Lead, poisoning by, 247. Ligation of arteries, 65. innominata, 00. subclavian, 07 carotid, 60. axillary. 68. brachial, 68. radial, 68. ulnar, 69. 26C INDEX. Litigation of artorloi, fsinoral, 69. p<>t)lltoul, 70. tiblulH, 10. Liglit, ciirliurvttod hTilrngon, poisoning by, ini, Livor, nipturo of, fiO, Luiitr, wounila oi, 50. Lubulla, poiHouing hy, 929. Mad niiirnolB [net Hydrophobia). Miila'nii, '.27. MiirHiiull Hull's motliod of artlfloial respiration, ir>(l. Mutohus, poisoning by (tee Pliosplio- rus). MinorrljiiKia, 41. ML'trorrhuKia, 41. MiTcury, 'Ji3. Morphia, po'iMoninif by (xe Opium). Mouth, htviuoirliiigu from (tee lileod- iiiK). Mushrouius, poisoning by, 223, Narcotics, polsonlnjr by, 211. Naros, plu^fging of, 28. Ni'clf, wounds of, 48. Nitrogen, effects of inhnlall'^n, 149. Kitrato of silver, poisoning by, 252. potasli, poisoning by, 2ttO. Nitric ucid, poisoning l)y, 256. Note, bleeding fVom, 21. foroi)?n bodies in, 05, Nux-vomica, poisoning by, 282. Obstruction in uir-passagos {see Foreign Bodies). (Edema glottis, 172. QCsophngotoiny, 95. (Esoplingus, foreign bodies in, 02. Oi>ium, poisoning by, 211. Oxalic acid, poisoning by, 264. Pain, effects of, in burns (see Burns), rnlmor arch, wounds of, C9. Paralysis in compression {see Compres- sion). Pttvacentesis thorocis, 55, Pericordium, wounds of, 68. Pericarditis (see Wounds), Penetrating wounds of chest, 61r abdomen, 67. Penis, hremorrhage from, 88. PsritonoBum, wounds of, 67. Pharynx, foreign bodies in, 92. Pliosphorus, poisoning by, 252. Pin mater, spasms of vessels of. 180. Piles, bleedinii^ from, 27. Placenta prsevia, 42. Pneumocolo, 53. Pneumothorax, 58. Poisonous wounds, 74. Poisons, vegetable, 211, metallic, 239. Poisons, corrosive, 264, Irritating, 236. Popliteol B])aco, pressure in, 16, Post-iiartuin hueinorihuge, 4;t. Potasli, carboiwif « of, poisoning by, SAD nitrate of, i!tiO, binoxalate of, 200. oxide of, 259. Premature labor, induction of, 188. Pressure in genenil hii'iiiorrhiige, 14. Pressure on carotid artery, 16. subclavian, 15. axillary, 16. liriichial, 10. ulna. 16. on audominal aorta, 16. femoral artery, 10. po])llteal, 15. Presentations, al)normn1, 208. Rabies (let IIydrophol)la), Kadial artery, ligation of, 08. Huttlesnalce-bltes, 81. Keaetlon in oonoussion (im Conons- slon). Ready method of artificial respiration, 156. Bospiration, suspension of (let As' phyxia), 150. Retention of urine, 207. Rupture of liver, 00. bladder, 60. cerebral vessels, 119. Salivation from mercury (see Mer- cury). Savin, oil of, noisoning by, 286. Socondarj aspnyxla, 154. Serpents, bites of, 81. Shock (tee Syncope). in burning (see Burns). Soda, poisoning by, 200. Spasms^ tonic and clonic (set Convul' Bions), Spontaneous combustion, 108. Stramonium, poisoning by, 221. Stomach, bleeding fVom (see Bleeding). Stertor, cause of (w< Coma). Sudden death (see Syncope), Sulphate of zinc, poisoning by, 261. of copper, poisoning by^ 246, Sulphuretted hydrogen, poisoning by, 149. Sunstroke, 168. Sulphuric acid, poisoning by, 266. Sylvester's metnod of artificial respira- tion, 156. Syncope, 133. Tapping of chest, 65. of bladder M'rough rectum, 208. Tampon, applicaL\-n of, 205. Tarantula, Dites o.', 84. INDEX. 267 TazU (»4» HernU). TotunuN, 10». Tliorox. wound* of, BO. Tlioraclo vUouriv, wouiuli of, fil, B6. Tliroinbufi (w"ploxy (ih CoiB* iiroKhlon). Iu«, 114. Volvu Wound* of throat, 47. tliorox, M. luni(t*, 51. jiurrcurillum, 50. Iiuart, 60. abdotncn, 57. intoiitino*, 57. blnddor, (10. urothra, 01. nrturius and vclnH, 6S (iCunMhot, 03. Tiurinteuni, 60. JxliitB, 02. 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