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Maps, plates, charts, etc.. may be filmed at different reduction ratios. Those too large to be entirely Included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams Illustrate the method: Les cartes, planches, tableaux, etc., peuvent dtre fllmte A des taux da reduction diff6rents. Lorsque Ie document est trop grand pour Atra raproduit en un seul clich6, II est f ilmA A partir da Tangle supArleur gauche, de gauche d droite. et de haut an bas, en prenant la nombre d'images nAcessalre. Les diagrammes suivants illustrant la mAthoda. 1 2 3 1 2 3 4 5 6 f I EMERGENCIES Asn HOW TO TREAT THEM. THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF THE ACCIDENTS, DISEASES, AND CASES OF POISONING, WHICH DEMAND PROMPT ACTION. DESIONEO FOB STUDENTS AND PRACTITIONERS OF MEDICINE. BY JOSEPH W. HOWE, M. D., TniTIBO BCRGBON TO CHARITY HOSPITAL; LECTUREK ON SURGERY IN THE MEDICAL DS- PARTHENT OF THE UNIVERSITY OF NEW YORK, ETC., ETC. NEW YORK: D. APPLETON AND COMPANY, 549 Jc 651 BROADWAY 1871. > • ;;/;. • • • .•*:••. • • • • • ;. • • • • ■ • • 1 • f • • • ••*.•• ••.••. >• • • >• • • • • • • • •••••:: « • • -RCS-). H s r • • • • • t t • • • • • e « • •• • • • Enterkd, according to Act of CongretiB, In th« year 1871. liy D. APPLETON & CO., in tlie Office of the Librarian of Congre^g. at Washington. ;/ 1 PEEFAOE. This volume, as its title indicates, is designed as a guide in the treatment of eases 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. 21G935 /V / / /O COIsITENTS. CHAPTER I. IIMMOBRnAOE. rtai Gonerol Considerations. — Eesulta of Negligence. — Arterial and Venous Hoomorrhage. — Effects of Profuse Itomorrbago. — Natural and Arti- ficial Methods of suppressing Ilsemorrbago.— Iltomorrhagic Diathesis. — Constitutional Treatment .—Transfusion, . . . . .9 CHAPTER II. SPECIAL HJEifOItRUAOES. Bleeding from the Nose, Mouth, Lungs, Stomach, Intestines, Kidneys, Ure- ters, Bladder, Urethra, Erectile Tissue of Penis, — Ecchymosis, . . 21 CHAPTER III. njEMORRUAO^ FROM THE UTERUS. Menorrhagia.— Metrorrhagia.— Accidental Hremorrhage.— Placenta Prrevia. — Post-partum Hiemorrhagc, . , . . .41 CHAPTER IV. WOUNDS OF IMPORTANT ORGANS. Wounds of the Throat, Lungs, Pericardium, Heart, Abdomen, Intestines, Bladder, PerinsDum, Joints. — Rupture of Liver, Perineal Section, Para- centesis, Thoracis. — Gunshot-Wounds, . . . .47 CHAPTER V. WOUNDS 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, ......... 65 CONTENTS. CIIArTER VI. POISONED WOUNDS. Dissecting Wounds. — Hydrophobia in Dogs. — Hydrophobia in Mnn.— Rattlc- sniUio-Dltos.— Insoot-Bites. — Coutipedo.—Tttrontulo.— Scorpion, . . ti CnAPTER VII. EXTRACTION OF FOIiEIOS BODIES. Foreign Bodies in the Larynx, Traclioa, Broncliinl Tubes, Pharynx, lEsopIi- ngus, Eyes, Nose, Ears, Urethra, Bladder, and lioctuin. — Tracheotomy. — Loryngocomy, — (Esophagotomy, . . . . . .85 CHAPTER VIII. • DCnXS AND SCALDS.— EFFECTS OF COLD. Varieties of Deformities produced by Burns. — Operation for closing the Eye. — Spontaneous Combustion — Classiflcntion of Burns — Constitutional Symptoms. — Duodenal Ulcer — Causes of Death — Post-mortem Ap- pearance.— Elfjcts of Cold.— Frost-Bite, ..... 101 CHAPTER IX. STRANGULATED HERNIA. Causes and Symptoms of Strangulation. — Ileus. — Volvulus.— Operations for Inguinal and Femoral IlernitD.— Taxis, . . . . .112 CHAPTER X. LOSS OF CONSCIOUSNESS. COMA. m Coma from Cerebral Extravasation, Depressed Fracture, Pressure of Inflam- matory Products, Embolism, Thrombosis, Urremia, Alcohol, Hysteria, Epilepsy.— Concussion, . . . . . . .118 CHAPTER XI. LOSS OF CONSCIOUSNESS-iCosTisvEV). srwcoPE. Syncope from Loss of Blood— Thrombi of the Pulmonary Veia— Anaimia. — Mental Emotions— Blows on the Epigastrium— Collapse, . .133 CONTENTS. 7 CHAPTER XII. ASP//rS/A. PiOl Respiratory Apparatiw.— ElFoctB of Non-iiOration of Blood.— Strangulation.— ComproHsion of tlio Thorax.- Inhalation of Poisonous GaBcs.— Signs of Death.— Drowning.— Iiijurics to the Spinal Cord.- Strycbuia, . . 13tt CHAPTER XIII. SUNSTIiOKE. Synonymos.— First Recorded Cases.- Sunstroke in Crowded, Ovorhoatod Buildings.— Varieties of Sunstroke.— Symptomc— Treatment.— Post- inortom Appearances, , . . . . ... 168 CHAPTER XIV. DYSPN(EA. Causes of Hurried Respiration.- DyspnoDa in Asthma, True and False Croup, Congestion of the Lungs, Cardiac Disease, Pulmonary (Edema, Pulmo- nary Apoplexy, 165 CHAPTER yv (EDEMA GLOTTIDIS. Location of the Effusion.— (Edema Glottidis in Bright's Disease— Inflammo- mation— Collateral (Edema— Syinptoras.-Treatraent, . . .172 CHAPTER XVI. CONVULSIO N S. Tonic and Clonic Spasms.— Irritation of the Tuber Annulare.— Infantile Convulsions.— Convulsions from Ura!mic Poisoning, Corebrol Extrava- sation, Hysteria, Alcohol, Epilepsy, Tetanus, . , . .173 CHAPTER XVII. SUSPENDED POSTAL ANIMATION. Pressure on the Umbilical Cord.— Injury to the Brain.— Rupturs of Funis.— Asphy.\ia.— Syncope— Congestion of Brain, . , . .195 CHAPTER XVIII. COMPLICATIONS OF LABOR, ETC. Rupture of the Uterus.— Prolapse of the Funis.- Short Cord.- Irregular Pre- sentations and Positions.— Tamponing the Vagina, . , ,198 8 CONTENTS. CHAPTER XIX. rial BotentioQ of Urine— Dislocution of tbo Nock.— It^jiirlos iVom Lightuing.- Colic, .......... 807 CHAPTER XX. roxjcoLoa Y. NAIiCOTIO rOISONfl. Opium, Bclladonnn, Ilyoscyninus, Aconite, Tobacco, Stramnium, Cliloro- form, Etlior, Alcohol, Ciiloral, Prussio Acid, llomlook. Lobelia, Calabar Bean, Woorara, MuHbroonis, Upas Tree, . . . . ,211 CHAPTER XXI. IRRITANT POISONS. Cantharidcs, Croton-oil, ColcUicum, Vcratria, Black and Wblto Ilollcboro, Drastic Cathartics, ........ 23S CHAPTER XXII. METALLIC POISONS. Arsenic, Corrosivi fcubliinato, Copper, Load, Tartarized Antimony, Zinc, Nitrato of Silver, Phospliorus, . . . - , .829 CHAPTER XXIII. CORROSIVE ACIDS. Oxalic Acid, Sulphuric Acid, Muriatic Acid, Nitric Acid, Corbolio Acid, 264 CHAPTER XXIV. CORROSIVE ALKALIES. Carbonate of Potash, Caustic Potash, Nitrate of Potash, Binoxolato of Pot- ash, Ammonia, ........ 269 EMERGENCIES, HOW TO TREAT THEM. CHAPTER I. lIJEMOUmiAGE. Qoncral ConsiJcrntions. — Ivosults of Nogligonco. — Arterial ond Vonnus Iloemor- rhngo.— Etloota of Profuso Ilaimorrliagc. — Natural and Artiflciul Methods of 8upprc8Biii{? llicinorrhogo. — Ilajmorrliagio Diathesis. — Transfusion. Medicine ia often roproaclifully cliarr *3terized as a sci- ence of experiments, a profession remarkable for its brill- iant uncertainties and conflicting theories. Superficial ob- servation and imperfect means of study gave origin to this sentiment wlion the healing art was in its infancy, and it is yet retained by a few who iind it a convenient excuse for all their errors. There are conflicting theories in medi- cine as well as in other professions. Such theories are the maint^rings of progress ; they develop strength and incite to laborious investigations. Opposition is the soul of ad- vancement; through its influence truth is attained and correct principles established. Uncertainty appertains to every science that has not arrived at its maximum development ; and it is not espe- cially characteristic of our profession. The discoveries of to-day will necessarily be modified by the developments of 10 EMERGENCIES, AND HOW TO TREAT THEM. to-morrow, and the theories of our own time will be replaced by tlie truths of the future. The cases of emergency, considered in the following pages, are entirely exempt from the charge of uncertainty ; but they are followed by disastrous results when treated by incompetent persons. The internes of our large hospitals know that it is not an uncommon occurrence for patients to be admitted in articulo mortis y their chances of recovery destroyed by the neglect or ignorance of the attendant out- side. The following cases from my hospital note-book may be of interest as examples : Case I. — Martin C, aged twenty ; occupation, machinist ; was admitted to ward eleven, Bellevue Hospital, suffering from incised wounds of the wrist and palm of the hand. On ai'riving at the hospital, he was partially insensible from loss of blood. The voice could not be raised above a whisper, and tlie face was extremely pallid and anxious. The pulse could with difficulty be distinguished. The entire clothing of one side of the body was saturated with blood. On making an examination, I found that a folded handkerchief was bandaged aver the centre of the wrist, and that the wound in the palm was untouched. The pad was placed on the wrist as if the greatest care had been exercised to avoid pressing on the radial or ulnar arteries. The sides of tlie pad scarcely reached them. This dressing was applied by a so-called surgeon shortly after the wounds were inflicted. The haemorrhage in this case was easily controlled by liga- tures. The patient, however, developed phlegmonous ery- sipelas, and, not having sufficient vitality to carry him through, succumbed on the fifth day after his admission. Case II. — John M,, aged thirty ; occupation, laborer; fell L n^MORRUAGE. 11 from the front platform of a car at Harlem and Lad his right foot crush ,d by the wheel. His friends carried him to a surgeon in the neighborhood, who placed an ordinary band- age on the limb, without any compress over the vessels. In bringing the man to the hospital, the rough jolting of the can*iage set the wound bleeding, and by the time he reached his destination he was apparently lifeless. The vessels were tied, and stimulants administered, but he never rallied. Death occurred six hours after his admission. His injuries, independent of the hemorrhage, might, indeed, have termi- nated his life ; still the chances would have been in his favor if a compress had been applied to the limb to prevent bleed- ing. The fact that such a thing was not done showed either culpable negligence or deplorable ignorance. It is through such treatment that the percentage of deaths from accidents is increased to an unnecessary degree. To remedy these evils, a thorough knowledge of the treatment of accidents should be impressed on the memory as indelibly as are the letters of the alphabet. Nor should this knowledge be entirely confined to medical colleges and professional men. ^Non-professionals, with a moderate share of common-sense, might learn to control haemoi'rliage, relieve syncope, extract foreign bodies, resuscitate the drowned, and administer an antidote in cases of poisoning. Such knowledge would as- sist, rather than retard, the labor and usefulness of profes- sional persons. The varieties of haemorrhage constitute a large and im- portant class of emergencies. Loss of blood, when profuse, is always attended with danger, and necessitates immediate treatment. The term " htemorrhage " is applied to a flow of blood 12 EMERGENCIES, AND HOW TO TREAT THEM. from any part of the vascular system, with or without rup- ture of the vessels. Arterial hoemorrhage is attended with serious conse- quences. It is readily recognized. The blood is of a bright- scarlet color, and is forced out in successive jets ; each jet is synchronous with the movements Oi' the heart. This char- acteristic spurting is caused by the intermittent force-pump action of the heart driving out the blood. Venous haemor- rhage is distinguished from arterial by the dark-blue color of the blood, which never flows in repeated jets, but oozes slowly from the wounded surface. Venous blood is travel- ling toward the heart, and there is consequently no force be- hind to cause a more rapid flow. This form of hsemorrhage is comparatively harmless, unless occurring from very large veins. In large wounds, arterial twigs are divided, and arterial bleeding predominates. In small wounds there is mixture of both varieties. The blood is dark red, and comes away gradually. The constitutional symptoms accompanying external or internal haemorrhage are distinctly marked. The lips and cheeks rapidly assume a pallid hue. There are great restless- ness and anxiety. The extremities are cold, and often bathed in clammy perspiration ; respiration is weak and sighing ; the pulse becomes small and rapid ; its increased rapidity being due to the eflforts of the heart to make up, by frequent impulses, the d: ainished quantity of blood sent to the tis- sues. The patient complains of vertigo and dimness of vision, is unable to articulate plainly, and finally lapses into a state of unconsciousness. The heart has partially suspend- ed its movements, and the pulse is imperceptible. With the n^MORRHAGE. 18 syncope the bleeding ceases. There is not sufficient vitality remaining to force more blood from the injured vessels, nor action in the heart to keep up the circulation. Here Nature takes the place of surgical skill. The stoppage of the cur- rent allows the blood time to coagulate in the mou'^hs of the bleeding vessels, and to plug them up completely before con- -ousness is reston d or the heart again at work. But, should this fail to occur, the signs previously enumerated are intensified. A slight convulsive movement ensues, and the patient dies. Occasionally, death occurs during a sudden effort of the patient to sit up in bed, or in some other active movement. The effort creates a necessity for increased ac- tion of the heart, which is unable to respond to the call, and paralysis of the organ results. The same thing takes place sometimes when persons are greatly debilitated by disease ; in rising to dress, or crossing the ^oom quickly, they drop dead. The pulsations are abnormally multiplied, as in the former case. There is a peculiar condition of the system known as the hsemorrhagic diathesis, in which the sli htest scratch or wound of any description produces persistent bleeding. The disease is hereditary, and both sexes are equally liable to it. In Germany, beyond other countries, the largest number of cases have appeared. Seemingly insignificant wounds in persons of this diathesis endanger life. Lacerated wounds of the gums from extraction of teeth or abrasions in mucous canals, which cannot be reached by local applications, are the most serious. The blood does not exhibit the usual ten- dency to coagulate. The cut vessels are lax and patulous, their contractile power is diminished, and the principal natural means of suppressing haemorrhage are unavailable. 14 EMERGENCIES, AND HOW TO TREAT TIIEM. Oiu' knowledge of its pathology ia small, and chemical analysis shows that the blood possesses the same elements, in normal proportions, as it does in persons entirely free from this disease. The vascular canals in one or two in- stances have been found thinned, but in the majority of cases there is no marked alteration. The general treatment of hemorrhage, when thoroughly understood, can be applied in special cases without difficulty. In this connection it will be well to consider Nature's meth- ods of closing bleeding vessels, before we pass to the ap- pliances of art. Our efibrts copy Nature as far as possible : 1. There is contraction of the muscular fibres in the artery, induced by the injury and by admission of air. The contraction closes the wounded orifice. i The artery retracts within its sheath, the effused blood coagulates in front of it, and the hemorrhage conse- quently ceases. 3. The blood may collect on the surface, coagulate, and compress the wounded ves ... 4. If the cut vessels are small, the bleeding will cease by coagulation of blood within them. ^ Syncope, by allowing coagulation to take place before the circulation is renewed, prevents a recurrence of the bleeding. In all our surgical methods of stopping external haemor- rhage, there are none more efficient or available than j>ressure. It can be employed over the main artery of the limb, be- tween the wound and the heart, or directly upon the wound- ed part. "When the main artery is to be compressed, an in- strument called the tourniquet is generally used. If this is not at hand, a fidd tourniquet may be applied in the fol- niEMORRHAGE. 15 lowing manner : A lumdkercliief is passed loosely arouud the limb above the wound, and its ends fastened together. A small block of wood, a folded towel, or any substance from which a firm pad can be extemporized, is placed over the artery and under the handkerchief encircling the limb. A stick measuring five or six inches in length is then passed under the handkerchief at right angles, and twisted around imtil the pad compresses the artery firmly. Turning the stick draws the handkerchief very tightly around the limb and over the artery, so that it is thoroughly secured. Bleeding from the upper extremity, at any point below the axilla, may be temporarily suppressed by placing a piece of wood an inch and a half or two inches thick imder the arm at right angles with the body, and then pressing the arm firmly against the chest-walls. A large book will an- swer the same purpose. In all cases the material employed must be placed as high as possible in the axilla. "When the wound is situated below the knee-joint, the bleeding may be diminished by raising the limb and placing it on the back of a chair, so that pressure will be made in the popli- teal space. The weight of the limb in this position is sufii- cient to close the popliteal artery. In some cases it may be necessary to fold a towel and place it behind the knee between the chair and the limb. Pressure may be made in a wound with the thumb and fingers, picked lint, compressed sponge, or towels. In hsem- orrhage from the ' carotid artery, pressure may be made with the fingers along the inner edge and lower half of the sterno-mastoid muscle. The subclavian artery is compressed as it passes over the first rib, by pushing firmly with the thumb in the subclavian triangle behind the sterno-mastoid. mr~-^ 16 EMERGENCIES, AND UOW TO TREAT TUEM. Pressure may bo exerted on the brachial artery at the inner border of the coraco-brachialis and biceps muscles. The femoral artery is readily controlled as it passes under Pou- part's ligament, midway between the anterior superior spi- nous process of the ileum and the pubes. The abdominal aorta may be compressed with the hand a short distance above and to the left of the umbilicus. In wounds of the palm of the hand, or other places where there are many inosculating vessels injured, it will be expedient to place a pad or compress in the opening. Whenever the bleeding is profuse, and the main artery can- not be controlled, it is absolutely necessary to stuff the wound quickly with picked lint ar other available substance. It must be filled up, packed tightly, and a bandage firmly applied. In the course of a few hours coagula may form in the vessels, when the lint may be removed and the wound properly dressed. Cold is a useful adjunct in suppressing haemorrhage. It is employed under various forms. For moderate bleeding, cloths wrung out of ice-water and placed over the part will answer. Ice in solid lumps, or pounded and secured in rub- ber bags, or without intervening material, is excellent in profuse hseraorrhage. Cold produced by the evaporation of ether, directed to the surface in the form of 6j)ray, has lately come into use. Prof. William H. Thompson, of this city, employs it with good results in jpost-partum haemorrhage. Cold acts by stimulatiiig the arterial walls to contract, and by assisting in the formation of coagula. Cold and pressure can be used together. Styptics. — Under this head are included all medicinal agents which con+^rol haemorrhage. The most efiicient are HEMORRHAGE. 17 certain i)rcparivtion3 of iron, as the solution of tlio per- sulphate and the sub-sulphate, commonly known as " Mon- eel's solution." Nearly all the vegetable astringents belong to this class. The best are tannic or gallic acids, oak-bark, catechu, and nut-galls. Preparations of alum, and common salt (chloride of sodium) are sometimes used. The iron and other substances are ap])liod by means of a camel's-hair pencil or a sponge. They are dippc-nio»i8. Ei'isTAxis, or Weeding from the nasal passages, is the most frequent and least dangerous of all internal hoomor- rhages. It occurs generally from one nostril. Repeated lironiorrlm<;o from the left nostril is said to be 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 oon^estion 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 bo the commencement of a healthy action. All cases of epistaxis, however, are not attended with the same good results : the bleeding may be so persistent as to seri- ously endanger life. The ancients considered bleeding from the nose as an indication of fever, and bled and piirged the unfortunate patient while any trace of the disorder remained. The blood was supposed to be overheated, and in a state of ebullition, which rendered its removal necessary. flS EMERflKNTIEH, AND HOW TO TREAT THEM. The causes of cpistuxis arc violent exercise uf'ter drink- ing, laceration of vessels by blows or fulls, cardiac disease, catarrhal inflannnations, congestion of the brain, syphilitic or scrofulous ulceration — the luuniorrhiigic diathesis and disordered conditions of the b'ood, such as occur in scor- Lutis, purpura, and continued fevers. Severe forms of cpistaxis are 2>i'ceeded 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 tlio right or lei., 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 .' nio time, a towel saturated with ice-water may bo laid on the forehead. The arm is raised to d'latnhute 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 mammoo of the female and testes in the male, or simply ])lacing the hands in cold water. "When pressure, raising the arm, or cold applications, are unsuccessful, styptics may bo resorted to. Inject with a syrin^o a quantity of ice- water, or a solution of common salt, in the proportion of one tablespoonful 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.lilMORRIIAnE. 23 nnd tlio posterior imrcs luubt then bo plugged. Tho opcrii- tion of pluj,'<,Mii<^ id biinplo, uiid does not require a ^reut nniouiit of Hkill. Tnlio a gum-elastic catheter (No. 4 or 5 will d(»), uiul through the eye of tho iuHtrunient pass a Btriiig, allowing tho ends to hang down. Introduce tho catheter through tho nostril into tho mouth, and draw tho string, which is hanging from its end, out beyond tho \i\>a. To this attach a piece of si)ongo suf- ficiently largo to fill up tho opening in tho posterior nares. Then withdraw tho catheter from tho nose, and make trac- tion on the string until tho sponge is drawn back into tho jiosterior narer>, completely filling its cavity. If necessary, tho sponge may be dipped in an astringent solution before its introduction. This method scarcely ever fails to control the most obstinate hajmorrhage. STOMATOKiniAoiA. — IlaMuorrhago from tho mouth. Tins variety needs scarcely more than a passing notice. It ro- quires special treatment only when occurring in persona with tho hemorrhagic diathesis. Inflammation of tho buc- C'vl cavity, ulcers, and injuries, are its princii)al causes. Kinsing tho mouth with alum-water, or some other astrin- gent preparation, will check it effectually. II.EMATEMKSIS. — Hemorrhage from tho stomach generally occur'' during the progress of some chronic disease of tho 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 (cirrhosis), in inflammation or thrombosis of tho vein, will occasion it. Chronic ulcer and cancer of tho stomach, gastritis, and corrosive poisons, are also prolific causes. 24 EMERGENCIES, AND IIOW TO TREAT THEM. In cirrhosis, tlie liver is diminished in size by the con- traction of new Jihrous tissiie, which is formed throughout t ue organ during the inflammatory process. This new tissue is either developed from inflammatory lymph {Roldtanshj), or by the proliferation of connective-tissu.^ cells ( Vlrchoio). It is located principally around the hepatic vessels. By its contraction, the ramifications of the portal vein are pressed upon, and their capacity diminished or destroyed, and the result is a damming back of the blood in the stomach and intestines. In a short time tlie distention is greater than the walls of the vessels can resi.^t, and consequently they are ruptured. Coagulation of blood in the veins (thrombosis), with or without inflammation, produces haimatemesis in a similar way. In chronic ulcer and cancer, molecular death of the tis- sue proceeds gradually, imtil 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 hrcmorrhage from the stomach occumng at the menstrual period. In this vicarious men- struation, the usual flow from the uterus is absent. In profuse hoemorrhage 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 extra vacated suddenly and in an empty stomacL, there will be little change in its physical or chemical characteris- tics. But if slowly exuded, and allowed to mingle with the gastric juice, Ci partially-digested food, it takes on a dark HEMORRHAGE. 25 color resembling " coffee-groiinds." 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 are particularly marked. Blood from wounds of the mouth 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 lirematemesis, is seldom attended Avith nausea. In passing out some may enter the larynx aud induce a fit of coughing, thereby leading to the supposition that the blood is from the lungs, instead of the stomach. On the other hand, a paroxysm of coughing, with hfcmorrhage from the lungs, may bring on nausea and vomiting, and cause the physician to locate the disorder in the stomach. It is necessary, there- fore, in making a diagnosis, to exercise care and judgment. It is well to remember that blood from the stomach is generally dark in color, mixed with food, and is acid in re- action. If coagula arc present, they will be found black and heavy, from absence of air. There will bo a previous history of pain, nausea, vomiting, and a disordered stomac'i, Avitb the special symptoms of the disease whicJi may have occa- sioned the hrematemesis. In hemorrhage from the lungs, the blood is generally bright red, 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 affection of the lungs or cardiac disease, and there is no history of disease of the liver or stomach. Moist rdles can be heard on auscultation, near the seat of the pain, and there may also be slight dulness on percussion. 20 EMERGENCIES, AND HOW TO TREAT THEM. In all doubtful cases, the mouth and fauces should undergo a careful examination. Ilseraorrhage from these parts is often mistaken for hcematemesis. A perfect knowledge of these points of difference, 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 hemorrhage. 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 stands at the head of all remedial agents for the suppression of hajmatemesis. It can be administered continuously in small pieces, or at dif- ferent intervals, as the case may demand. Cloths wet with ice-w'ater, or pounded ice in bags, may also be applied over the epigastrium. Ether-spray, directed over the stomach, produces intense cold, and is woi-thy of trial. Of the various styptics employed, some prefer the following : 5 . Liqnor ferri subsulphatis Aqua .... 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. HEMORRHAGE. 27 If vomiting is produced by one preparation, let something else be substituted. The contractions of the stomach in the act of vomiting increase hoemorrhage. 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 haemorrhage 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 the preceding chapter. Melmna is a term usually employed to denote hajmor- 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 hajmatemesis. The portal venous sys- tem, which carries blood from the stomach, also takes it from the intestines. Any abnormal condition, therefore, 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 ulceration of the mucous coat, from chronic or acute inflammations, and rupture of capillary vessels dur- ing inflammatory congestion, as in dysentery and enteritis. SoBmorrholds, or piles, are also classed as common causes. In low forms of fever, such as typhoid or yellow fever, hem- orrhage from the bowels is not of infrequent occurrence. In 28 EMERGENCIES, AND HOW TO TREAT THEM. 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 resemblinpi; tar. In profuse haem- orrhasce it has the same characteristics as when occurring from other organs. When the bleeding is due to ulceration, the blood is generally redder than in rupture of portal capil- laries or in piles. Ilremorrhage from intestinal htemorrhoids (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- sons, 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 distention reaches its maximum, so that, in a violent effort to evacuate the bowels, some of the engorged capillaries rupture and relieve themselves. This variety of melaena occurs inde- pendent of any organic disease, not even hasmorrhoids being present to account for it. Haemorrhage of this character acts 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- HiEMORRUAGE. 29 water, or injections of ice- water, or of pounded ice, into the rectum, arc beneficial. The vegetable astringents, such as logwood, oak-bark, catecliu, tannic and gallic acids, given by the mouth or rectum, act well in mild forms of hoemor- rhage. Some i)refer the styptic solutions of iron, men- tioned in the treatment of haematemesis. Small doses of opium, to diminish peristaltic action of the intestines, should always be given. I have found tannic acid and opium, ad- ministered by the mouth, and the application of cold water to the abdominal walls, answer admirably in ordinary cases of melajna. IIjiMon vsis. — The occurrence of ha3morrhage from the lungs was at one time considered a certain indication of tubercular deposit. It was a sign of fatal significance in the eyes of physician and patient. A closer investigation of pathological changes in the lung-tissue has demonstrated conclusively the erroneousness of this idea. Hemoptysis is found, in the majority of cases, to depend on conditions which do not seriously endanger life, and which are amen- able to treatment. The class of persons most subject to this hsEmorrhage are those who grow rapidly in height, without a corresponding development in bulk, who are pale and delicate, and subject to common colds and scrofulous inflammations. In these cases there is a general lax condition of the system, a want of tonicity in the capillary vessels, and in other tissues throughout the body, which predispose to haemorrhage. In inflammation of the larynx, trachea, or bronchial tubes, the vessels of the mucous membrane are distended with blood. A paroxysm of coughing increases the internal pressure on these vessels to such an extent that they rupture, and blood 30 EMERGEN'CIES, AND HOW TO TREAT THEM. 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 inflam- mations of the air-passages this rupture and extravasation are liable to occur, independent of other affections. If the blood were expectorated, the hremorrhage 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 {Niemeycr). Organic disease of the heart is accompanied by hajmop- tysis. When insufl[iciency 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 laming 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 {jndmonary apoplexy), lacerating and destroying its substance, and hat>tening 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 fibrino 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- HEMORRHAGE. 31 sated into the air-cells, terminal bronchi, and between the elastic 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., hannoii'haglc infarction^ to distinguish it from another variety of pul- monary apoplexy in which the clot is diflFused, and lung- tissue destroyed. Tubercular deposit induces hfemoptysis 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, which is relieved by the walls giving way ; or, 3. The softening and degeneration of tissue which accompany the second and third stages of tuberculosis, ir olve the capillaries, destroy them, and haemorrhage is the /esult. Gangrene of the lung is seldom accompanied by htemop- tysis. When present, it is due to the morbid process in- cluding the vessels in the general destruction. The hajmoptysis which occasions the characteristic rust- colored sputa of pneumonia either arises from laceration of the minute capillaries, or by the jiassage of the red globules through the wall of the vessel without rupture. The latter process is doubtful, to say the least of it. The inhalation of chlorine gas, sulphuretted hydrogen, and other irritating substances, likewise occasions haemop- tysis. "Wounds of the lung arc always attended by more or less expectoration of blood. One curious and rare variety of htemoptysis 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- 32 EMEUGENCIES, AND HOW TO TREAT TIIEil. Btruatcd once naturally at sixteen years of age, and, from that time until the ago of fifty, she euircrcd from haemop- tysis regidarly once each month. Accompanying the loss of blood were the usual uneasy sensations of pain in the pelvis and general malaise. In slight cases of haemojitysis the patient has lirst a tick- ling sensation, beneath the sternum, which compels him to cough. The effort brings up a warm fluid having a pecu- liar sweetish taste, which when expectorated is found to bo blood. It is generally bright red, and filled with bubbles of air. At other times the sputa for some days aro 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 iunnediately 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 'ronchial 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 haemoptysis, 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. e>> HiEMORRnAGE. 83 and bo expcctorntod, tlins leading to an erroneous diagnosis. The differentiation between hosmoptysis and htematemesis is readily made. In the latter the blood is dark-colored, acid in reaction, uncoagulable, 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- lablo, filled witli bubbles of air, is brought up by coughing, and there is a previous history of some variety of lung- disease {see Ilcematemesis). Treatment. — The patient should be 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 movenients4)e 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 : 5 . Ext. veratruin viride . Ext. ergot Acid, sulpb. aro. Aqua . . . . fl. 3 88. fl. 3 ij. 3ij. §ij. M. Administered in 30-drop doses, largely diluted, every half- hour, until the desired effect is produced. Digitalis may be substituted for veratrura, or given separately. Great care must be exercised in its administration. For the urgent dyspnoea, which also accompanies this hsEmorrhage in heart- disease, the application of half a dozen dry cups to the thorax will be found an admirable remedy. They relieve 84 KMKIlOENCIEa, AND HOW TO TREAT THEM. / / tlio troublesome bliortncsa of l)reatli, and, by drawing blood to the surface, diminish the congestion of the lungs. If there be no Bpcolul contraindication, the following preparation of sugar of lead and opium, although incom- patible, will often answer the purpose : ]$. Plumbi acotatis Pulv. opil . , 3 8. grs. ij. 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 hajmorrhajre is controlled. Q . Acid, sulpb. dil. Alumon Aqua |y. 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 proj)ertie3 would tend to excite coughing, and therefore sho.Ud not be employed. Gallic acid in three-grain doses, and other vegetable astringents, are found efficacious. In connection with the internal remedies mentioned, cold applications to the dorsal region of the spinal column, and to the chest, will be found of service. "When 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. HEMATURIA. — Blood in the urine is a symptom of many varied pathological conditions distinct in character and in n^MORRIIAGE. 35 location. Having its origin in different organs sonic consid- erable distance apart, a correct appreciation of its sonrce is attended with greater difficnlty than are liromorrlmgcs 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 hcematuria. Constitutional blood-diseases, as purpura, scurvy, ty- phus or yellow fever, are classed as causes independent of special disorders in the organs mentioned. Iloomorrhago 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 large 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- trium, acute cystitis, fungous degeneration of the mucous membrane, and cancerous disease of the organ. Urethri- tis, chordffi, and injuries of various kinds, are prolific causes of hcemorrhage from the urethra. Yarious 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 hcematuria. When called to a case of supposed hcematuria, 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- / 86 EMEROEN'CIES, AND HOW TO TREAT THEM. tity ia largo. Tho reaction in most cases is alkaline, and tlio Bpecific gravity in increaBcd, On being allowoil to btand, a diirk-roddish unxM Hinkd to tho bottom, whilo the ftuperna- tant fluid still nniintains, to a certain extent, its smoky hue. Heating tho liquid will give a cloudy preciijitato of albumen, tinged with tho coloring matters of tho blood, whilo tho rest of tho urino remains 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 tho urine. An excess of urates in other- wise normal urino will induce a red or brown dej)osit when tho liquid cools. To determine their presence apply heat, and the urine will resume its natural transparency. Tho use of beet-root, madder, logwood, etc., also occa- sions a red color. The applications of heat in these cases will not produce a precipitate, showing that tho tingo is not duo to blood. AVhen the blood proceeds from tho kidneys, it will be, generally, diflfused throughout tho urino. It will be attend- ed with a history of injury, the passage of a calculus, or signs of nephritic inflammation. A microscopical investi- gation will show small blood-casts of the uriniferous tubules, red globules, and epithelium from tho pelvis of the kidney. If the blood come from tho commencement of the ureter, small plugs of fibrine, resembling maggots, may sometimes be seen in the bottom of the glass. In ha3morrhage from the 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 .^-^^^ niEMOnRHAOR. 37 instanco. Thoro is a liistory of injrry, Rij^ns of cystitirt, such as frequent desiro to micturate, pain durinj^ the act, and pain on pressure over tlio pubea, or eigns of stone. When tlio bleeding takes place from the urethra, the blood precedes the stream of urine. Thoro is one exception to this rule, namely, where partially-healed ulcers yxist in the canal. Tlio contraction of the \irethral walls, as the last dro])s of urine pass out, lacerates soino of the delicate vessels in the ulcer. I have known this to occur in several ^ances. A careful consideration of the foregoing points of dift'er- enco will, in most cases, enable the practitioner to make a correct diagnosis. Treatment. — "When injury or disease of the kidney causes hffiniorrhage, little treatment is necessary, except that which is calculated to remove the existing morbid condition of the Oij^iin. In hnsmorrhago from the bladder the cause is different. Profuse bleeding from this organ is not infre- quent in malignant disease, or fungous degeneration of the raucous membrane. The patient should be placed on his back, and cold wet cloths applied over the hypogastric region and perintEum. 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 be injected into the bladder, by means of the catheter : I Q . Acid, gallici Aqua 3iu- 5iv. M. fl^^ \ H 1 38 EMERGENCIES, AND HOW TO TREAT THEM. Or, ^. Alamen 3,1. Aqua |iv. M. Many of the vegetable astringents, as uva ursi, hydras- tis, 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 hcemorrhage, 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 — 5 • Liquor ferri subsulphatis Aqua .... 3j. liv. M. Any thing stronger than this creates much irritation and pain. After amputation of the penis, or the removal of tumors, the subsequent hajmonhage from the erectile tissue is some- times so profuse and uncontrollable by ordinary means as to compel the surgeon to apply the actual cautery. 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." HiEMORRnAGE. 39 Ecchymosis follows blows and contusions of all kinds. Its extent depends on the tissue bruised, and tlie amount and kind of violence which produced it. Yery slight injury will occasion large ecchymosis in old persons, and in those who suffer from anreniia or other debilitating affections. In pur- pura and scorbutis, blood is effused in small, irregular patches. This is due to deterioration of the circulating fluid, and not to injury. The ecchymosed spot may be black, green, yellow, or crimson. Sometimes there is a mix- ture, the central part being dark blue, while the rest vai'ies 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 extra vasated material shows that no cor- puscles are present. All bruises which are not attended with grave destruc- tion of tissue mav bo 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. Tr. arnica f j. Ammonia murias 3 j. Spts. vini rect § ij. Aqua I iij, M. For children, a further dilution is necessary, as their in- tegumental covering is much more delicate than that of adults. One or two ounces of water added will weaken it sufficiently. This solution has an admirable effect in pro- 40 EMERGENCIES, AND HOW TO TREAT TDEM. 1 I i V ducing rapid absorption of the effused material, preventing inflammation and excessive discoloration. If there be mnch pain, the officinal lead and opium wash will give relief. A large extravasation of blood should be removed by incising the integument. \ CHAPTER III. HEMORRHAGE FROM THE UTERUS. Metrorrhagia. — Accidental HoBmorrhngc. — Placentia PrDCvio. — Post-pnrtum Htemorrliago. The periodical discharge of blood from the uterus, which takes place every twenty-eight days, is a physiological occurrence, and does not require attention here. It rarely calls for active treatment, even when in excess {menor- rhagid). Metkorkhagia, or bleeding between the monthly periods, may keep up so constant a drain on the system as to destroy by exhaustion, or predispose to fatal diseases. Congestion of the uterus from chronic inflammation, tumors, ulcers, and abrasions of the cervix, are its principal causes. The treatment of metrorrhagia consists principally in the application of cold to the hypogastrium, vulva, and neck of the uterus, and the internal administration of astringents, such as gallic acid, acetate of lead, etc. India-rubber bags, filled with ice-water, introduced into the vagina and pressed against the cervix uteri, may be used with good effect. The diseases causing the hsBmorrhage should subsequently be removed, and the patient's strength increased by fresh air, exercise, good diet, and tonics. Ante-paetum II^morrhaoe is that variety which occurs l! 42 EMERGENCIES, AND HOW TO TREAT THEM. in the pregnant female before delivery. It is due either to partial separation of the after-birth from blows or falls {acci- dental hwtnorrhage), or to placuuta 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 {unavoidable hcemorrhage). Placenta prsevia is attended with great danger, both to mother and child. It requires to be diagnosed from accidental hromorrhage. 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 the time of labor, and is not accoi .panied by a history of injury. The cervix is soft and patulous, the placenta can bo 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 aj)plied 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 Convulsiono). Placenta Pe^via 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 HEMORRHAGE FROM THE UTERUS. 43 at one side when tlie os is dilated, and the child delivered by version. 4. An opening r^ay be made in the centre of tlie placenta, the hand intro(.uced 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-PAKT0M II^MOERnAOE is ouc of the most dangerous sequela) of labor. Perhaps in no other haemorrhage is there such urgent necessity for presence of mind, or active inter- ference. There are few varieties which bo 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 sufiicient to destroy life. Protracted labors which fatigue and lessen the vital forces of the parturient woman, or labors which have been attended by operative procedures, are apt to be followed by profuse bleeding. Neglect 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 exceedingly 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 44 EMERGENCIES, AND HOW TO TREAT THEM. hcemorrhagic diathesis, are also causes of immediate Loemor- rhage. When portions of the after-birth remain behind after delivery of the child, hoemorrhage 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 itself. In post-partum hnemorrhage the blood may be effused in the cavity of the uterus, or, as is generally the case, it may be poured out through the vagina. The first indication of hcemorrhage 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 htemorrhage 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 HyEMORRIIAGE FROM THE UTERUS. 45 advised. When the bleeding is very profuse, the surest metliod is to introduce one liand 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 is 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 surtace of the uterus, if necessary. The physician must be governed by circumstances in its use. There are cases which cannot be controlled without it. Some 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 o;i the inner surface of the contracting uterus will certainly not produce greater harm than the pressure on the irregular prominences of the child's 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, erffot should be administered in large doses at repeated intervals. Its use is always indicated. The subsequent treatment 46 EMERGENCIES, AND UOW TO TREAT THEM. !l f depends on the amount of blood lost. If there be much exhaustion, the 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. {See article on Ilaamor- rhage.) CHArTEE IV. WOUNDS OF IMPORTANT ORGANS. Wounds of tlio Throat, Lungs, rericnnlium, Ilcnrt, Abdomen, IntcstincH, Blad- der, PeriniDum, Joints, Arteries, Veins. — Pcriuoal Section. — Paracentesis, Tlioracis.— Gunshot Wounds, etc. Wounds of the throat vary in extent, from siniplo 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 he 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 and hyoid bone, and over the larynx. In the former the thyro-hyoid mem- brane is cut through ; the epiglottis may be cut off, or in- jured so as to seriously affect the power of swallowing. The food may pass without hindcranco into the larynx and out of the external opening, as the epiglottis is not in p?ace to prevent it, or is in a semi-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 4S EMERGENCIES, AND DOW TO TREAT THEM. I wound is thcroforo not a positive indication of injury to tho oodopliagus. Wounds inflicted on the side of tlio neck may cut tho pneumogastric or j)hronic nerves. In such cases there is interference with the respiratory nioveinents, and subse- quent congestion of the lungs, which may ultimately destroy life, independent of any other complications. Wounds of the back of the neck, unless implicating the spinal cord, are not fatal. Some authorities say that they are followed by paralysis of the lower limbs and loss of sexual power ; this is doubtful. Wounds inflicted between tho lower jaw and hyoid bono are the least dangerous of anterior wounds, although they are sometimes attended with great hoemorrhago and with difficulty in swallowing (dysphagia). The danger and causes of deatli in wounds of the throat arc : 1. Hemorrhage ; 2. Asphyxia. 3. Inflammation of the air-passages and lungs, as laryngitis, l)ronchitis, 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 largo vessels, such as the carotid arteries or jugular veins, are cut, death occurs in a few moments. Secondary hromorrhage not unfrequcntly 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 mucous membrane of the larynx at its upper part {(sdema WOUNDS OP IMPORTANT OROANS. •10 (/loti/'ft), or from blood flowing down into tho air-passagoH. Internal lupniorrliago may go on slowly for some time with- out attracting special attention, tho shock of tho injury and deficient aeration of tho blood benumbing tho sensibility of the mucous membrane. Laryngitis may occur from extension of inflammation from surrounding parts, or directly from a wound of the larvnx. Tho most dan^jerous inflanunations are bronchitis and pneumonia. ThcBO complications arise principally from tho inhalation of cold air through tho opening in tho throat. In ordinary breathing, tho air is heated by passing through the nose, and thus loses its irritating qualities. In all suicidal attempts upon life, there is extreme men- tal depression, which tonds to prevent recovery. Treatment. — As tho great danger arises from loss of blood, tho first efforts aro directed to suppress the flow. This is accomplished cither by means ot pressure , or with the ligature. If tho bleeding vessel cannot bo reached in the wound, sufficient pressure maybe made to stop the ha3m- orrhage, while the upper or lower portions of the wound aro eidarged and the vessel searched for. Should it riot be found, and the haemorrliago be still threatening, the carotid arteries must be tied. If the wound does not implicate tho air-passages, the edges may be drawn together with strips of adhesive plaster. In doing this, care should be taken to leave an opening for the discharges from the wound. The cellular tissue of the neck is very loose, and, unless this be done, pus and other inflammatory products will burrov 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 60 IlMEllOEXCIEa, AND HOW TO TREAT THEM. ii should bo mado to close tlio aperture for Hoveriil hours, or until all dauber from h!cmorrha<5o haa passed away. Even then the central portion of the wound Hhould remain un- closed for the exit of tlie sulwequent diseharf^en. In closing the wound and preventing gaping, the head whould bo ilexed on the neck, and retained there by mcaurt of bandages passed over the head and under the arms. Cloths wet with cold water may then bo applied to lesson inllamniation. If there is venous oozing in the canal, a large tube may be in- troduced, and pressure made by plugging around it {Ericc- son). When the oesophagus is wounded, the patient can bo fed through the opening by means of a flexible catheter, or the tube of an ordinary stomach-pump. I have found thd hitter to be much better for tho purpose than the catheter, as a larger quantity of food can be introduced in a given space of time, and the wound therefore sooner relieved from the presence of an irritating substance. Patients should always bo removed to a very warm room, with a temperature of from 80 to 85° Fahr. Stimulants, and nourishing diet, in the shape of beef-tea or chicken- broth, should be freely administered. Wounds of the Thorax, Lungs, inc. — Non-penetrating wounds of the thorax are treated like simple wounds in other parts of tho body. They do not require consideration here. Penetrating wounds may involve the internal mammary and intercostal arteries, the pleura, lungs, heart, and great vessels, cither alone or collectively. When tho internal mammary artery is cut, the blood flows slowly into the an- terior mediastinum, or into one or the other pleural cavities. It is diagnosed by the location of the wound and the grad- WOUNDS OF IMroUTANT ORfiANH. 61 iial ilovoloptncut of Hyncopo consequent Uiion the lo.ss of blood. Tho protection afl'onlcil to the intercostiil vessels, by the long groove in which they run, happily proveiitu thcni iVoni being wounded, oxce[)t in very rare instances. Tii wound.s of these vessels, tho hromorrhngo may take phic! in tho cavi- ties of tho ])lcura, underneath tho muscles and fascia of tho chest, or escape internally. Tho immediato danger to lifo is not very great, but tho utmost ditHcidty in suppressing tho hrcmorrhago is commonly experienced. Penetrating wounds of tho chest, ^^ "thout injury to tho lungs, aro exceptional. Injury to tho lungs may be ex- cluded, if there is no expectoration of blood, or ha.nnorrhngo from tho wound. If tho hole is large, sulHcicnt air may pass into tho cavity of tho pleura to compress tho lung and completely destroy its action. In such a case, death may ensue. Tlio most dangerous wounds of the lung are produced by bidlcts. Foreign bodies in the delicate structures of tho lung cause grcr.t irritation, and more inflammation than simple laceration woidd. They are not, however, necessarily fatal. Many instances are on record of foreign bodies re- maining embedded in tho lung-substance for years, without interfering specially with respiration. In the summer of 1808, I made a post-mortem examination on tho body of Major D , an old Mexican veteran who had received a gunshot- wound twenty years before. • In tho upper portion of the left lung was embedded a large, old-fashioned musket-bullet, completely encysted. Tho lung was about one-quarter its original size, and was carnified around the projectile. The major had enjoyed comparatively good health, notwithstand- 62 EMERGENCIES, AND HOW TO TREAT TUEM. ing its presence. lie, 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 (di/sptima), expectoration of blood (hcvmopti/sis), and of red, frothy mucus from the air-passages, and emphysema. There may or may not be haimorrhago from the external open- ing. On auscultation, small moist rales may be heard near the seat of 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 tbe 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 near the wound, and broncliial breathing. The passage of air into the cellular tissue {emphysema) is a common accompaniment of wounds of the lung. It may occur 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 ruptiire of the vesicles alone, and extends to the surface, its usual course is through 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 my care in Bellevue Hospital, in a patient whose chest had been severely injured by a derrick. The ribs were not, however, broken. lu a few hours after ad- WOUNDS OF IMPORTANT ORGANS. mission to the ward, emphysenia 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 pr.c"iimonic 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 '^rack- 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 jpneiano- tJiorax. In certain cases of haemorrhage, this has a salutary rather than an injurious effect, as the compression of the lungs will stop the flow of blood. Pneumocele, or hernia of the lung, may take place be- fore tlie 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 64 EMERGENCIES, AND HOW TO TREAT TIIEM. ■I remote result of tlie wound, and covered by tlie integument, all that is necessary is to protect it by a lioUow 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 tlie 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 ligature around the rib, drawing tightly, and thus closing the wounded vessel. 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 al>ove. If it do not succeed, ligation may be resorted to. This operation is usually performed at some point above the fourth interspace ; below this point, the operation cannot succeed. The method of ligating the artery is described by Dr. Poland * as follows : " An incision is made two inches in length along the side of 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. i I WOUNDS OF IMPORTANT ORGANg. 55 into view; the intercostal mnsclo is now carefully divided upon a director, and the edge drawn apart by retractors, and the arteries exposed." In "Wounds of the Lung an attempt must be made to con- trol the hffiraorrhago by internal medication. Small doses 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 clianging tlie 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 hemorrhage remains. Some prefer enlarging the external wound, while others allow it to heal, and after- ward -pcrfoi'm jya^'acentesis 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 trocliar and canula. "When the point of opening is selected, the integument is incised with a scalpel, and the trochar 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. Bowditch, of Boston, uses a suction apparatus to prevent air from passing in, and to assist in evacuating the liquid. It is very highly recommended. "Wlien the hemorrhage has ceased, the external wound is thoroughly closed, and the lips held 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 sufficient extent to compress 56 EMERGENCIES, AND HOW TO TREAT THEM. llil iili! 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 Pericardium. — A punctured wound in the prajcordial 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 upjn the heart so as to i)aralyze its movements. The inflfaimation 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 tlic 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 bkin, and anxious face. When the haemorrhage 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 prrecordia, 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. lie received a bullet- wound in the heart, and walked home afterward. Death did not occur for hours after the injury was inflicted. WOUNDS OF IMPORTANT ORGANS. Small punctured wounds of tho heart have been known to terminate in recovery. A wound of th^ auricles is more rapidly fatal than a wound of tho ventricles. Tho walls of the former arc thin- ner, and the fibres more uniformly arranged, and their con- tractions less likely to prevent luiimorrliage. The muscular walls of tho ventricles are thick, and the fibres interlaced, and, if the wound be small, profuse bleeding cannot occur. The sijrns of wounds of the heart are those of shock and loss of blood. The patient becomes rapidly insensible, and the pulse ceases. There 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, tho 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 cm- ployed as in the. preceding case. AVouNDs OF THE Abdomex 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 iuipossible 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 58 EMERGENCIES, AND HOW TO TREAT THEM. I aro also tympanitis, constipation, and vomiting. The pulse is hard, tense, atid wiry. The skin is dry and the temperature increased. When the intestines aro wounded, there is still greater liability to peritonitis. If the 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 evcrsion of the mucous mem- brane. Treatment — If the intestines protrude externally, and cannot easily be returned through the wound, the opening should he 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. Ericceou 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. Sume believe that the sutures should merely include the skin, and 7iot the deeper structure below. It is reasonable to suppose that, in closing tlie wound in this way, a separation to a greater or less extent would take place in that |5ortion 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. w^ WOUNDS OF IMPORTANT ORGANS. 59 it should bo opened, kept clean with carliulic-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 inHucnce until his respirations are down to 14, and his skin 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 percei)tible lesion of the walls. Severe contusions are scarcely ever recovered from. As a good example of the manner in which these wounds arc received, and their mode of termination, the fol- lowing case may be of interest : James D., aged twen ty -seven ; occupation, laborer; was admitted to Ward 11, Bellevue Hospital, suflcring from a severe contusion of the abdomen, lie had been ridin": on the rear platform of a Third-Avenue car, which was driven at considerable speed. The car suddenly came to a halt at the corner 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 shock, 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-7no7'tem examination showed that a portion of 60 EMERGF.NCIES, AND HOW TO TREAT THEM. tliG small intestine was much bruised, but its walls had not been torn through. Pus and lymph in considerablo 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 or rupture of the bladder is succeeded by peritoneal inflammation. The nrine may pass into the ab- dominal cavity or into the abdominal walls. In the latter case, the wound is below the part where the pcritonneum is reflected over the organ. If the laceration is at the base, the point of a catheter may pass through and be felt in the rectum. The escape of nrine into the peritoneal cavity is attended with a sharp pain, which rapidly increases till the peritoneum, through its extent, is involved in inflammation. In the cellular tissue of the pelvis or groin, it excites diffuse suppurative inflammation. Treatment. — "When the nrine 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 t«j run out througli a catheter introduced for tliat purpose. Opium, in full doses, is beneficial. WouN-Ds OF THE Perix.eum. — Laccratcd wounds of 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 perino3um, and, if it is at all resistant, ruptnre takes place. As soon as labor has termi- nated, the edges of the wound should be brought together by sutures. WOUNDS OF IMPORTANT ORGANS. Gl In tlio male, these wounds arc liable to injure the ure- thral canal, and oi)crative measures are necessary to relievo the resulting retention of uriuo and effect a cure. Perineal section is usually performed. When the patient has been fully auffisthetized, a staff or steel sound is passed down to the laceration and through it, if possible, and the tissue of the ])crina3um divided in the median line down to that point. The external incision ex- tends from the termination of the scrotum to within hulf an inch of the nnus. The knife is then carried on in the di- rection of the iirethrtk, until the injured portion has been passed. A catheter is then introduced into the bladder and retained for forty-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 he opening and filled with ice-water. Dr. Synott, one of the Bellevue house-surgeons, first employed this method. It has proved successful. Another plan is to place a piece of oil-silk, or other suitable material, around a lead-pencil, 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- oa EMKIUIF.NTIKS, AM) HOW TO TREAT THEM. narins, n sound h pp.sscd down the canal and the pcnia compressed against it with a baiKhige. Fractures of the pelvis are soinetinies associated with lacerated wounds of the perinwuni. The following case is a good ilhistration : 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 wliarf. He was brought to Ward IG, Bellevuo Hospital, a few hours afterward. An external examination failed to detect a frac- ture. A catheter was introduced, but met with an obstruc- tion about the termination of the membranous portion of the urethra. As there was considerable urine in the blad- der, it was decided to perform perineal section without de- lay. Ether was administered to the patient. An incision was then made through the tissues in the median line, com- mencing near the base of the scrotum and carried within half an inch of the anus. When I reached the membranous por- tion of the urethra, I found fragments of bone pressing upon, and completely obliterating, the canal. The ramus of the pelvis, and a portion of the body of that bone, were broken in several fragments. The dchr'is 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 patient died on the third day. Penetkatixo Wounds of 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 OUC.ANS. 08 limb. Tlio joint it) known to ho itort'onitcd by tlio a[)i)OiU'- anco of a thick, transparent lluid {ni/fiovut) i'vum tho joint. This may ho ahsont when tho wound passes into tho part from nhovo downward. Treatment. — If tho wound is small, tho edges shoidd bo drawn together as closely as possible and hehl in closo ap- position by adliesivo plaster. lee-bags, applied afterward, may prevent, or at all events modify, tho amount of inflam- niation. Largo wounds should not be entirely closed. In- flammation of tho joint is an invariable accompaniment, and a space must bo left tlirougli which tlie discharges may pass. GuNSHOT-Wouxns. — Under this hcud are included all wounds which result from the cxiilosion of gunpowder. They may bo made with bullets, cannon-balls, or splinters of wood and stone. The worst wounds are those inflicted by cannon-projectiles and 8])linters. All gunsliot- wounds, whether external or internal, are attended with danger. A greater amount of shock, contu- sion, and laceration, accompanies gunshot-wounds than is found in other varieties. Inflammation and suppuration follow in tho track of the bullet. Pus is liable to be re- tained and burrow in the neighboring tissues. Deep suppu- ration is one of tho principal dangers. Tho wound made by the bullet is smaller where it enters tliau wliere 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 easilv driven out of its course by bony projections. The missile may strike a rib on the left side, and, passing under the tissues, emerge on tho right side of tho body. lEcnner relates a case where the bullet entered the upi)cr portion 64 KMEIKJENTIKfl, AND HOW TO TIlKAT TIIKM. of tlio linn and i)a9scd down to tho thigh on tho i)i)posito Bido. 2W'Uteal artery. — This vessel is rarely tied except for Avounds wliicli involve its walls. In the upper third of the ancry the operation is performed by cutting the integument and fascia, at the edge of the semi- membranous. The i.Miscle is drawn iuAvard and the artery ex2)0sed. The popliteal vein is external, and snpcrficial to the artery, and the internal popliteal nerve external and superficial to the vein. In the lower third, the incision is made in the median 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 boon done the limb is flexed, and the 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 pollicis, and is covered by the integument and fascia. These latter are incised — the tendons separated, and the artery exposed. The nerve is in this situation superficial to the artery. The veme comites are separated from each side of the vessel, and the ligature applied in the \isual manner. Posterior tibial. — It is extremely diflicult 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. When the integument and fascia have been cut, the edge of the gastrocnemius muscle is turned aside, and the soleus detached from the tibia by cutting its fibres on a director. The fascia underneath this WOUNDS OF ARTERIES AND VEINS. 71 1 muscle is next divided, and the artery exposed from tlu'ce- qnartera of an incli to an inch from the inner border of the tibia. The tibial nerve in tliia 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. Wounds of Veins, Entkance op Am. — Fatal haemor- rhage takes place in a short time when large veins, as the jugular or vena innominata, are wounded, unless immediate assistance is rendered, and the wound closed by ligation or pressure. In wounds of small veins the danger from hremor- rhage is slij'ht. "Wounds of veins may be followed by phlebitis or by the entrance of air. The latter complication occurs particularly in the veins of the 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 movements of the body, which may last for several hours before a fatal termination is produced. In the majority of cases sudden 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 72 EMERGENCIES, AND HOW TO TREAT THEM. heart from the presence of air ; * others, again, ascribed it to the impossibility of a frothy licpiiJ passing through the lungs. In the absence of any accepted theory, I would suggest the following : In the great majority of cases the accident occurs in removing tumors froui thj 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. Wlien 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. "When 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 efforts to restore the respiratory movements, and with them the action of the heart, should * Holmes's Surgery, article Wounds of Veins, WOUNDS OP ARTERIES AND VEINS. 73 be made. Marsliall Hall's or Sylvester's methods of arti- ficial respiration can bo tried. Stimulant enemata and friction of the snrtaco are always necessary. Galvanism may also bo tried. In mild cases, brandy and ammonia may be given by tbo stomach. Hot plates over the epi- gastric and precordial regions arc also serviceable. l! ■^ CHAPTER VI. POISONED WOUNDS. Dissecting Wounds.— IlyJrophobiii.—Snako-Bites.— Insect-Bites. Dissecting Wounds. — During the process of putrefaction a poison is generated wliicli is capable of exciting inflamma- tion in liealtliy 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 post-mortevi 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 harmless, while those inflicted in a post-mortem exanunatiou often destroy life. Whether the material injected in the arteries of subjects about to be dissected modifles 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, pyaemia, typhus, etc., are pecu- POISONED WOUNDS. 76 liarly diuigorous. Tlioy seldom fail to produce cither local or constitutional poisoning. On the other hand, i)arturicnt women are sometimes infected by the poison of the dissect- ing-room carried on the hands of a physician. Erysipelas, l)uerpcral fever, etc., are not unfrcquently 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 below par. In merely local poisoning, the wound shows little ten- dency to heal, closing for a day or two and then breaking out afresh. Around the wound the integument is thick- ened, and of a dusky hue. There is an exudation from the cut surfiicc, of a sero-purulcnt character. This 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 rimning up the arm, indicat- ing the extension of inflammatory action to tlio lymphatic vessels [angeioleucitis). The arm is swollen and painful. The axillary glands enlarge and often suppurate. Abscesses may form Pud burrow in the cellular tissues of the arm and chest. The skin is hot and dry, the pulse rapid, and urino 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, I'T 76 EMEIUJF.NTIES, AND HOW TO TRKAT TIIKM. within a period nui^iiijij iVoiu twciity-tVmr to turty-ei«^lit hours after tlio wouiul ia rucoivcd, in seized with violent chilJH. These are succeeded hy unniistakiihlo evidences of l)lood- poisoning. The pulso hccomes rapid and very Mtnall, tho countenunco anxious, and tongue brown and dry. TIio in- tegument is of a tawny color, and may bo jaundiced. There is profuse peri^piration. Meanwhile, tho wound beconies very painful ; tho tissues around it arc thickened and infil- trated with pus. Abscesses are not confined to tho injured tissue, but may show themselves in any part. The lym- phatics are involved as in tho preceding case. Delirium sets in, and is soon followed by death. In severe cases, death may occur within forty-eight hours after tho infliction of tho injury. Treatment. — In wounds of this character, proper pre- cautions should bo immediately resorted to in order to pre- vent the retention of the poison and its subsequent entrance into the circulation. Tho wound should bo washed by hold- ing it under a stream of water for a few seconds. Tho lips are then applied and tho virus removed by suction. There 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 tho 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 roiSONKD WOUNDS. neccssiiry, to the whole liiril). I'liiritirig the iiithiiiieij lym- phatic vessels with iodine hiw hccii reeoniiiieiKled. Opium irt freely >^\ven to relieve jmiii uiid to produee Bleep. Euriiiy-digeiitcd nutriment, sueh »s heet'-teu and ehickcn-broth, is to bo administered utl llhitiim. Stimu- lantB are sometimes necessary. The treatment lor the third vorlety is similar, with the addition of stimulants used freely, and hir^o doses of quinine. irvniioi'nomA. — Phobodipson, rabies, canine madness, lyssa, and a variety of other terms, have been used to desig- nate thi-i malady. It has been known from the earliest his- torical i)eriods. The disease attacks man and many of the lower animals. Dogs, cats, and wolves, are most subject 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 tlio salivary secretions introduced through wounds inilicted by the teeth. Other secretions in the body are said to be harndess and unable to transmit the disease. The period between the inoculation and the develop- ment of the disease is subject to considerulde 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 the 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. I 78 i:MKIliii:X('IKM, AND MOW TO TIIKAT TIIK.M. Uill)iu.^ iit tliudoi^ irf divided by Virchow into lliroo Htaj^os : 1. Till) iiu'luiiulioiic!; 2. Furious; and >). Panilyfic. Tim iininial iiU'octod Kwoa its iippctito — slirirdvS from wiitor and ordiniiry food — ondoavorrt to liido in hid keuiiol, imd can with great difliculty bo coaxed out. The bead droops, nnd the eyes are bloodsliot and heavy. There is great tliirtit, and water in not refused. In the Hccond stage the animal yelps or howls, and runs wildly about, biting at every thing. The tongue hangs from the mouth, and the eyes are congested and wihl. In the third stage emaciation is aj)parent and rapidly progresHcs, great exhaustion Bupcrvencs. Little ff1\»rt is made to move, and the saliva dribbles from the mouth. In walking, both hind-legs arc dragged on the ground as if paralyzed. Death ensues in from four to eight days from the eonnncnccment of the disease. irYDUDiMioniA in man has many of the characteristics just described. A person bitten by a mad dog is usually on the watch for some manifostation of the disease. The wound may heal readily, but the dread remains. If the cicatrix begins to inflame and is painful, and other signs appear which show that his fears arc about to bo realized, the depression of spirits and anguish are intensified. All cases are pre- ceded and accompanied by this terror. It is one of tiio 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 tho disease the muscles of tho throat, and especially those con- cerned in deglutition, become stiff and sore. Attempts at POISONED WOUNDH. ':< 7!) pwiillowiiip; aro followed l)y flpasinodlo (.'oiitrnction of tlicso jiMirtcIes, and of tlioso concerned in iXMi)invtion. Tlicso con- vulsive inovenientrt increase in frequency, excited by tlio sniallest proviKMition. Slainniin^ doors, cold currents of air, l)ourin^ water from one vessel to urnitlier, or eliun^ing the hedelothes, brinj^s tliein on. In some cases there aro general convulBioiis. Thirst is intense, and tlio unfortuinite patient does not relievo it for fear of choking or renewing tho spasms. Sometimes there aro small i)ustules under tho tongue (Marselietti). Tlio ])atient'ri countenance expresses all his terror. Tho eyes are staring and bloodshttt. A thiek saliva is constantly thrown from tho mouth. The voice ia husky. Aft the end ai)proaehes, tho skin becomes cold and clammy, tho pulse almost imi)ereei)tible, and the resjjlra- t(»ry movements irregular. A convulsion may terminato life by involving the muscles of respiration, ov tlio patient may die gradually from cxhaustioii. After death, the fauces, throat, and lungs, nre dark-colored and congested. In some cases, there are congestion of tlio cord and etfusiou into tho ventricles of tho brain. Tliero is nothing definite in any of the lesions to indicate tho speeilio action of tlio virus. Strange as it may seem, hydrophobia is sometiiiios imitated for mercenary purposes. A ease of this kind was admitted to Ward 0, Bellevue Hospital, in tho winter of ISGT. The patient stated that, when seven years of age (ho was then twenty-live), he was bitten by a mad dog. One year after- ward, symi)tom3 of hydrophobia manifested themselves. Ho recovered from that attack, but exactly one month afterward at " the full of the moon," he was alt'octed in a similar manner. This peculiar tendency to a monthly re- i. f II 'I so EMERGENCIES, AND HOW TO TREAT THEM. currence kept up for two or tlareo years, and then ceased up to within two years of his first appearance. At that time they again commenced, and liad 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. lie 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 a^ter his .admission, and while in a convulsion, he was seen by Dr. Flint, who advised the application of h t 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 cajiital 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 POISONED WOUNDS. 81 :e a " mad procedure is useless, because the circulation through the deep veins cannot be completely stopped. If placed on the fiii"'erB 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 i)ainful. "When the disease is fully developed but little can be ac- complislied. Stimulants can be given in large quantities by enema, and other liquids in like manner. Opiates and annesthctics 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 disinfecting poultices, sprinkled with laudanum, will be serviceable. Free discharge should be kept up continu- ally. SxAKE-BrrES. — 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 resiilt more quickly than the others. Rattle- snake-bites stand next in order of virulence. Viper and adder bites are fatal only to very young animals, or to children of tender years. In the more deadly classes the symptoms following a bite, and the action of the poison, are the same. Rattlesnake-bites 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 sharp tooth or fang. The tootli is channelled throughou centre to make a place of exit for the poison. When thu .ooih is inserted inio the tissues, the 82 EMERGENCIES, AND HOW TO TREAT TIIEM. M\ I poison-sac is compressed, and tlio vciioni ejected into the ■wound. The person bitten is overcome, either innncdiately or after tlio 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 rapidly. 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, Avhich e^ tends up the limb, generally in the course of the principal n*. rves. Inilammation extends to the neighboring tissues, and, if the patient live long enough, diifuse su])puration may occur, and abscesses form throuuhout the limb. Rattlesnake-bites produce death in from live to ten hours. The post-mortem appearances show nothing of the special effects of the poison. Sometinaes there is congestion of the brain, M'ith serous effusion imderneath the arachnoid and into the ventricles. Tlierc may also be congestion of the lungs and mucous membrane of the stonuich and intes- tines. The blood remains fluid in the cavities of the heart in many cases. Treatmeni. — 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 liave been iiroposcd. Bib'on's antidote in one wbieh has been strenuously advo- cated. Dr. W. A. Hammond, after a series of experiments, came to the conclusion that it was a remedy of great efficacy. Its formula U as follows : 5- Potassii iodidi llyd. bidiloridi Brouiino grg. IV. grs. ii. 3iv. 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 spohen of. Guaco, Virginia snalceroot, and other medicines of vegetable origin, have also acquired temporary reputation as antidotes. The the most efficacious treatraeiit is to administer large doses of carbonate of ammonia repeatedly in conjunction with enemata of whiskey or brandy. Tlie ammonia can be ad- ministered in ten or twenty grain 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 Avith poison follicles. Scorpions are found in all tropical climates. The largest scorpions arc the most venomous. The tarantula, a species of spider which inhabits South- ern Europe, was at one time held in great terror on account % a i'i 8:t KMEIinKXCIKR, AND HOW TO TREAT THEM. ot* hA reputed deadly iuiluenco. The stories of its ravages are, however, not founded on fact. Ccnti])edes arc less dangerous tlinn either of the pre- ceding varieties. Tlie most veiu)nious grow to a length of six inches. A nuniher of poison-claws project from the body. As the insect crawls over the surface, these arc in- serted into the integument, and the virus introduced. Some writers deny the existence of any special i»oison in members of this class. The constitutional symptoms following the bites of these insects arc exhibited in the form of headache, vertigo, dim- ness of vision, and sometimes febrile excitement. The Avound, in some cases, is not inflamed ; in others, it becomes red and painful, and the inflammation spreads to other parts of the extremity injured, ending in dilfuse suppuration. Treat nioit. — When the wound is cleansed, it should bo sponged thoroughly with a strong solution of ammonia, and afterward covered with cloths moistened with the same sub- stance. Brandy may bo given internally in conjunction with ammonia. vJlS j^ CHAPTER VII. EXTRACTION OF FOREIGN BODIES. Foreign Bodies in the Lurynx, Trachea, Bronchiul Tultos, I'lmrynx, (Ksopii. a^'us, KyuH, Nose, Kiirs, Urotlirn, liliiJUor, and liuutuin. — Trauliootomy. — Luryiigotoiuy Liirynfjutomy. — (Esoplmgotomy. FouKKiN Jjodiks in tiik Aiit-i'ASSAGKs. — Forcl;^!! bodics are usually lodged in that ])ortiou of tlio air-passnges known as the larynx. This organ is situated in the median lino of the neck, between the tracliea and base of tlie tongue. The anterior margin of its superior opening is guarded by a car- tilage called the ephjloUis. During the act of deglutition, the epiglottis closes the aperture in the larynx, and prevents the etitrance 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 cervical, and bifurcates about the third dorsal vertebra into the right and left bronchus. The riglit bronchus is shorter than the left. Its orifice lies directlv under the tracheal canal, so that for- eign bodies which pass below the trachea drop 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 air-passages. In talk- ing or laughing, the air is passing out of the lungs, and the epiglottis is raised. Heavy substances contained in the nm 86 EMERGENCIES, AND IIOW TO TREAT THEM. mouth (luring these uctt*, readily roll backward, notwith- standing; the outward current. Taking a gudden inspiration 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 particles of food into the larynx. It is not unusual for worms to lind their way into the larynx during sleep, or for bronchial glands to become detached and carried upward, producing serious and even fatal results. The presence of a foreign body in the pharynx, or ccsophagus, 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 prolang will settle the difficult}'. Children are more often subjected to this accident than adults are. The habit of carrying in the mouth beads, marbles, or pennies, is very prevalent among them. As an instance of the dangerous results attending it, the following incident, whici 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 pur[)le hue, and death seemed imminent. A])preheuding that the chloro- form was the cause of the difficulty, I commenced artilicial respiration. While I compressed the chest, my assistant introduced his finger into the mouth to clear the throat of mucus, and draw forward the tongue. In so doing he fouiul a coi>per coin completely closing the superior aperture •A' the larynx. The removal was soon followed by a renewal f the res[)iratory movements, and disappearance of all the EXTRACTION OF FOIIEION BODIEH. 87 alarmiii^!^ symptoms. The child hiid been playing with tlic penny, nnd had placed it in her mouth previourt to my arrival in the ward, and, when insensibility was induced by the ana3sthetic, 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. Tlie size of the foreign body bears no special relation to the severity of the symptoms, uidess, 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 occai^lons greater distress than one which is sta- tionary. When the material lodges in the larynx, Avhethcr large or small, it produces a spasm of the laryngeal muscles Avhich 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 tu breathe, and the patient dies at once, or receives temporary relief from a relaxation of the spasms. The cur- rent of air which now enters, eitlier passes the obstruction, or carries it farther down into the trachea. Once in this organ, the intense suffocative symptoms become less marked and continuous. There is more or less difficulty of respira- tion all the time, pain over the point where the foreign bodv is loilged, and a distressing consxh. The countenance has an extremely anxious expression ; the pulse is rapid. Se%'ere dyspnoea occurs now only at intervals. "Whenever the substance is forced up into tlie hirynx, violent efforts at n't ii ^ i iii 88 KMEROENCIER, AND HOW TO TREAT THEM. expuls^ioii uj^iiiu ensue, with the siiiiio paroxysm us cliar- acterizoil the first stage. AVhcii the Ibreigii body reaches one of the broiielii, the lung on the correspoiuling side gives but little rcs])iratory murniur 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- ])assages gives rise to symptoms like those mentioned above — they only ditfor in degree. After a day or two has elapsed we have more pain — the cough is increased, the ])ulse becomes accelerated, the countenance retains its anx- ious expression, the voice is husky, and general febrile ac- tion is developed. There are also the s[>ecial signs of in- flammation in the part occupied by the irritating material. Death may occur instantaneously in the Jiriit turned on Ids i'lie>t. Il' the ojieninj^ l»e too nniall, the incision may ho carriwl (h»\vii throu;:;h tho t-rieoid earti- la;^e and npper rinj^ of the trachea. The ejection ol' thi; l'on'i;!;n hmly often occurs ms soon as the operation is coniploti'd, hut, if this (K'sirahle result do not follow, and the snhstanct! ho within reach, a lonn'-curveil forceps may bo carefully intro(luce(l to roujovo tla; ohstruc- tion. When tho passay keeping; exactly in the median line the anterior jugular veins are i:XTKACTfoN OF FollKlCS ItoDlKS. \)i avoided. Tlicrto V(!HH(!lrt iiro pusliccl jijitlf, iiml llic iiui. ion ciirrii'il tlin»ii;;li llu; I'asciii, wliicli cuviTrt tlu! hlcnm-lijoi"! luid Htcrno-tliyi'oid iiiiirickirt. Tlit'so imisclort iins hf|(!ii'uli!d, iiiid llu! inlt'rior thyroid plexus ttl" veins is ri'.icln'd. The ImiidK! of tho Kcidpel is now to Iio (jiirefully usoil in ^(.'Itini;' them out. of thi! way without hiccnition. A tLMuieuluui is inserted into the trueliea to th'aw it forwurd. The knife is intru(hi(!ed hetwc^en tho rint^s, and two or thre;; (»f them divided from helow upward. The; eiit-ends are heM aj»art by li;j;ature or widened hy diUitors, and the i)ati(!nt is [daeed in a supitio posture, and, if the oltstruetioii still remains and is within reaeh, it must ho removed with the fon-eps. When these operations are performed fop other patho- lo;:;ieid conditions, as hirynf^eal inllammiitions, Imnors of the larynx, :>> >y 7 /^ Photographic Sciences Corporation 33 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 f €i. 0-2 EMERGENCIES, AND HOW TO TREAT TIIEM. esophagus. The food passes into it from the mouth, and is carried down into the oesophagus by contraction of the pharyngeal muscles. The ce:^oi)hagus commences opposite the cricoid carti- lage, to Avhich it is attached by muscular iibres, 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 lenu;th, 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 ou the larynx cause spasm of tlie glottis and consequent suffocative 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 l)odios, such as pins or needles, pierce the mucous membrane, and cause more pain and irritation than other varieties. If they stop at the lower ante."ior part of the pharynx, spasmodic closure of the glottis is induced, often to a greater extent than when bodies of a large size press on the same part. Irregular sharp substances in the pharynx EXTRACTION OF FOREIGN BODIES. 93 or upper end of the ossophagus cause nausea and vouiit- ing. In tlic average of cases tliere 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 tlie pharynx or oesophagus, the first endeavor sliould 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 point 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 {IlaW). Force must not be emplo^-ed in removing needles, pins, or other sharp articles, for fear of piercing, or lacerating the 11 I'il yi EMERGENCIES, AND HOW TO TREAT THEM. mucous meuibvane, and tlic important neighboring parts. Obbtructions in the uj)per portion of the pharynx may be extracted with the finger, or when farther down with curved forceps adapted to the puiposc. Among the instruments tliat are used for pushing foreign bodies into tlie stomach the j)^-ola7i(/ 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 intro- duced by Dr. Sayre, of this city, for the removal of foreign bodies. It consists of a gum catheter, from Avhich the end lias 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 tlie M'halebone, 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 fiar as possible, the bristles surround the whalebone very closely and compadtly. 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 Surgnry, vol. ii., page 325. EXTRACTION OF FOREIGN BODIES. 95 all around in such a manner, that when the instrument is withdrawn it carries the foreign body with it. "When foreign bodies ai*e 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&sopliagotomy. 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 the median line, and is therefore more easily reached. After the patient is fully under the inilucnce of an anes- thetic, the shoulders are raised, the head turned to one side, and an incision is made 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 phitysma- myoides muscle. The omc-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 ti'achea are moved slightly inward. A bougie is new passed down the throat, and protruded below so as to bring the oesophagus 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. FoKEiGX Bodies ix the Kose. — Children of tender years are particularly liable to this accident. It is of frequent ^:l| 90 KMERCEXCIES, AND UOW TO TREAT THEM. m I I occurrence, but happily there is more inconvenience than danger attending it. Peas and beans in the nasal cavities are specially trouble- some ; they eidarge in size by their absorption of moisture, 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 shcUd be taken that the substance is not forced back throngli 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. FoREiGX EoDiKs IN TUK Ear. — Tlic length of the ex- ternal auditory canal is about one inch and a quarter, and at its inner extremity is the membrani 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 OP FOREIGN BODIES. 97 and, tlirongh tlie 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 tympanum. 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 difficulty. 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-four 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 I I >h •i! D8 EMERGENCIES, AND HOW TO TREAT THEM. ¥ piece of " cotton-wool," tliorotiglily saturated with a strong solution of common salt or vinegar, and sufficiently largo to plug the orifice completely. After its introduction turn the patient on the atfected 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 bo 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 upper 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 these instruments, and very 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 symjitoms have subsided. In the majority of cases the foreign body will come away in the purulent discharge. Foreign Bodies around 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 efi'usion which may have collected around the hair; the latter is then readily EXTRACTION OF FOREIGN BODIES. 90 removed. For tlio extraction of dirt, santl, etc., the follow- ing fiimple 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. AVhen 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 oftener, without injury. Some use a small scoop made from wire, which is moved around under tlie eyelid from one canthus to the other. FoRKiGN Bodies in the Urethra, axd 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 amonj; the lonj; 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 jneans 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, 1 '1' ifW||H| ill tl f 'II ■\\\ frn" r • » I I • t I • t • » til' 100 EMERGENCIES, AND IIOW TO TREAT THEM. 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 bo effected by a forceps adapted to the canal. If this fail, urethrotomy mnst 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 o])era- tions for stone, are usually made. Substances may bo 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 Bodiks in the Eeotuth is a rare accident. Fall- ing on the rung of a chair, or on fence-ppokes, 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 organ. 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. CTTAPTER YIII. BUIiNS AND SCALDS. Varieties of Dcfornutios produced by Burns.— Spontpnoous Combustion. — Clns- siflcntion of Burns. — Constitutional Symptoms. — Duodenal Ulcers. — Cuuscs of Death, etc.— EflTccts of Cold.— Frost-Bito. TiiuuJi are few accidents ■wliicli combine so many un- natural elements as burns and scalds. In none do we wit- ness so much agony or such poor results from treatment. Burns arc to bo dreaded in their remote results, as well as in their immediate co?:' sequences. Recovery in many cases is accompanied by hideous deformity. Severe facial burns not unfrequently leave the face twisted and distorted to such a degree as to almost destroy its semblance to humanity. The cheeks may b' 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. Burns 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, fi'om want of sleep. A case I .-■ml lil iM I i 102 KMERGEXCIES, AND HOW TO TUEAT THEM. of this kind caiiie under my caro at Bcllovuo, in a female patient who suifered from a severe burn of the foreliead and arm. The upper eyelid was drawn up on the forehead, and fastened above the Buperciliary ridge. The sufl'ering for want of elccp was considerable. Even opiates failed to bring relief. Ordinary covering for the eyo only produced irritation. Finally, as there was no integument near frona 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 tho healing process became complete, by means of a fine silver wire passed through, near the fr'>e margin of the lid, carried down across tho end of the nose, and fastened at the back part of tho 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 imcover tho 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 tho 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 a light, 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. nUIlNS AND SCALDS. 103 Recovery iVom such burns is rare, owing to the extent of sui'fttco injured. Dangerous burns are also produced by the eontaet of melted metals with the body. They buvrow into the flesh, and cause 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 coinhistifm may bo mentioned in this connection. Several cases of it are recorded by reliable observers. It takes place in persons who imbibe the worst varieties of ardent spirits. There is muclx 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 u 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 111 ,' I ■t ii-„ if'- 104 EMERGENCIES, AND HOW TO TREAT THEM. A superficial bum, involving a li.'ge integumental area, is apt to prove fatal. Localized deep eschars are not par- ticularly serious, rrless 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 surgeons have increased the number. For our present purposes four degrees of burns will be sufficient : The first 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 bullae or eschars of a brown color result. The third class includes all which extend through the subcutaneous cellular tissue into the muscular substance. T\xq 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 affected. "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. The immediate symptoms accompanying severe burns 81 m ■ I 1611 ■ BURNS AND SCALDS. 105 may be dividecl into three stages, eacli 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 collaps5e. The pulse is small and feeble. The extremities are cold and clammy. There are great thirst, with diificulty in swallowing {dysphagia), and nausea and vomiting. The patient's countenance is shrunk- en, and has an expression of anxiety. Chills and rigors are present. Tlio 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-mortem 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 .urface of brain. There is also marked congestion of all the inter- nal organs. 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 {eephalalgid), and sometimes delirium. Yomiting may also be present in this stacre. The 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. Inflammation 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 il m !i 106 EMERGENCIES, AND HOW TO TREAT THEM. II !i ;l severe burns may take place in tliis period, althougli it is more frequently seen in tLe third. 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 secretion. ^« is recognized bj pain in the right hypochondrium, loose and sometimes bloody evacuations from the bowels. Usually it appears on the tenth day, but it may commence as early as the fourth. The duration of this stage varies from one to two weeks. The post-mortem appearances are principally those belong- ing to different inflammations. 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 com- mencement of suppuration, usher in the third stage. In severe cases, the patient's condition is similar to that of the first stage. If the suppuration be 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 changes, and ulcers are more frequently found. The most common causes of death in each period are, in the first stage, collapse from injury to the nervous system ' I i BURNS AND SCALDS. 107 and coma due to cerebral congestion. Second stage, in- flammatory disorders, as meningitis, pneumonia, peritonitis, etc. Third stage, exhaustion from excessive suppuration, hajmoi'rliage, or peritonitis from perforation of an ulcer, and tlioracic inflammation. The constitutional treatment varies '•>. each period. In the first stage the intolerable pain should be relieved by opiates, and the patient roused from his pi'ostration and collapse by the free use of stimulants. And it must be borne in mind that, when excessive pain exists, the system can bear double doses of narcotic medicines. Two or three grains of opium may be given to adults at short intervals, and increased if necessary. Morphia is best administered in solution, and, of the two liquid preparations employed, Magendie's is the best. From twenty to thirty drops may be given by the mouth, or by hypodermic injection. If tlie preparations of opium fail, hydrate of chloral in half- drachm doses, or antesthetic inhalations, may be tried. Do not let the unfortunate patient sufier, 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 ►.timuiants. 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- ,111 1 li-' i 108 EMERGENCIES, AND HOW TO TREAT TIIEM. quired. Bccf-tca, broths, and other light, nourishing diet, arc always beneficial, and cannot bo dispensed with. In the third stage there is great exhaustion, and ciforts must be made to sustain the rapidly-failing vitality of the patient. Brandy, with or without ammonia, should be ad- ministered freely in conjunction with 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. They 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 injection. There are three important rules to be remembered in the local treatment of burns : 1. Exclude atmospheric air. 2. Only remove the dressings when t\u y become loosened by the discharges. 3. Prevent the contra Hon 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 lirae-w ' r {carron-oil), 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 unle'^>s foul odors arise. In changing, every particle should be cr i-efully DURNS AND SCALDS.— EFFECTS OP COLD. 109 removed, and the parts thoroughly washed with some dis- infectant liquid, such as 5. Acid carbolic Aqua 3j. S viij. M. This solution may also be sprinkled on the dressings and bedclothes. AVhen 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 wliich 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. — FEOST-BIIES. Cold is a valuable therapeutical agent in many diseases. Cold shower-baths or ordinary cold-water baths have a stim- ulating eft'ect on the system, invigorating both the mental and piiysical 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 m ,1; i I I no EMERGENCIES, AND DOW TO TREAT TIIEM. I • str.to of profound coma is reached which may end in deatli. The desire to sleep is beyond tlie control of the suHerer, and it is here that the great danger lies. If the power of re- sistance, or an appreciation of the danger were felt, the person exposed might he enabled to resist until assistance was obtained. When the coma is developed, it is almost impossible to arotise the patient. The comatose condition is brought about by congestion of the brain. The intense cold propels the blood from the surface to the 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 jirobable that an accumulation of carbonic acid takes ])lace in the blood owing to the diminished respiratory movements, and throngh 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. The condition of the atmosphere modifies the effect of cold. Thus a much lower temjierature 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 of protection, and lessen the demand for a higher temperature. When only a portion of the body is exposed to the cold. ill' si FROST-RITES. Ill ns tlio eyes, ears, nose, etc., tlierc 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 wliicli is known as frorit-bite ; where the exposure has been lonj; continued, and the life of the part totally de- stroyed, <;angrene rapidly ensues. Little or no pain is ex- perienced until recovery begins, and tlio circulation is renewed. The pain is intense, and always the forerunner of more or less inflanxniation. The parts becoino red, swollen, and hot, and the cuticle peels off. Ilcsolution may occur in a day or two, or the inflammation may continue until sloughing or gangrene takes place. Extrcjne degrees of cold and heat have analogous eflccts. In botli the vitality is destroyed, and in both there are subse- quent inflammation and sloughing of tissue, with constitu- tional disturbance. Treatment. — A person suffering from frost-bite should bo 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 wet with ice-water may then be applied to the part. If the inflam- mation extend to tlic deeper tissues and suj)puration 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 be briskly rubbed with the hands and warm flannel. 'f-?i ':i ^1 ••'■I ';li J SB 'II M Ill ! 1 CHAPTER IX. STRANGULATED UERNIA. OauBCs and Symptoms of Strniiffulation. — Ileus. — Volvulus. — Taxis. — Operations for Inguinal and Fouioral Ilurnlui, The escape of any viscus from its natural cavity is called a hernia. The term is in a measure restricted to the pro- trusion of a portion of intestine or omentum from the ab- dominal cavity. The affection is of common occurrence. In ordinary cases it is attended with little inconvenience or danger. If, however, a constriction takes place at the neck of the hernial sac, which cuts off the circulation of blood, and obstructs the passage of fecal matter through the intestines, the patient's life is at once in jeopardy. The portion of intestines so constricted is termed a strangulated hernia. Hernial protrusions usually occur at the inguinal or crural canals ; but they may pass through the umbilicus, or other part of the abdominal walls. A hernia may become strangulated: 1. From the addi- tional protrusion of intestines or omentum into the sac during the act of straining, or other violent exertions which bring the abdominal muscles into violent action. 2. Thickening of the sac or its contents by cell-pro- liferation, or deposit of adipose tissue. STRANGULATED HKRNIA. 113 8. Contraction of bands of fibrino over tlic neck of the Bac. 4. Spasmodic contraction of tlio muscnlar fibres at tlio Bamc point. 5. Contraction of the ring, from growtli of new tissue. All of these causes may combine to induce straii}:,iilation. In inguinal hernia the constriction is usually situated at the internal or external abdominal rings. In femoral hernia it maybe at the crural ring, or tlio saphenous opening. The strangulation is first manifested by pain over the liernial tumor. The pain increases in intensity, and rapidly spreads to other portions of the abdomen. Soon there are nausea and vomiting. The vomited materials consist first of the contents of the stomach, and then of stercoraceous matter. The bowels are obstinately constipated. Cathar- tics fail to influence them. The pulse is rapid, increasing in feebleness as the strangulation continues. The abdomen is tympanitic, and pressure at any part is attended with great pain. This indicates the extension of the peritoneal inflammation. Finally, the extremities become cold and clammy, and the pulse can scarcely be distinguished at the wrist. All the signs of collapse are present, and death rapidly ensues unless the strangulation be relieved. AVhen collapse sets in, operative measures are of little avail. In all cases where a patient is vomiting, and complain- ing of pain in the abdomen, an examination should be in- stituted for hernia. Fatal mistakes are made by neglecting this precaution, and the sick person treated for colic and indigestion. At the same time it is well to avoid the other extreme, and take care not to cut into an inflamed bubo, or an inflamed incarcerated hernia, on the supposition that 8 ■i:.i it I Mi lil iJiiiil! Il!l;; % ' 'I! ii-t EMElUiENClES, AND HOW TO TREAT TIIKM. strangulation cxif^tn. Tlicso tliliij^rt arc occasionally done evon by men of standing. It' obstinato coiiHtiitation and V()niitinj)iiiin, hot bathn, or amustlietics. Tho thigh U then partially flexed and addueted, ond tho body of tho pa- tient raided in bed. Finn pressure iii then made with the right hand on tho tumor, whilo tho loft is placed at tho neck of tho sac, to keep it from bonding or doubling upon itself in tho reduction. Taxis miist not bo kei)t up too long, or performed ^vith violence. Great ])rc8suro may force the hernia, constriction and all, back into tho peritoneal cavity. Such an accident complicates matters. Should tho ma- nipulations be without avail, the constriction must bo re- moved at once by an operation. Tho patient is lirst put imder the influence of an anrcsthetic. If tho hernia be of tho oblique, inguinal variety, an incision is made through tho integument in tho long diameter of tho sac. Tho suc- ceeding layers arc opened on a director. They are in order from without, inward — two layers of superficial fiiscia, intercohunnar fascia, cremaster muscle, infundibnliform fascia, subserous areolar tissue, and poritonrenm. When tho tissues ivo thickened, a greater number of layers may be made by splitting up the fascia with the director. These layers are not always recognizable. Some surgeons repudi- ate them altogether, and rely npon the appearance of the sac or its contents as a guide. The peritonajura is recog- nized (provided it is not thickened by inflammation) by its- tension, and the arborescent arrangement of its blood-ves- sels. If the peritonceum cannot be recognized before, it maybe after it is cut through, by the escape of dark-colored' serum, which generally exists inside the sae. The intes- tines are known by their dark color and polislied surface. "When the intestine is exposed, tho little-finger of the left no KMEROENCIES, AND IIOVV TO TREAT TIIKM. m hand is pnflscd up to tho pnrt i)f stricture ^vliicli can be felt like a " Imrd, bony rinj:^" at tbo neck of tho huc*. A berniii- knifo, or an ordinary bistoury, with its \nnnt protected by adhesive plaster, is then introduced on its fhit siirt'iice, be- tween the nail of the little finger and tlio constriction. When it lias i>assed under, the edge of the blade is turned up, and the stricture cut directly upward. Jly cutting in this direction, tho epigastric artery, which runs up between tho two rings, is avoided. If tho intesti o is in a fit condition to return to the ab- domen, it will change color soon after tho stricture is re- lieved. In this 'jaso it is retf'ied slowly — the part which came out last being replaced first. Should gangrene have set in, there will be a fetid odor, the intestine will be of a dark-gray color, and may crepitate on pressure, from tho presence of putrefactive gases in the walls. The gangre- nous portion is to be removed, and an artiileial anus made by sowing the cut ends to the edge of the opening. In direct inguinal hernia, the layers ra'o somewhat dif- ferent, but the operation is precisely similar. Instead of the cremaster muscle, tho conjoined tendon of tho internal, oblique, and transversalis muscles is substituted. In operating for femoral hernia, a crucial or a T-shaped incision is made — the first one in the long diameter of the sac, parallel with Poupart's ligament, and the second meet- ing the first at right angles. Tho layers to be divided are : The integument, superficial fascia, cribriform fascia, crural sheath, septum crurale. subserous areolar tissue, and perito- nreum. The svricture is divided by cutting upward and in- ward. In order to avoid cutting the obturator artery, which occasionally runs along the inner edge of Gimbcrnat's STRANOULATED IIKIINIA. 117 li^'iimcnt — tlio C(l<;o of tho knitb imiy bo bliiiito»l prior to tliu openitioii. "VVIicii tliit^ Is done, tho artery will bo purihod before tho knife, iiiHtojul of boiii^ womulod. Tuxis is eini)h)yed in foniorul hernia, by firrit llexinjj tho thigh, rotating it inward, and pressing the protrusion down- ward, backward, and th, i upward. it; li '1 nil CHAPTER X. loss OF CONSCIOUSI^ESS. COMA. Coma from ComprcBsion of the Brain — Embolism — Urtcmia • Hysteria — Epilepsy. — Coucusaion. Alcohol. A SUSPENSION of cerebral activity and unconsciousnesa is tlie common sequence of many abnormal clianges. It may result from structural lesions in the brain, or from the effects of poisonous substances carried to that organ by the blood. It may arise from a deficient supply of healthy blood to the nerve-tissue, as in syncope, or from defective aeration of the blood, as in asphyxia. Coma which arises from cerebral lesions, or from the circulation of urea or alcohol in the blood, will be consid- ered in this chapter. By the term coma we mean a state of partial or com- plete insensibility — a suspension of the ordinary powers of sensation and volition, accompanied by stertorous breath- ing. As this condition is merely a representative of diverse disorders, a just appreciation of the cause of each variety is essential to effective treatment. The causes of coma are: 1. Pressure on th'i brain- Bubstance, from extravasated blood, depressed fracture of rORS OF CONSCIOUSNESS. 119 craiiiiil bones, and accumulation of pus; 2. Anocnua of the brain, as in embolism and thrombosis; 3, Blood-poisons, as urea, alcohol, etc. ; 4. Epilepsy ; 5. Hysteria. Extravasation of blood on the surface of the brain is usually the result of external violence. When it occurs in the substance of that organ, it proceeds from a diseased condition of the cerebral blood-vessels. They may be all'ccted by simi)le fatty or atheromatous degeneration. According to Virchow, the latter connnences as a low grade of infliinimation in the lining membrane of the arterv. There is a slight exudation between the inner and middle coats, and subsequent softening and breaking down of the different layers. In the debris of disintegrated tissue we iind fat, cholcsterinc, calcareous salts, and albumen. If there is any increased action of the heart while this morbid change is in progress, the weakened walls of the capillaries are liable to give way, and allow the blood to escape. The extravasation is most frequently located in the corpus striatum and optic thalamus, portions of the cere- brum possessing the greatest vascularity, and therefore more liable to the affection. When the blood is found on the surface, the meningeal arteries are generally ruptured, the middle meningeal more frequently than the rest. The coma which arises from laceration of diseased arte- ries, in most instances, is sudden in its development. In very rare cases there are premonitory symptoms, appearing in the shape of slight facial paralysis, twitchings of the mus- cles, local points of anesthesia in the extremities, and bleed- injr from the nose. In some cases the delicate vessels of the retina rupture, and produce blindness. This occurred in the case of the late Dr. George T. Elliot. He suffered 1!! .It . li.- 'r -!''■! m \:': 'H J). ft 120 EMERGENCIES, AND HOW TO TREAT TIIEM. from retinal apoplexy several mouths previous to the 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 a[)peiir- ance ; one pupil may bo dilated and the other contracted, or botli may be dilated. They will not act readily to tlic stimulus of light. If the clot of blood involve both sides of the pons Varolii, both pupils will be contracted. Stra- bismus exists in many cases. The respiration is labored and stertorous; with each expiration the cheeks are puffed out, as in the act of blowing. The peculiar noise, or stertor, accompanying i;he respiratory movement, is due to a partial paralysis of the soft palate and i)illars of the fauces. The pulf,e is slow and full; the integument is warm and moist, but there is no increase of the natural temperature of the body. Paralysis of one side {Jiemijyle- gia) is usually present. When both side? are paralyzed, the extravasation will be found in the pons. In the face the paralysis is indicated by a drawing down of the angle of the mouth on one side, and a diminished movement on the other, or perhaps with inability to close the eye (lagoph- thalmus). If the clot involve the crura cerebri so as to press on the third pair of nerves, there will be inability to open the eye (ptosis), convergent strabismus, and dilatation of the pupil on the side opposite to the general paralysis. Paralysis of the face is, in the majority of cases, on the same side as the hemiplegia. Paralysis of the extremities is seen in the different effects produced by counter-irritation, one limb moving more than another when pounded or pricked. An instrument called an oesthesiometer is now employed to as- )iipil >i3 of the the limh An to as- LOSS OF CONSCIOUSNESS. 121 certaiu the different degrees of sensibility existing in vari- ous parts. The sphincter muscles which guard the rectum are also paralyzed, and the fceces arc passed involuntarily. The orifice of the bladder is guarded by elastic fibres, which retain the urine when the sphincter of that organ is para- lyzed. The coma whi'V ^ollows external violence presents similar symptoms, wh •• connected with depressed bone or extravasated blood. There are exceptional cases of cerebral extravasation which do not exhibit these dangerous characters for two or three days succeeding the injury. The patient may have been treated for a slight scalp-wound, without any suspicion of the real nature of the lesion. He may pursue his usual avocations with little trouble until he suddenly sinks into a state of coma, with the signs of compression plainly mani- fested. A. post-mortem examination in these cases shows that the effused blood is located principally at the base of the brain, and that it is connected with fracture of the base of the skull. "When coma supervenes three or four days after an in- jury, accompanied by an increase in the pulse and temper- ature, the pressure of inflammatory products, such as serum, lymph, or pus, may be suspected. The formation of pus, or the occurrence of pyaemia, is announced by severe rigors. An injury to the head may be followed by entirely differ- ent symptoms from those previously described. The pa- tient may have concussion of the brain Avithout compression. There is loss of consciousness in both ; but, in concussion, the patient is more easily roused, the face is pale, and the :. '4. m illi 4 . I 'ml^ 122 EMERGENCIES, AND HOW TO TREAT THEM. surface of the body cold. In compression, the face is flushed and the body warm. Stertorous breatliing characterizes tlie latter; in the former the respiration is natural or sighing. The pulse, in concussion, is small and rapid ; in compression, it is slow and full. The pupils are generally contracted in concussion, while in compression they are dilated. The con- dition of the pupils, however, should not be relied on in di- agnosis, as it is subject to much variation. In compression of the brain, there is usually paralysis, which alone is suffi- cient to distinguish it. In rare instances, compression aud concussion are combined. In such cases, remedial efforts arc mainly directed to relievo the former. It is necessary to diagnose apoplectic from urn?mic coma. "With the latter there is usually a history of Bright's disease of the kidneys, oedema of the lower extremities, a pale, waxy countenance, and albumen and casts in the urine. In the former, these signs are usually absent. Apoi^lectic coma is attended by paralysis of one side of the body, and the pupils are irregular. In ura?mia there is no paralysis, and both pupils are dilated. The temperature of the body is said to be higher in ura?mia than in apoplexy, but this cannot be depended on in diagnosis. When the iirinous odor of the perspiration exists, we have further evidence of uriemia. Treatment. — Very little can be done to relieve the coma which results from the rupture of diseased arteries. If the patient is plethoric, the abstraction of a few ounces of blood from the arm may prevent further extravasation. Axithori- ties differ as to the utility of this measure. The after- treatment consists in the prevention of inflammation and the administration of medicines, which assist in the absorp- LOSS OF CONSCIOUSNESS. 123 tion of the clot. For the latter purpose, iodide of potassium may be admiuistered in doses of from five to ten grains three or four times each day. If tlie stomach is disordered, or an eruption of the skin is produced by its use, it should be discontinued. If inflammation be apprehended, mustard- poultices may be applied to the nape of the neck and to the feet, and the bowels should be thoroughly moved by an ac- tive cathartic. Croton-oil and elaterium are the most efficient. If the extravasation proceed from a blow or fall on the head, the operation of trephining can be performed in one of two places, viz. : near the course of the middle meningeal artery on the side opposite to the paralysis, or directly un- derneath the point where the injury was inflicted. A cru- cial incision is made through the scalp, which is turned back and the bone exposed. The skull is then cut carefully through with the trephine. If the blood is found between the dura mater and the bone, it is readily removed. If the membrane swells up through the opening, and there appears to be blood underneath, an incision can be made through it to allow its escape. After the operation, the wound is cov- ered, and simple water-dressings applied. The usual reme- dies, previously mentioned, to prevent inflammation, are then employed. When the coma arises from depressed fracture of the Bkull, trephining is resorted to, or the depressed bone is raised by an elevator. Coma from Embolism axd Thrombosis. — Inflammation of the valves of the heart and atheromatous degeneration of the aorta are attended with the formation of fibrinous masses, which project beyond the natural dimensions of the artery and valve, and are liable to be washed away by the 1 !■ 1 ll n i K.'f im I i t. : j ,, 121 EMERGEXriKS. AND HOW TO TREAT THEM. current of blood. -e small particles may be carried to the brain and plug up one of the cerebral arteries, cutting off the supply of blood from that portion. The artery most frequently involved is the left middle cerebral. The plug is called an embolus. Diminished action of the heart, with loss of elasticity in the walls of the vessels, may predispose to the formation of a clot of blood (thrombus) in them. The supply of circulat- ing fluid is cut off as in the former case, and anajmia of the part results. Either of these accidents, taking place in the brain, may produce coma. In some cases this is gradual, in others the attack is sudden. The coma differs very little from that which depends upon cerebral extravasation. In coma from i)lugging of arteries, the face is usually paler than in cerebral extravasation, and there is with it some disease of the mitral or aortic valves. Another important point in the diagnosis is, that consciousness is restored more rapidly in the former (often within two or three days), and that the paralysis is not so persistent. Treatment. — In these cases we can only wait for devel- opments. If softening of the brain be apprehended, stimu- lants and tonics are indicated. Some recommend the ad- ministration of ammonia to absorb the clot of iibrine. Its remedial action is, however, questionable. Ur.emio Coma results from the same poison which in- duces urajmic convulsions. Frerichs developed the fact that these phenomena were caused by the accumulation of m'ea in the blood, and its subsequent change into carbonate of ammonia. Spicgelberg, a later investigator, has fully con- firmed these views by a series of carefully-conducted experi- ments. \^'k LOSS OF COXSCIOUSXESS. 125 Urea is produced by the decay of nitrogenizcd tissue. It is eliminated by the kidneys. When these organs are diseased, its channels of escape are almost wholly closed, and it accumidates in the blood. There it is decomposed, one atom of urea taking two atoms of water from the blood, and forming by this combination carbonate of ammonia. Urrcmic coma occurs during the progress of Bright's dis- ease of the kidneys, and may have all the symptoms of that affection connected with it. The patient's face has a pale, waxy look. There is dropsical effusion in the cellidar tissue of the lower eyelids, and behind the ankles, or over the whole of both lower extremities. The urine is of low sj^e- citic gravity. It contains albumen and casts. Preceding the coma there are headache, dimness of .sion, and vomit- ing. The patient passes into a somnolent condition, which hourly increases, until a state of profound coma is reached. Sometimes the coma is preceded by a convidsion, without other premonitions. This is observed especially in the small contracted kidney. The coma is accompanied by a certain amount of ster- tor. The pupils are dilated, but not irregular. The pulse is more rapid than usual, and lacks firmness. The tempera- ture is sometimes slightly increased. Poisoning by belladonna presents some similarity in its symptoms to urjemic coma. The pupils in both are widely dilated, and the insensibility is profound. The history of the case, and the absence or presence of signs of Bright's dis- ease, determine the diagnosis. Treatment. — Our principal efforts in all cases is to elim- inate the poison from the system, through the medium of the skin and bowels, with diaphoretics and active cathartics. m 120 KMEROEXCIES, A\D UOW TO TREAT THEM. 'I Mix c(iual parts of croton-oil iviul ordinary swcot-oil, and apply lour or five drops of tlio mixturo to tlie back of tlio tongue. Tills can be done by moistening the end of a pen- cil or pon-liandlo 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 be repeated in thrce-cpiarters of an hour, if free evacuations from the bowels do not follow. If preferred, ehiterium may be administered in cpiarter-graiu doses every hoin* 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 surface, 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 uricmic 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 : I' i 3 5. ITyd. bichlor, Tr. cincli. comp. 5 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 III m III LOSS OF CONSCIOUSXESS. 127 use. When urajmic coma is the result of ncute inflnmma- tion of the kidneyfl, the treatment varies. In addition to the ordinary remedies, the application of wet or dry cu])s over these organs is required, and is generally followed by great results. Rum Coma. — When large quantities of alcohol arc taken into the system, n, state of insensibility is induced which in certain i)articular5 resembles the other varieties of coma. 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. Tlio breath usually smells strongly of alcohol. Too much re- liance, however, must 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 urcemic 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, uraemic coma is profound, while 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 imder such circumstances must be the u: i .11 \i m "ri ■ 1 I ii 11 128 EMEROEN'CIES, AND HOW TO TREAT THEM. history of the case and tlio BurronndinfTn of tlif ])atiLMit. If the tonguo has not been bitten, and there ia a history of a spree, wo may then cxchido epilepsy. Treatmetit. — If an emetic of mnstard can be admin- istered, and the stomach emi)tied, mnch good ■will result. Subsequent applications of cold water to the head and chest will bo beneficial. IIvsTEUicAL Coma is one of the manifcstatiorrs of the hydra-headed nervous affection hysteria, a disease j)eculiar to n<;r ous 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 sinudate 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 unfortunates cannot be charged with fraud. The case of a young liystcrical patient, who was at one time in "Ward 24, Bellevue Hospital, furnished an excellent example of *his 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 suffering from nearly every prominent symi)toin exhibited by her dying 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- LOSS OF CONSCIOUSNESS. 129 other ward of the snnic hospital was a young Irish girl who Buffered from retention of urine. Tiio catheter was regular- ly employed for several days before the real nature of the disease wag discovered. Her will, or her disease, ciud)led her to remain three days without passing water. At the end of that period she 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 tho disease. It is often preceded by general excitability, and by spells of violent laughter and crying without assign- able cause. There is often a sense of choking {globus hys- tencus), duo to contractions of the oesophagus, from below upward. It gives a feeling as if a ball were rising iu the throat. Previous to tho 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 till ..1' H\ .15 r ilff 'ff 130 EMERGENCIES, AND HOW TO TREAT TIIEM. best known renjcdy. Two or tliroo i)itclicrB of coM water, poured from a height upon the face, will genenilly i^ullluo to bring about a recovery. Tlio ufter-treutnicnt eonnihtrt in dcveh>ping Hulf-control, Hustaining tho general health with IVchIi air and good food, tho removal of any exibting diseario of the generative apparatut^, and the admiii'stration of anti- spasmodicB, na muuk, valerian, asriaftetida, cte. Krii-Ki'Tio Coma follows un epileptic convulriion. Tho insenaibility is never com])lete. Blood n'ay <'ollect on the lips. There is laceration of tho tongue. Tho sudden oc- currence of tho convulsion when tho patient is in good liealth othcrwi-o, and ilio oomploto recovery when tho attack has passed away, servo to distinguish this disease in all cases. {/See article on Epileptic Convulsions.) Treatment. — Epilci)tic conui does not require treatment. To prevent a recurrence of tho convulsion, bromide of po- tassium can bo given. Ton grains, four times a day, will bo enough for an adult. CONCUSSION OF THE BRAIN. Concussion of tho brain may be defined as a shaking to- gether of tho 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 tho 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 CONSCIOUSXKSS. 181 ami sol'teiiiiig of Biiiall portioiiH of tlio iicrve-BubKtniu'o, are found. Millar, AV^ooil, and others, divide concussion into three stages: I. That of inscurtibility ; 2. Keactlon ; nnd 3, Ex- cessive reaction or inflaniniation. 'J'he 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 tho j)nlse small and rapid. liesj)iration ia natural or sighing. The pupils are contracted, or one may bo contracted and tho other dilated. The sphincter muscles are not often interfered with. In the second stage, tho patient vomits and shows evi- dences of returning consciousness. Tho ])idsc becomes stronger, warmth returns to tho body, and slight color to tho lips and cheeks. If this reaction bo excessive, showing a tendency to inflammation, tlio third stage is u' ')red in. Tho skin becomes dry and Lot, and there is considerable headache. The pulse rises, and is firmer than during the preceding stages. Finally, if tho case progresses unfavor- ably, all the signs of meningitis aro manifested, such as in- tolerance of light, intense headache, contracted pupils, sub- sultus tendinum, delirium, and finally coma. Tho difleren- tial diagnosis between compression of the brain and con- cussion Las already been given. In many instances, tho concussion is extremely slight, lasting but a few moments. This is tLo case wLere tLe pa- tient is merely stunned, and tlio effect soon passes away. In otLer cases, tlic concussion is so groat as to cause instant deatL. Treatment. — If there be collapse, Lot bottles and blank- ets are to bo applied to tLe extremities, and the circulation li,' I ^'1 182 EMERGENCIES, AND HOW TO TREAT TIIEM. fitimulated by friction with the hands. Dihited enemata 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. ■!l CHAPTER XI. LOSS OF CONSCIOU-SJV^ESS-iCoimTavED). SYNCOPE. Syncopo from irtpmorrlingc. — Thrombi in tlio Pulmonary Vein. — Anocmia. — Mi'Dtal Emotion. — Ulows on tlio Epigastrium. — 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. Tlie 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 powex'S of volition. The regular contractions of the heart depend upon several conditions: 1. A sufficient and regular supply of blood, which exercises a stimulating eflfect on its fibres ; 2.. A normal proportion of the necessary ingredients in the circidating fluid ; 3. A healthy state of the brain and of the nerves and syn;pathetic ganglia which supply the heart ; 4. A special irritability possessed by the muscular fibres, which causes its contractions to continue even when all connection 1 ni:. ' 'ti ff 134 EMERGENCIES, AND HOW TO TREAT THEM. with tlio body has been severed, and the extraneous sources of stimulation removed. This innate power is, for want of a better name, denomi- nated irritability. Of its nature we are totally ignorant. In cold-blooded animals it is particularly noticeable. Any morbid change, which directly or indirectly disturbs the con- ditions spoken of, is liable to induce syncope. Syncope is produced by excessive hemorrhage. This, however, when not too prolonged, is rather of benefit than otherwise. The cessation in the movements of the heart allows the blood to coagulate in the bleeding vessels, and prevents the possibility of haemorrhage when the circula- tion is renewed. Thrombi in the pulmonary vein causes fatal syncope by preventing the blood from passing through the lungs to the left side of the heart, and by producing distention of the right auricle and ventricle. Syncope arising from a deficiency in the ordinary stimu- lating ingredients of the blood is witnessed sometimes in ana3mia, and in chlorosis. In these diseases the watery portions of the blood are increased, the red corpuscles are diminished, the circulation being at all times exceedingly feeble. Inleucocythajmia, where there is a very great excess of white corpuscles, and in phthisis, where there is mucli general deterioration of the blood, sudden 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 peculiar and unknown manner upon the nerves of the heart, sus- pending their influence. In some cases the emotion has been so great as to destroy life. :i-i ^] LOSS OF CONSCIOUSNESS. 135 Anaemia of the brain and concussion are attended with syncope. Blows on the epigastrium may injure the solar plexus, and cause a fatal reflex paralysis of the heart. The cases of sudden death from drinking cold water while per- spiring are similarly accounted for. Sedatives may induce syncope if the doses are large or too frequently repeated. The majority of sedatives, such as tobacco, colchicum, antimony, prussic acid, 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 with this theory the authenticated cases of syncope, or collapse, following its use in the usual medicinal doses. Chloroform, when administered to debilitated individuals, may act directly upon the nerves of the 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 the functions of the nervous system, and diminished action of the heart, which is commonly known as shock or collapse. Although in many essential points resembling ordinary syn- cope, tliore are important difierences which distinguish them. Tlie duration of syncope is more brief. The pa- tient either dies suddenly or recovers rapidly. Collapse is prolonged. SA'neope 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 i" il eri'eet ventila- tion, we may mention the destruction of life which occurred on an Irish steamer some years ago while crossing the Channel. During a storm the captain compelled one hun- dred and fifty of the jjassengers to go below, and afterward closely fastened down the hatchways. Seventy persons i>crished 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- (piently brought to our notice. They generally arise from design or neglect. The condition resulting from a complete eessaticm of the respiratory movements is usually known as aftj)/i>/.r!(i or apnoea. The word (fsp/ii/xia, derived from two (ireek words signifying pulselessness, does not define the condition. Aj)- noea indicates the prominent features of the morbid pro- cess with greater accuracy ; but, as a8[)hyxia is the word in general use, it will be adhered to in the present chai)ter. The first effect 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 them. Should the ingress of air bo still further prevented, this state of congestion ends in com- plete stagnation or stopppge of the circulation. Unaiirated 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 asjfhyxia / and that the obstruction in the capillaries throws the blood 1 ■«ij .1 f'S W 14 i EMERfiENTIER, AND HOW TO TREAT THEM. back on tho heart, and ovorpowerd it, so that it entirely ecascH. Some consider that tlio congcwtion of tho Inng.s iri alone tho can«o of death ; others, that tho blood p>inj; to the brain, loaded with earboiuc acid, destroys the activity of the cerebrum, and through it acts upon the heart and the nerves supplying that organ. Where so many phenomena exist, involving different vital parts, it is almost impossible to separate them, and definitely say which is the cause of death. To repeat, defec- tive aeration causes the rapid increase of carbonic acid, and induces capillary congestion in every part of the system ; this congestion demands more Jabor from the heart, and the con- gestion of tho lungs increases tho ditRcidt respiration, and makes it moro labored. Tho blood, which is loaded with carbonic acid, necessarily obtunds nervous sensibility, and, acting through tho cardiac nerves upon the heart, cond>inc3 with tho other morbid influences in weakening the contrac- tions of that organ, and bringing about a fat.al 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 t^e changes. The face generally is of a dark, livid color : jr foam, streaked with blood, sur- rounds the n^ iO eyes protrude. In suffocation from hanging, tl ^ae is swollen and pushed out between tho lips. Rigor mortis appears soon after death. The lungs are heavy and dark, and contain a large quantity of black blood. Tho 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 tho arteries forcing out the ASrilYXIA. 145 itll icre of a 6ur- Toni tlio ings lack illed left due t tlie blood. It H not confined especially to death fi'oin Huil'ucii- tioii, but oc(.'urrt in other fornw. The auriclo and ventricle on the loft Bide of the heart arc diHtcnded with dark blood, and all the blood in the bodv k blacker than under ordiiuiry circunistaneeB. Thiti k caused by the absence of oxygen, which gives the circulat- ing fluid a rod color. In the liver, kidneys, and Hi)lcen, theie is generallv more or less congestion. There arc vari- 0U9 opinions advanced respecting tho conditions of the brain. Some modern investigators {Ackecmiw, Jknuhm) cndoavoreil to show that aiuuinia of tho brain is nioro com- mon than congestion. This idea, howover, is not sustained by facts, or accepted by many in tho profession. Tlie cerebral vessels, except in rare cases, are engorged with blood. Having now dwelt on the physiology of respiration, and tho pathological changes which depend upon tho defective ai5ratii>n of the blood and total cessation of tho respiratory act, wo now come to tho various forms of asphyxia anost-mortem examinations do not confirm this statement. AVater, 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 '''f1 "11' 154 EMER(JKNCIES, AND HOW TO TREAT THEM. tho lungs may account for tlio rapid disappearance of the li(piid. As liunian beings, wlicn drowning, alternately Bink below, and rise again to the surfiicc of tlio water, occasion- ally giving them opportunity to obtain a fresh supply of air, we cannot di'diiitoly determine the maximum of time they can remain under water and yet recover afterward. Tho experiments quoted are uot proper criteria to judge by in the majority of drowning cases. When submersioix is con- tinuous, however, five minutes is the longest period after whieli life nuiy be restored. There is a peculiar condition, known as secondary asphyxia, which occurs at times in per- sons who have been restored by artificial respiration. It shows itself generally within forty-eight hours after respira- tion has been fully established. When the symptoms seem favorable, and all anxiety removed, the i)atient is suddeidy seized with urgent dyspnrca, tlie chest expands imperfectly ami irregulrrly, the patient struggles for breath, and in a short time all the worst features of asphyxia return. Death soon su])crvcnes, unless innnediatc relief is afforded by arti- ficial respiration. Tlie 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 fur. Exces- sive and laborious resipiration immediately follows. The ap- pearances presented in as}>hyxia resulting from immersion vary somewhat from other kinds. The livid discoloration of the face and fulness of the blood-vessels are not so dis- tinctly marked. There arc more general pallor and coldness of the surface. Rigor mortis or post-mortem contractions of the muscles a])pear very soon after death. ASPHYXIA. 155 Treatment. — There are four special rcquit^ilvs in tlio treatment of drowned persons : 1. Artijicial resjju'utlon / 2. Warvdlt ; 3. Friction} 4. Stlmidailon, All these are cnii)h)yed together, hut the first is generally relied on. Strip the patient of clothing, and enveloj) the Uody as far as possible in warm blankets. Then clear the mouth and throat of water, mucus, or other substance which might pre- vent the ingress of air.* To do this perfectly, cover the index-finger closely with a handkerchief, and carry it in as far as possible, and sweep it around the pharynx and \ipper part of the larynx. The cloth takes up more of the moisture than the linger alone would. The tongue is now drawn out as far as jjossible. Unless the organ is pulled forward with considerable degree of force, the aryteno-epiglottidean folds at the upper border of the larynx will close the aperture sufHcicntly to inter- fere with the admission of air. This is a point of consider- able importance in all cases where artificial resi)iration is resorted to, and cannot be too strongly insisted upon. A forceps attached to 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 rcspiru tion. "When the immersion has been short, and the patient only partially asphyxiated, simple compression of the lower half of the thorax and upper part of the abdomen will answer. The hands are applied on each side of the chest- walls, the fingers reaching as high as the nipple, and firm ■ i:i ^\ * Some advise suspension 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. 'm I 150 EMERr.KN'CIES, A\D HOW TO TREAT TIIEM. pressure iniulo to diniinisli the cnvity of the clicst. Tlio hands are tlioii lifted for n few seconds, and tlic parts allowed to resume their natural position. This is done rapidly and continuously until all danj^er has passed. Diminishing the thoracic cavity by pressure forces out some of the ft>ul air from the lungs, and with the sub- sequent expansion a certain amount of fresh air passes in. This interchange gives more oxygen to the blood, and relieves it of carbonic acid, stimidates the circulation, and through it the nervo-muscular api)aratus, niul finally restores all tlie functions of life. In severe cases, either ]\rarshall Jlall's or Sylvester's method of artificial respira- tion is to be preferred. The latter is said to be superior, as it enables more air to pass out of and enter the chest. The preliminary steps, such as clearing the throat and drawing out the tongue, are the same. In Marshall Kail's method the i>atient is placed on the side, with the arm toward the posterior plane of the body. The body is then rolled slowly over on the face, while the hands of the surgeon at the same time are jircssed tinnly on the back and sides of the chest, diminishing its cavity. When this movement is completed the patient is turned on his back, and the chest-walls re- sume their original position ; these movements are to be kept up until natural resi)iration is resumed. The principal effect to be produced in all cases is a renewal of the air in the lungs. In Sylvester's method the patient is placed in the recumbent position, with the head and chest somewhat raised. The operator stands at the head of the patient and grasps both arms midway between the elbow and wrist- joint, moving them gradually to a vertical position so as to make them nearly meet above the head. They arc held in ASPHYXIA. IW ' thiu position for a inoinont, and then slowly retnniod to tlio eidea. At tho tonnimition of tlio second niovcnicnt, jirudsure ia nmdo with tlio arms on tlio sides of tlio tlioniciu walls. Tlicrio movenieiita are continued as loii{^ as the asphyxia remains. Ilaisliii; the arms in this manner elevates tlio ribs, and allows comparatively a largo quantity of air to enter, while relaxation causes them to resume their normal relations. Conjointly with all varieties of artilicial respira- tion, the patient's limbs should bo briskly rubbed by au assistant, and brandy and ammonia should bo administered through the mouth or rectum. Hot bottles and blankets are to bo applied to the extremities before and after tho patient has recovered. Ilcat, by means of liotair baths, is Bometimes useful. Ammonia, in tho form of vapoi* or in solution, may be api)lied to the nostrils. Should ordinary artilicial respiration fail to revive the patient, pure oxygen may be forced into the lungs. This may be done by cutting a hole in the trachea, inserting a tube, and forcing the gas through it. The ordinary elastic l)ng employed for inhala- tion of oxygen, if pressed with moderate force, "will send in enough gas to distend the lungs. If the gas is not at hand, the nozzle of a bellows may be attached to the trachea-tube, and the necessary expansion accomplished with atmospheric air. Injuries to the Spinal Cord, above the origin of tho phrenic and intercostal nerves, paralyze the inuscles of respiration and produce death by asphyxia. Poisonous doses of nux-vomica or its alkaloids cause spasm of the same set of muscles, and terminate life in like manner. " CHAPTER XIII. SUySTliOh'F. Si/nhoro t»f a huilding may likewise produce it. Dr. ^laclean * speaks of thirteen cases which occurred under ^Ir. Longmore, in the barracks at I'urrackpour, India, while only three arose froni outside exposure. The samo thing has been witnessed on crowded vessels, in laundries, aiul sugar-refineries. I recall three fatal cases which were admitted to IJellevue, of persons who were })rostrated while at work in a sugar-reiincry. Dr. Swift gives the history of twelve persons who, while at work in a large laundry in this city, were similarly alFccted. Some of these patients may have been exposed to the solar rays, but the majority were at work in-doors. About the third or fourth day from the commencement of a heated term, sunstrokes usually appjar. The suilerers in most cases are exposed to the heat for some days pre- ceding the attack. In the summer of 1800 the majority of sunstroke cases — generally laboring-men — were brought to Bellcvuc Hos- pital in the morning or early in the day. ii '■•[ * Reynolds's Practice, article Sunstroke, p. 150. m I ,n^ r m I "i I 160 EMERGENCIES, AND HOW TO TREAT THEM. Persons of intcmpenite habits Jind debilitatoil systems are most liable to attack. Any thing tending to lower the vitality of the system j)reclisposes to the atleetion. Wear- ing heavy, dark clothing, or compressing the chest, is also unsafe, Tlie close-litting regulation uniform and equip- ments worn by the British soldiers in India swelled the bills of mortality from sunstrokes when that country was lirst occu[)ied. Better sanitary ideas of suldiers' dress have been developed within the past few years, and the death-list has consequently diminished. Suustrokcs nuiy be classed under two heads : 1. Those in which the nerve-centres arc principally involved, or the cercbro-spinal variety of Morehead; 2. The varieties which are characterized bv exhaustion. Death in the former case results from voma/ in the latter, from fii/ncojw. In some forms death is ascribed to asphyxia, or apncea. Persons of full habit addicted to the use of spirituous liquors arc generally victims of the cerebro-spinal variety. Hard-working individuals are more liable to the cardiac form. In typical cases of sunstroke the symptoms may be di- vided into i)remonitory and immediate. The premonitory symptoms are not always evident. The patient complains of headache and a burning sensation about the head, and during the night is restless and wakeful. The skin is dry and uncomfortably hot, and there is frequent desire to evacuate the bladder. Tho face is flushed, and eyes con- gested ; the bowels are ui^aally constipated. A person pre- senting these symptonii^j^ who, nevertheless, continues to work under the hot sun, or in an overheated building, will be suddenly seized with vertigo, intense headache, and SUXSTROKE. 101 and (liiniiess of vision. Hid limbs refuse to support liiin, and ho soon fiillri to tlie ground. Insensibility sets in; the breathing becomes stertorous, pupils contnict, find the skin is intensely hot. The temperiituro of the bod_ iiscertained by Ji thermometer in the axilla, varies from 100 to 107, in rare cases reaching 109. The pulse is ra]ticl, and often full ; as the case progresses toward a iinivl termination, it becomes weaker and irregular, but still very rapid. The coma may be either partial or com])lete, and occasionally there are convulsions. The bowels are sometimes relaxed, and vom- iting is not infrequent. There arc various grades or manifestations of sunstroke. Some who come under the physician's care complain of in- tense weakness, and pain in the head. Others are stupid and wandering, while complete insensibility accompanies the great majority of cases. In some the general malaise and warning symptoms precede the insensibility for several days ; others arc stricken down in a moment, without pre- vious uncomfortable sensations. In those varieties of sunstroke characterized by exhaus- tion or syncope the patients are more apt to die suddenly without special premonitory troubles. In such cases the countenance is paler than in the cerebro-spinal variety. The respiration is sighing or gasping instead of being stertorous. The pulse is generally rapid, compressible, and irregular. The jjupils may be dilated, the heat of the skin is not ex- treme ; sometimes there is a combination of the cardiac and cerebro-s2>inal varieties. The reason why consciousness is lost, from exposure to extreme heat, is not fully understoou , overheating of the blood is said by some authorities to call for excessive action 11 •i'M i i:- 162 EMERGENCIES, AND HOW TO TREAT THEM. ) i ¥ in the nerve-centres, which rapidly exhaust their force and power. Maclean and others regard the heated blood as produ- cing great depression of the nervous system, and thus pre- venting it from performing its functions. The latter theory seems the most jdausiblo. Even if we accept this view, there are changes in the nerve-Hhres and cells which we have as yet been unable to recognize or fully understand. These changes, in many cases, make recovery from sunstroke more to be dreaded even than death itself. They give rise to the varied secpieliu of sunstroke, such as amaurosis, obstinate and distressing headache, and impairment of the intellect. Insanity in its varied forms is a common sequence. In some instances, the brain is found to be softened after death, in others there is no special lesion perceptible. On j)ost-mortem examination the brain and its mem- branes are usually found to be congested. In persons who die from exhaustion this feature is less marked. The ureat mass of cases, however, show this cha *e. Out of twenty- two post-mortems which I made in Bullevue, twenty pre- sented cerebral congestion. All had marked congestion of the lungs. Two of them showed evidences of inllammation in the mucous membrane lining the stomach and intestines. Before death they had violent attacks of vomiting and purging. Congestion of the lungs is almost always present. The right side of the heart is distended with blood which is entirely fluid, and without tendency to coagulate. Decom- position proceeds rapidly after death from sunstroke. Treatment. — It was considered imperative at one time to abstract blood in all cases of sunstroke. Modern enlight- SUNSTROKE. 1C3 ennieiit lias cxchulod this therapeutical agent. Depleting measures ofeverj' kind are now considered injurious. The patient should he removed at once to a cool room, and placed in a rccumhent position near an open window. The clothes are then stripped off, and a stream of water poured over the body. The vessel containing the liquid is to he held about four or five feet above the patient, in order that he may receive the benefit of the shock. The stream of water should at first be directed on the head, then on the chest and abdomen, and finally on the extremities, and thus alternating from one part to another, until consciousness returns. Ice rubbed over the body is liked by some ; the cold douche is, however, preferable. When the dyspnoea is marked, a few dry cups placed on the thorax in front and behind will be of service. Internal medication is useful in all cases. Among the numerous drugs employed, bromide of potassium has been found most efiicient. The best results were obtained from its use in Bellovue Hospital, in the years ISGO and ISGS. This drug may be adiijinistered in all stages of the afiection. When the patient is unable to swallow, it can be given by injection, always remembering to increase the dose one- quarter more than when given by mouth. In mild cases from five to ten grains may be given, at intervals of from half an hour to one hour, until the grave symptoms disap- pear. In several forma from ten to thirty grains may be administered every half-hour ; when the pulse becomes weak or intermittent, stimulants are needed. Stimulation should be resorted to in all cases where exhaustion is the prominent feature. Brandy-and-milk, or brandy with ammonia, must be introduced into the stomach or rectum. : M i I Hi ! . Bill; m if 'I liii^ 1G4: EMERGENCIES, AND IIOW TO TREAT THEM. The colli douche must be 8parin<;ly employed, or alto- gether dispensed with in this latter class of cases. If the skin is cold, it will do no good whatever. After consciousness has returned, mustard-plasters or Misters are to be applied to the back of the neck or be- hind the cars. The bromide need not bo discontinued for one or two weeks. As soon as convenient, the patient should be sent to a cool district in the country, and kept free from all sources of excitement. The brain must rest from all work. Exer- cise in the open air and nourisiiing diet are essential ; regu- lar habits must be rigidly enforced. A continuance of this treatment for several months prevents or at least lessens the danger from nervous affections which follow sunstroke. M 'I I n CHAPTER XIV. D YSPN(EA. Dyspnea from Astlima — Croup— Congestion of the Lungs— Cardiac Dlsoaso — Pulmonary Qi^duma — Pulmonary Apopluxy, etc. SiioiiTXKSs of breath or diflicult respiration arises from defective aeration of the hlood. Any condition which diniiiiislies tlie amount of oxj-gen sent to the tissues, or creates a demand for more than the lungs in ordinary respi- ration can furnish, will occasion dyspnoea. Over-exertion produces the simplest illustration of the manner of its pro- duction. A^iolent muscular movements (juicken the cardiac impulses, and a larger amount of blood is sent to the lungs as Avell as to other organs. There follows a demand for more oxygen, and the respiratory movements are increased" to make up by rapidity of inhalation the diminished quan- tity of that element in the blood. In the category of diseases characterized by dyspnoea are included asthma, croup, congestion of the lungs, cardiac affections, pneumonia, bronchitis, pulmonary cedema, pul- nionary apoplexy, and cedema glottidis. The dyspno3a which is caused by mechanical obstruction or occlusion of the air- passages is considered in another chapter. Asthma. — In this disease there is a spasmodic contrac- tion of the muscular fibres of the smaller bronchial tubes. ■;■(■ if Mft "^.M fl ^ IGG i:Mi;Rr.KNciK.s and how to trkat thkm. r s ' ' 11 !■ I I •; t i. t . and a coiiscquoiit climinirilicd ealibro of tlicsc tubes, wliieli ja'cvcnts tlic free inu;rc;iH df uir. Asthma oxlilbit:^ a pref- erence for certain localities and seasons of the year. It may occur at any season, but prevails specially in the autnnm. It is said to be caused in some instances by tlic inhalation of new-mown hay, ipecac, coal-dust, and other substances. Intlanunation of the bronchial tubes also ex- cites it. It is not an nnfrecpient accompaniment of emphy- sema. The paroxysms usually develop suddenly. The patient struggles for breath, and runs to tlic open window. The respirations are not quickened. A wheezing noise is heard with each respiratory movement. The voice is low and husky. The face is congested, the lips blue, and the eyes prominent. A cold perspiration appears on the surface. The pulse is small, and in some cases very rapid. There is inability to maintain the recumbent position. The patient usually sits bent forward and resting on his knees, bringing every auxiliary muscle of respiration into use to obtain air. On auscultation, loud sibilant and sonorous rales are heard over both lungs. The attack usually lasts from half an hour to four or five hours ; but it may continue with vary- ing degrees of severity for two or three days. The absence of wdema, valvular lesions, febrile excite- ment, etc., and the comparative good health between the paroxysms, are sufficient to distinguish the disease. Ticatment. — Pure oxygen has lately been employed with considerable benefit in this disease. Five or six gallons should be inhaled every fifteen or twenty minutes until relief is experienced. Even where it does not completely subdue the paroxysm, it will at least diminish the distress. w DYSPNffiA. 107 Ions Intil fess. Chloroform, ether, and otlicr jvnoosthetics, may al^o bo given with advimtago. There arc some cases whieh can only he relieved hy the^c medicines. The majority of practitioners employ simple antispas- modics, snch as stramonium, helladonna, or lobelia. The former drug nniy he given in two-grain doses every half- hour, or the leaves may be smoked in a pipe, or in the form of cigarettes, until relief is obtained. Hoffman's anodyne may be used in conjunction with inhalation of steam. A basin of hot water is held under the patient's head, the ano- dyne is ])Oured slowly in, and the ethereal vapor mixes with the steam, and is inhaled. A blaidcet throAvn over the head of the patient prevents the steam from escai)ing. Belladonna in quarter-grain doses of the extract relieves certain varieties of asthma with great rapidity. Emetic doses of lobelia, cupatorium, or ipecac, arc recommended by some. Cuour. — There arc two principal varieties of this disease, viz., membranous and spasmodic. The first is an inflam- matory afl'ection, attended with fibrinous exudation, and is usually fatal. In the second there is a spasmodic contrac- tion of the muscles which govern the vocal cords. It may appear with or without catarrh of the larynx, and is rarely if ever fatal. As the spasmodic variety is more rapidly developed, and as a rule unattended by premonitory symp- toms, it may properly be considered a case of emergency, and discussed in this connection. The spasm of the vocal cords which occurs in spasmodic croup may arise from the reflex irritation of worms in the alimentary canal, from teething, or from a cold or catarrh. The attack comes on in the night. The child wakes from ,1: >'^ iil .ii 1G8 EMEROEXCIES, AND HOW TO TREAT THEM. its sleep with a loud, heavy, crou])OU3 cough, husky voice, unci intense ilyspiuea. The face heconicrf dusky and livid, and the extremities are cold. In a short time the spasm relaxes, and the child resumes its natural hreathing ; hut the hard cough and changed voice rcnuiin longer. If the attack 1)0 connected with catarrh, the hoarseness is more likely to continue, and the paroxysms will recur at various intervals during the night. It is differentiated from mem- branous croup by the absence of exudation on the tonsils, constitutional ami local signs of inflammation, and also by the fact that in spasmodic croup there is comjdete i'clief between the paroxysms. In the membranous or true croup the dyspna>a continues or increases as the disease advances. Treatment. — An emetic composed of a drachm or two of the wine of ipecac, or four or live grains of the powder, should be administered without delay. The child should then be immersed in a hot bath for live or ten minutes. "When taken out, warm blankets should bo wrapped around the body, and hot flannels or hot hop-poultices api)lied to the throat. To prevent a recurrence of the paroxysm, all sources of irritation should be removed, and the general health sustained by attention to diet, nutritious food, good air and exercise. If there be a strong predisposition to these attacks, small doses of bromide of potassium, bella- donna, valerian, etc., may be given with salutary efl:ect. Membranous croup is treated by inhalation of steam, ox^'gen, and internal administration of iodide of potassium ; tracheotomy is sometimes performed. Recovery is rare. CoxoESTiON OF THK LuNos. — Dyspxcea wliicli occurs from engorgement of the pulmonary capillaries is rarely as as DYSPN(EA. 160 Huddeii in its origin as that wliicli arises from croup or aritlmm. Congestion is duo to a variety of causes. It is an accompaniment of pneumonia and bronchitis, and is a fatal element in tlio hitter stages of cardiac disease. Patients witli valvuhir lesions or other organic affection of the heart are after nnusual exertion liable to congestion. The debili- tated heart beats with greater rapidity and violence, and the lungs, already overloaded with blood, become rapidly engorged. The respiratory movements are almost doubled in endeavoring to introduce the necessary amount of oxvgcn. The patient sits up in bed, moving the head from side to side, and gasping for breath. There is an expression of great anxiety, and the face is bathed in cold perspiration, and marked by the characteristic cyanosis. The pulse is irregular, rapid, and intermittent. Sometimes the over- loaded blood-vessels relieve themselves by rupture, and pour out blood into the parenchyma of the lung, and into the bron- chial tubes. If the extravasation is great, a fatal termina- tion is reached in a short time ; a small hajmorrhago is of little consequence. Treatment. — Medicines -which diminish the frequency of the heart's action are indispensable. Digitalis is the best remedy we i)Ossess for the purpose. Aconite and vera- trum viride are preferred by some. Digitalis may bo given in powder, tincuire, or extract. The tincture is the most reliable preparation. It may be given in five-drop doses every half-hour mitil the patient is relieved. With the in- ternal medication the application of a dozen dry cups to th' chest is called for. If the patient is not \erj much debili- tated, a few wet cups may be applied. Inhalations of „.J "i ■ 'I f J' r 170 KMElKiENClKS, AND HOW TO TIIEAT THEM. 1^: l\,' ' t oxygen gaa nro iiko beneficial. Tlu> rtul)80([niMit treiilmcnt consiBtd in rentrnining the ]mtient from all active exercise, nnd keepiiif^ the action of the heart within ])roper limits. Every soureo of mental excitement must ho avoitleil. Ton- ics, good diet, and fresh air, are always necessary. Congestion dependent upon pneumonia or bronchitis is relieved by cathartics, counter-irritation by means of blisters, abstraction of blood with wet cups, and promoting diapho- resis by email doses of antimony or ipecac. PuLMoxARY Q*]uKMA is induccd by conditions which give rise to ccdema in other parts of the body. It occurs in cardiac disease, and in degeneration of the kidneys. Tho serum is poured out from the distended vessels into tho air- cells and areolar tissue of the lungs. ]>oth lungs usually are aflfected. In tho recumbent position the serum gravi- tates to the posterior portion of these organs. The exuda- tion usually takes place gradually, but it may bo poured out so rapidly as to destroy life in a few moments. Urgent dyspuceii marks its occurrence. Tho patient's face and limbs may be swollen from oedema, or other signs of Bright's disease, or cardiac diseases, may be i)resent. The immediate symptoms are tlie same as those arising from congestion. A positive diagnosis, however, cannot bo made without the physical signs. There is dulness posteriorly over the lower lobes of both lungs, which was not ])reccded by inflammatory symptoms. The respiratory murmur is diminished in intensity, and small sub-crepitant or crepitant rAles of a litpiid character are heard over the same locations. There is also a cough, witli a frothy, limpid expectoration. Treatment. — The chief indication is to diminish the quantity of serum in the lung-tissue, and this is done by DYSI'NCEA. y 13 ITl u1)rttriu.'tiii<:; soruiii from tlio blootl throuj^li tlio bkiii iintl l)i)\vclrt. It' tlio debility is not too great, fiinall dosort ofelii- terium or crotoii-oll iiiiiy bo given, to prodiiec free ovacna- tions from tlio iiiterftiiiet*. Ilot-air batli.-i, hot bottles and bhinketrt are useful in promoting perspiration. Acetate of potash may bo given to act on tho kidneys and increase the flow of urine. Wet cups, applied to tho chest- walld posteriorly, aro also beneficial. Dyspncua, arising from (edema glottidis and mechanical occlusion of tho air-passages, is considered iu other chapters. ,;-' le >y r ill ? aJ ll !t CIIAPTi: II XV. (E 1> E M A G L O T T I l> I S . I\ tliifl nffcctioii tlieru m an exudation i»t' Hcriim, under- neiith tlio inueourt nioiiibrano liiiiiif^ the mipcr portion of the larynx. Above the vocal cordri this nifuihrano is loosely iittuelied to the undorlylnf^ structures, and is more liable than other parts of the orj^an to be the seat of serous exu- dation. The (l life tliiiii in yuutli. Tim «iri.'('fi()ii (U'pcudrt on (.'((iiditioiirt which give rise 1(» exiidatidiH of Heriim In other piirtH of the hody, hucIi as ohstructiuiirt tt) the eirculatioii ; iMllaniinatioiiH, lack of tonicity in the vascular walls, or a watery eondition of the hlood. It is not unusual during the proj^ress of all ehronie kidney-diseases, erysipelas, sinall-pox, et^ntinued levers, etc. It is in most cases an attendant of acute and chronic inllainination of the larynx ; it nniy arise, however, as an independent atl'cction. "NVlicn it prt)cceds from inllannnation, Virchow apidius to it the term collateral CBdenia. The inllamnuitory «f«fitfi otters an ohstruction to tho circulation in the diseased part, increases the pressure in tho blood-vessels, so that the watery portions exude in tho areolar tissue. Exceptionally, it has been known to occur in thoracic aneurism, and in (piinsy sore-throat, and jduirynj^itis from extension of the inlianimation. Whether occurrinj^ alone, or in connection with local or constitu- tional diseases, tho symptoms of cedeina <^lottidis are dis- tinctly marked. The patient complains ctf great dilHculty in breathing, which seems to proceed from an obstruction located in the throat, and ho coughs violently in order to eject it. If tho epiglottis be involved to any extent, there will bo pain in the act of swallowing. The dithcult resi)ira- tion rapidly increases. Extreme distress is api)arent. The patient 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 'M i: m \ :l I 17 J: EMERGENCIES, AND DOW TO TREAT TIIEM. expiration, owing to the fact tliat the pendulous hags of serum at the edge of the larynx are forced down hy the current of air, and almost completely close up the Canal. The expiratory act will he found comparatively free. If laryngeal inflammation he present, hoth inspiration and cxj)' ration will he difficult. On examination of the throat the epiglottis may he seen enlarged and prominent, and, if the linger he carefully inserted, the puffy, codcmatous swelling is readily felt. If the symptoms are not relieved, the patient soon dies asphyxiated. The duration of oedema glottidis is variahle. It may destroy life in a few moments, or it may last for hours hefore a fatal termination. Tvcatment. — There is no time for vacillation in these cases. Some measure for relief must he insatuted without delay. Should the affection he complicated with laryngitis, and the dyspnoea not very urgent, a hrisk cathartic may he given, and leeches may he applied to the top of the sternum, and at the sides of the neck. Leeches should never he applied directly to the larynx in inflammation, as a great deal of local a'dcma gencrallv follows the hite. In the majority of cases this kind of treatment will not avail much ; operative measures have to he resorted to. Local scarification, as employed hyDr. Buck, of this city, is highly recommended. i\\ performing this operation, a curved histoury, covered almost to the point with adhesive jilaster, is used. The forefinger of the left hand is passed down to the hack of the tongue until tl e swelling is reached. The knife is then iutioduceu, following the finger as a guide, and the hags of serum are punctured. Great care must he taken not to wound any part hut the oedematous (KDEMA GLOTTIDIS. 175 Btrictm'e, or the flowing of blood into the larnyx may clioke the patient before the cedema is removed. Scariiieation is sometimes rendered extremely difficult, because of the eff rts at vomiting induced by the irritation of the finger in the thro"t. In such cases perseverance ceases to be a virtue, and tracheotomy or laryngotomy should at one ! be performed {see pages 89, 90). Either of these operations is to be performed in all serious cases. \i I iiil 1 . m iil' ' ' '•■ f' m m 'M ••'■■ 'it. \M I i:i!^ CIIAPTEK XVI. i< it; W ., f f i co^'VULslo^''s. lufantilc Convuliiions. — Convulsions! from Uriuniie Poisoninnf, Cerebral Extrava- sation, Hysteria, Alcohol, Epilepsy, Tetanus, /S^i/nonymcs. — Eclampsia, Fits, Falling-Sickness, Spasms. A eonviilsiun is an involuntary contraction of one or more muscles, with or without loss of consciousness. The sensorial and intellectual faculties are seldom affected ex- cept in general convulsions. The mnscular contractions may be either tonic or clonic. In the former the s])asm is continuous, in the latter each contraction is followed by relaxation. The spasmodic movements succeed each other with 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 the braiii are converted into motor impulses through the tuber annulare. Irritation of this ganglion, whether proceeding from ex- ternal sources or acting through the blood, will excite irreg- ular muscular movements throughout the body. to all ifil Ha cx- •rc";- •CONVULSIONS. 177 Convulsions arc increly symptomatic phenomena, repre- senting diverse i)atliolo<5icul conditions; tlic significance of a convulsion, therctbrc, depends upon its cause : it may be the premonition of death, or only the residt of indigestion. Convulsions may occur at any age, but they are most fre- quent during infancy. The rapidly-developing delicate tissues of the child pos- sess a susceptibility whicli intensifies every irritation, and slight causes will excite irre^';ular action and disarrange the nervous system. As children advance in years this sensi- bility decreases, and conserpiently 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 the first den- tition and euriy part of that period. The first few months after birth give the greatest percentage of cases. Convul- sions ill utet'o 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 hereditary ten- dency. A debilitated state of the system is a predisposing cause. Those who have soft skulls from rachitis suffer 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, unhealthy milk, and 12 fi i : 'S;6 : ■ :u(i :li ■1 m i: i .iji I I ■ I 178 EilKIlGENCIES, AND HOW TO TREAT TIIEM. arrow-i'oot, or other articles partially coolved, and rcinaininjjj imacted upon by tlie digestive fluid. An irritation is con- sequently produced, which is carried by the sensory nerves to tlie brain, and convulsions follow. Worms in the ali- mentary canal have a direct irritatinp; action upon the mu- coi;9 membrane of the intestines. Tliey also diniinisli the digestive functions, and lower the vitality of tho system; hence both causes, acting together, may excite tlie abnormal muscular movements. During the first dentition, convulsions are remarkably frequent. In fact, the great majority of di:^eases peculiar to infancy develop during the evolution of the teetli. At this time the swollen and tender gums give rise to constant irritation. Tlie 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 \uicommon sequence. Irritating applications to tlie integument, in the form of blisters or mustard-poultices, are attended with danger. Great care should be exercised in their application. A blis- ter scarcely two inches square may cause alarming attacks. Diseases of the brain in children arc 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. Many of the narcotic medicines cause convulsions. Poisoning by stramonium-seeds is not uncommon. Tho only reliable test of this occurrence is the presencu of the seeds in the matter vomited. CONVULSIONS. 3 79 Convulsive movements may uft'cct all tlic mnscles of the body, involuntary as Avell as voluntary, or lie limited to a siuj^le muscle, or to one set of muscles ; one side of the 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. Tlie premonitory signs, however, arc not always present. For a variable length of time prccedhig the fit, the child may be feverish and restless. The sleep is disturbed, and muscular twitchings are observed. If teething, the 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 bruin-affections, the abdomen is flaltencd; there may be vomiting, projectile iu character, and without nausea. There is pain in tlie head, and, when carried rapidly from one place to another, the child screams violently. The convulsive movements commence suddenly. The child cries sharply, and tails. The muscles for a moment become rigid. The corners of the mouth are drawn down, the eyes are cither fixed or oscillating, generally the former. There nuiy be either convergent or divergent strabismus. Respiration ceases. The child's face, Avhich 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 throat. The rigid condition of the muscles, or tonic 'M '■A. 180 EMEUGFAX'IKS, AND HOsV TO TREAT THEM. W. til f '; contractions, continue but a few HcconiLs, and tlicy arc suc- ceeded by alteiiiiito contractions and relaxations, or clonic spasms. Tiie limbs are moved violently about, rapidly extended and flexed. These clonic movements cease, and the patient sinks into a deep sleep or a semi-comatose con- dition. The convulsivQ movements in children usually continue lonjier haii in adults. The whole paroxv»ni lasts from half a 'ninute to two minutes, or even longer. The lits may succeed each other with such fre(piency as to seem continuous, but this is rare. The innnediate elfects pro- duced by the nniscular contractions are worthy of notice. They may be witnessed in all kinds of couvidsions. The abdominal muscles, by pressure on the intestines and blad- der, may expel the tlcces and urine. It is not unusual for a tit to terminate in this manner. The spasm of the respira- tory muscles, including those which govern the glottis, j)re- vents ingress and egress of air, and a ])artial asphyxia is the consequence. The pressure of the muscles at the base of the neck, and the non-expansioix of the chest, by ju'eventing the venous blood from leaving the head, cause congestion of the brain. The muscles which act upon the tongue pro- trude it from the mouth. AVhcn this occurs during the spasmodic action of the muscles of mastication, the tongue is caught between the teeth and severely la ./ated. Spasm of the vessels of the i>ia mater is said to produce insensi- bility. All the symptoms described are common to true e})i- lepsy, and it is impossible to distinguish them during the tit. In infantile convulsions the period of spasmodic action is continued over a greater length of time than in true epi- ;ue epi- c action [Viic epi- COXVULSIOXS. 181 lopsy. The history of tlie cnso will bo t>t' ai^iistancc in dc- tcnniiiinri; its true nature. For iustauce, in epilepsy, wo would [)robably learn that the patient had had fits before, coming at comparatively long intervals, and without appar- ent cause. In the other case there would bo evidences of worms in the alimentary canal, of indigestion, or some of the other special causes previously enumerated. Again, the occurrence of attacks rapidly following each other would be rather strong evidence that they were not epileptic. A rigid condition of one or more muscles, after conscious- ness is restored, is an imfavorable sign, often indicating injury to some part of the brain or spiiuvl cord. These con- vulsions usually cease when the exciting cause is removed, but the possibility of a fatal termination must not be over- looked. Convulsive attacks may occasion death — 1. By asphyxia; 2. Congestion of the cerebrum, or other injury to the nerve- centres ; 3. Syncope; 4. Gradual exhaustion from successive or protracted convulsions. Poftt-mortcvi appeai'anccs are of little value in detcr- miniui' the causes of the affection. The con<>;cstion of the brain and spimd cord, which we find, is probably the result of the convulsion, and not its cause. Among the varied sequehx; of infantile convulsions wo find paralysis of different parts. It may appear in one limb, or in one set of muscles, or may involve the lower half or lateral half of the body. Iiccovery from it is rare. Convergent and divergent strabismus likewise occur, the latter most frequently. Idiocy may result from continu- ous convulsions. A loss of coordinating power in the muscles which 1! 1 If ; 1 ,1 1 ■ I 1 r '1 if: r i 182 EMEIIGENX'IES, AND UOW TO TUEAT THEM, produce nrticuliitc souiuls somctiincd occasions Btaunncr- uig. Amaurosis and deafness also occur. Very little can l,o done to relieve them. T/vati/ient. — The preventive treatment consists in ut- tendinri>;Iit's disease; of tliu kidncyri were fully cousideird. It is said to act on the base of the Itrain and nicdulla like anv otlier irritant, calling forth irivijruhir ami vi»»k'nt nius>cular muvoniciils. These convulsions may also he due to o'denia of the l>rain-8ul)stance, which exists in eoinnion ■with o'dcnia of other parts in r>ri_i;ht'ri disease (AV'c/'Av). The pressure of the ell'used serum empties the arteries, and diminislies the amount of blood in the organ. Preceding tlie commencement of tlie convulsion, the patient complains of headache, dimness of vision, dizziness and other sym]>toms referable to the nervous system. The stomach is irritable, and the bowels are usually relaxed. The countenance has a ])ale, waxy aj>pearance. There is nnlcma under the eyes. Pressure on the lower limbs nuiy leave a pit or indentation under the linger, showing the presence of (cdenui. Coma may or may not occur ])efore the paroxysm. The urine may be scanty, and of a high color. It must not, however, be forgotten that urremic convul- sions, occurring with the small contracted kidney, may have none of these characteristic symptoms of diseased kidney preceding them. The paroxysm appears suddcidy. 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 rli CON'VITLSIONH. 186 IVoiu HuU) to side {iii/x/di/iiinx), TIic imiiils iir(! ('(»iitni(Mcion, or the eonvulsittns may succeed each other at short: intervals for several hours. The points of dillerencc! which di.-tin<,niish a uncmic convulsiitn from epilepsy, or from apoplectic convul- sions, recpiiro careful investigation. In uniMuic convulsions both sides of the body ai'eccjiudly afl'ected by the spnsnu)diu movements. In ciiilcpsy one side 19 convulsed more violently than the other. There are few exceptions to this rule. In urjvmia we find o'dcnia of the face and extremities, and urinous odor to the pers])iratioii, -which are generally absent in cerebral extravasation and in ei)ilepsy. A chemical and microscopical examination of tho urine will probidtly show, in urn-mia, albumen, and fatty, granular, or hyaline casts, -while in epilepsy and cerebral extravasation they are usually absent. In one case wc have an antecedent history of Ijright's disease of the l «// V /- *v. X" % v.. (.0 I.I 11.25 mm ■ 50 •a 1^ •fc |40 M M 1.8 U 111.6 V] <^ /2 /a m. .oy^ ^^> %. # % ' y >^ Photographic Sdences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 5^ ..% e vV f^ 186 EMERGENCIES, AND HOW TO TREAT TUEM. ment of urffimie convulsions is similar to that ptirsued in uraernic coma {see Coma). PuERPEUAL Convulsions. — Convulsive attacks are not unusual during the period of utero-gestation, particularly toward its termination. They may arise from hysteria, epilepsy, etc., hut the vast majority are duo to uroemic poisoning. The enlarged uterus presses upon the hlood- vesscls of the kidney, causing congestion of that organ, and subsequent retention of urea in the blood. For a vari- able period previous to the convulsive seizure, the woman may present all the ordinary signs of Bright's disease (see Urfemic Coma). The convulsion is similar in all its features to that previously described. The seizure may cause the death of the child in uiero. The placenta may be compressed, so as to prevent the foetal blood from being aerated, or the child may be poisoned by the urea, and die in a convulsion. Treatment. — Inhalations of chloroform are employed to stop the convulsion. Should the attacks continue, prema- ture labor must be induced, and the uterus emptied of its contents. If the cervix is undilated, sponge-tents may be inserted. When these have enlarged the canal somewhat, Barnes's dilators are passed up, and distended with water to such an extent as to thoroughly dilate the cervix. A catheter introduced between the membranes and walls of the uterus is sometimes employed to hasten delivery. When the cervix has been suflSciently dilated, the child is delivered by version, or with forceps. The subsequent treatment consists in eliminating the poison from the blood of the patient, and building up the health by tonics and good diet. CONVULSIONS. 187 cr tlie '» lup tlie Epileptic Convulsions are move common than any otliev variety. They may arise at any period of life. Tlie hirgest jn'oportion of cases, however, occur between the ages of ten and twenty {lieynolds). But little is known as to the pathology of the disease. Among the ninnerons causes given are : 1. Cerebral amemia arising from spasmodic con- traction of the vessels which supply the brain, diminishing the quantity of blood going to that organ. 2. Irregular distribution of blood to the brain, giving an over-supply to one part of the organ, and too little to another, exalting the excitability in one portion, and diminishing it in the other. 3. Excessive sensibility and excitability of the medulla ob- longata, with or Avithout spasm of its vessels {Ilam.nond). 4. Softening of the pituitary body. 5. Induration of L-ain- substance ; and, G. Thinning and dilatation of the cerebral blood-vessels, with resulting anaimia, and exalted excitability of the medulla. Epilepsy is often connected with masturbation, venereal excesses, syphilis, cerebral tumors, fright, etc., etc. IIow far venereal excesses and syphilis tend to develop the disease is uncertain, unless by increasing the general excitability of the nervous sj'stem, and by lowering the general health. Cerebral tumors excite convulsions by direct irritation, but we cannot place them under the head of true epilepsy any more than those arising from cerebral extravasation, or urnemia. Many authorities give two varieties of true epilepsy : a mild form (Je petit maJ), where there is sudden unconscious- ness, and little or no spasm ; and le haut mal, where the loss of consciousness is complete, and the convulsive move- ■I jfn i m m 188 EMERGENCIES, AND HOW TO TREAT TUEM. ments general. It is very evident that tliere are two Ibnns of epilepsy, differing in severity, but ■we can hardly apply the term epilepsy to every slight loss of consciousness, or " absence," without convulsive movement. Many persons have moments of pnrtial unconsciousness, who have never had muscular twitchings of any sort, and who are free from hereditary taint. These persons are ana?mic, dyspeptic, or both, and the attacks partake more of the nature of syncope than any thing else. I am acquainted with a gentleman •who is affected siiddenly once or twice in the month with partial or complete unconsciousness. It always takes place immediately after a hearty dinner, and is without spasm of any kind. Occasionally it is connected with a little ver- tigo. Such cases should not be classed under the head of epilepsy. A true epileptic attack is commonly preceded b}' a warn- ing called the epileptic aura. Strictly speaking, this term does not fipply to all varieties of altered sensation Avhich give notice of the coming tit, but onl}'' to those which give the feeling of a wind or breeze blowing on the person. However, as it is in common use, it v.'ill be retained in this connection. This premonitory symptom assumes different forms. Sometimes it consists in a general fec'ing of weak- ness, or of unpleasant sensations in the epigastrium or head. It may be a sharp pain in one extremity or the other, which seems to extend upward until it reaches the head, wiien the paroxysm appears. These warnings are not present in all cases. At the commencement of the attack the patient usually ntters a loud cry, and falls suddenly to the ground, completely unconscious. The countenance is pallid. All the muscles are fixed in a tonic spasm. The CONVULSIONS. 189 pulse sometimes cannot bo distinguislicd at the wrist, owing to the contraction of the muscles. Respiratory movements have ceased. The eyes are fixed, the pupils dilated. Some say that the pupils are contracted in the early part of the stage, but this is doubtful. This condition of tonic spasm lasts from ten seconds to half a minute, wlicn the clonic spasms commence. The countenance is now eugc^rgcd with blood and livid. The blood-vessels of the face and neck are distended enormously. Bloody foam collects around the mouth. The eyes roll from side to side. The pulse is full and labored. The clonic stage continues from thirty sec- onds to one minute. All the muscles then relax and the patient sinks into a deep sleep, which may last several hours. In these typical cases of epilepsy the patient is entii'cly without knowledge of the fit when consciousness is restoi'cd. Sometimes epileptic fits take place during the night and continue for some time, the person being utterly ignorant of theui. lie only knows that he wakens in the morniufj with sore limbs and wounded tonjjjue. These night-fits are apt to be milder in form than those occurring during the waking hours. The sequeljE of epilepsy are idiocy and insanity. Long- continued attacks are often followed by cither one or the other of these affections. When they reach this point, very little can be done to remove the disease. A fatal termina- tion is so extremely rare in epilepsy that we arc not in pos- session of any peculiar or charactQi'ist'ic post-7norte7}i changes. The points of difference between an epileptic convulsion and one arising from uroemic poisoning have already been given. Epilepsy is easily diagnosed from hysteria. In epi- lepsy there is complete unconsciousness, and the patient '/I 190 EMERGKNCIES, AND HOW TO TREAT TIIEM. >. falls, ■wherever slio may be, soinctinics into the fire or down the stairs. In hysteria the pi'tient knows every thing that is going on, as can be ascertained by watching tbj eyes; and she will fall in a soft, comfortable place, -where there is little danger of receiving injury. Hysterical spasms are not so violent, nor is the tongue bitten, as in epilepsy. The face is not livid, and usually there is a choking sensation as if a ball were rising in the throat. These convulsions are sometimes feigned by a class of persons called malingerers. Such cases are recognized by the fact that respiration does not cease, nor is the tongue bitten. The malingerer never falls where he is likely to hurt himself, and threats to use hot irons or hoc water Avill bring about a speedy recovery. From apoplexy it is distinguished by the absence of ir- regularity of the pupil, of paralysis, and also by the fact that the subseipicnt coma is comj)lete. Cerebkal Extravasation. — Convulsions from this cause are extremely rare. The patient previous to the convulsion may be affected with muscular twitchings about the face or slight numbness in one of the extremities. He may complain of a •' fulness " about the head, and severe pain. The fit comes on sud- denly, at the time of the extravr.sation. Convulsions from cerebral extravasation resemble the convulsions already de- scribed, in all the main features and symptoms. The pupils are usually irregular, one contracted and the other dilated, or they may be both dilated.* There is alsvays jiaralysis, generally of one lateral half of the body ; * There is an exception to this in extravasation of blood into the pons Varolii. In taat case, the pupils are markedly contracted. CONVULSIONS. 101 but this id not clearly manifested nntil the subsidence of the convulsion. Wlicn the spasms have ceased, the patient exhibits all the signs of compression of tho brain — such as deep coma, slow, full pulse, dilated pupils — and he cannot usually be roused from his stupor. In epilepsy the patient is easily aroused. The absence of albumen and casts in the urine, and of oedema of the extremities, ■will be sufficient in most cases to exclude ura3mic poisoning. The fact, however, of the occurrence of Bright's disease in connection with apoplectic extravasation must not be overlooked. Such'cascs are not unfrequent. The presence of paralysis will under such cir- cumstances lead the practitioner to the real seat of the lesion. Treatment. — If the patient is full-blooded and plethoric, and the pulse full and hard, the abstraction of nine or ten ounces of blood from tin arm will be decidedly beneficial. Even if it does not relieve in a marked degree the severity of the convulsive attacks, it Avill lessen the intra-cranial con- gestion, and thereby the danger of further extravasation. "When the patient is not plethoric, and when other dis- eased conditions tend to decrease the vital force, blood- letting should be avoided. The treatment in such cases is limited to the prevention of inflammation, absorption of the clot, and restoration of power to the paralyzed parts {see article on Coma). rii KUM CONVULSIONS. KUM EPILEPSY. Persons who indulge freely in alcoholic stimulants not unfrequcntly sufl'er from spasmodic attack's resembling those of true epilepsy. The affection arises probably from -■tSiS feiul 192 EMERGENCIES, AND HOW TO TREAT TUEM, irritation ])ro(lucecl in ilio nervc-eentrcs by tlie alcohol, and also from coni^cstion of the same parts. Miicli clitHculty is encountered during tlie attack in distinguishing its true character. It will be found, however, that the tongue ia not bitten, nor is one side of the body more convulsed than the other, as in true epilepsy. The history of a long-con- tinued " spree," and the odor of alcohol, will also serve to distinguish them. It is also necessary to decide between these convulsions and those due to cerebral extravasation. Here, again, the presence of paralysis is an important featui-e. It is never found in simple rum convulsions. Following the latter there is also a stupor from which the ])atient is readily aroused, wliile in apoplexy the coma is persistent. Hero the history of the case is likewise of advantage. Treatment. — During the attack little is to be accom- plished by treatment. Subsequently cold water may be poured on the face, and opium or L; omide of potassium may be given to moderate the nervous irritability, and pro- mote sleej). Hysterical Convulsions are peeul":ar to young unmar- ried females ; but they may occur in the married state or in advanced life. Delicate women of nervous temperaments and excitable dispositions are generally the subjects. The disease is often connected with functional or organic disease of the generative organs; unsatisfied and uncontrollable passions, masturbation, etc., are not unfrequent causes. The patient for some time previous to the attack may complain of a sensation in the throat, as if a ball were rising up and choking her {globus hystericus)^ or she may be afl'ected with violent fits of laughter and crying, or with CONVULSIONS. 193 es. ck may U were may he or with some of the other varied forms of liysterical inaTiifcstatioi\3. As tlie attack appears the patient sinks clown in a coinfort- ahle spot where there is no clanger of injury. The Hnihs are jerked about irregularly, and with less force than in an epileptic convulsion. The breathing is jerking and spas- modic ; sometimes she appears as if choking. She shrieks loudly at one moment, and at another mutters incoherently ; close inspection will show that the patient is not uncon- scious, and that the pui)il3 are in a normal condition. There is none of that lividity of the face or distention of the blood- vessels Avliich is characteristic of epilepsy. The paroxysm may terminate in another fit of crying or laughing, or it may be followed by sleep. Often its close is accompanied by the discharge of a large quantity of pale urine. Treatment. — A pitcher of cold water should be poured slowly on the face and head. This procedure may be repeated until the convulsion ceases. Should the attack bo repeated, a shower-bath will be found an excellent remedy. In very delicate females, however, this would not answer, but the cold douche to the head can be employed without injury. The subsequent treatment has reference to the general weakened nervous system of the patient. Cold bathing, tonics, antispasmodics, good diet, and the practice of self- control, should be recommended. Tetanic Convulsions occur in tetanus. The disease arises generally from traumatic causes, such as wounds from rusty nails, etc., involving branches of nerves. Some cases arise from cold. The convulsions are caused by ir- ritation of the spinal cord, which has been excited by in- jury of the peripheral nerve. They are tonic in character, 18 1^1 m m 1 V,' It 194 EMERGENCIES, AND HOW TO TREAT TllEM. '.:» and extremely violent. When the muscles ot mafttication are alFcctetl, the jaw is tightly closed, giving rise to t/us>nu8 or locl'jaio. When the muscles of the back are involved, the body is arched and rests on the head and heels {o2>'is- tJiotonos). Contractions of the muscles on the anterior sur- face bend the body forward (emprosthotonvfi), contractions of one side give a lateral inclination, called ^;^t'wro.vMo/«?itf«. When tetanus is once fully established, a breeze, the creak- ing of a door, and other slight causes, sutHce to excite a con- vulsion. Tonic spasm of the respiratory muscles generally kills, the patient dying from asphyxia. Treatment. — Anaesthetics, opiates, chloral, or assafojtida, can be administered in large quantities. ^n •: ,: ml CHAPTER XVII. SUSPENDED F(ETAL ANIMATION. Pressure on Umbilical Cord. — Injury to Brain. — Rupture of Umbilical Cord. — Aspbyxia. — Syncope. — Congestion of Brain. During the progress of labor the cliild is subject to iTiftny accidents which may supend for a time the functions of life or completely destr ly it. Thus, the ximbilical cord may be pre3scd upon by the head in its passage through the straits of the pelvis ; the cord may bo wound uround the neck; the air-passages filled with mucus so that the child's blood remains unaerated, and a condition of asphyxia in- duced. Profuse hoemorrhage, 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 cliild 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 y n I, i% m I 1 ■ i ;i m 196 KMKRGENTIES, AND HOW TO TKEAT THEM. II li tho heart arc extremely fool )lc ; as long as any movement can bo distinguishetl, there is hope of resusc'tation. A favorable result is scarcely ever obtained v/iien tho heart has entirely ceased its action. In cases where ^ho asphyxia is produced suddenly, livijlty may to a certain extent bo absent, but this is rare. In tho second variety, or the state of syncope, the child is pale and cold. Tho lips are colorless. Ilespiratory move- ments are sighing in character or absent. The extremities are limber and flaccid. Tho pulse cannot bo detected ut tho wrist, but weak pulsatory movements of the heart may bo heard with a stethoscope. When congestion of tho brain exists there is some li- vid'ty about tho head and face, but the color is not so dark as in asphyxia, and the capillaries of tho extremities do not present tho same blueness. Treat7nent. — In all cases exertions to restore life should be made so long as tho faintest movement of tho heart can be detected. Life has been restored after an hour'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 resp'ration has been established tlio treatment should be continued until the cliild cries vigorouslv. 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 aldo 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 insufllation, must be tried. In doing this the SUSPENDED FU;TAL ANIMATION. 197 mouth juid throat of the patient must ho cleared of mu- cus, the larynx pressed aganist tho spinal colunm to pre- vent air from cnterin<^ tho (csophaf^us, while tho physician, with hl3 lipa applied to those of tho child, blows steadily into tlio lungs until they are expanded ; when this is done pressure is made on tho lateral walls of tho thorax to force tho oir out. Again they are inflated and again compressed until tho respiratory movements aro naturally performed. Sylvester's method is preferred above all others. Tho chief requirement in tho condition of syncope is to furnish more blood to the child. This is accomplished by "stripping" the cord from tho placenta toward tho child's abdomen, i. e., pressing the blood along tho vessels to the child. Friction and warmth to tho surface are also neces- sary. In tho congestive variety tho umbilical cord is cut at once and allowed to bleed freely for a few minutes, while tho surface is rubbed and respiratory movements assisted by alternate pressure and relaxation on the thoracic walls. ild may [o excite itaucous the flat method tpiration (inflating this tho i'm i CIIArTEE XVIII. ^i 1 ^il ^i 'i\ COifPLI CATIONS OF LABOR, ETC. Rupturo of tbo Uterus.— Proltipso of tlio Funis.— Sluirt Conl.— Irregular Prc- BontntioiiH. — Applieutioii of llio Tmiipoii, XlrrruKE of the Utickus.— Among tlio seriona accidents to wliicli parturient women arc cx})osecl tliero is not one more serious tliau rupture of the \Uerus. It is one of the worst complications of hibor. 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 li-^ble to it. The successive enlargements of the uterus dinn'nish the strength and firmness of its walls, and develop a tendency to rupture. Rupture of the uterus may occur at any period of utero- gestation, but usially it takes place during the second stage of labor. At this period the resistance to the uterine con- traction reaches its maximum. The liead of the child en- gages against the bony walls of the pelv is with considera- ble force. If, now, the linea ilio-pectiuca be abnormally prominent and labor delayed, the 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. tl 1 COMPLI(!ATIONS OF LAIJOU, ETC. 199 jon- en- lera- jally the lults. but Al)i»oniml tliiniicRH of tlio ntcrinc walls, and fatty roduce retention. This condition occurs not unfrequently in females whose opportunities for emptying the bladder are often re- DISLOCATION' or THE NECK— INJURIES I'UOM IJCIITNINO. OQO Btrictcd. It iji relieved by frequent introduction of the catheter, cohl hip-biiths, nnd tonics. When retention arises from injuries to the spinal cord the bhidder bhoukl bo emptied twice each day by means of a catheter, and thorou«;hly washed after the urino is evacuated. DisLocATiox oi'' THE Nkck. — This accidcnt is usually fatal. In death from han<;iiig the transverse li<5ument is ruptured, the axis is dislocated from the atlas, and the odontoid process of the former bono presses upon the upper portion of tho cord. Death in such a case is almost instantaneous. Partial dislocations of tho cervical vertebra lower down aro 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 tho 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 fkom Lightning. — 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 tho tissues, paralysis of tho extremities, loss of sight, speech, and hearing, and hcemon'hage from the mucous canals. Burns 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 U fk: '''l^ if l'".5 210 EMKRGEXCIES, AND HOW TO TREAT TIIEM. 1 1 clothes. Siiiiilnr curious occurrences have been recorded by othoi observers. The Bymptoms presented by a patient suffering from a lightning-stroko are coldness of the extremities, sighing res- piration, absence of radial pulsr», and insensibility. After death the ordinary rUjor mortis is not witnessed, and the blood is said to bo 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 wv nilar walla of the intestines is generally attended with great pain. It is occasioned by cold, or over-ihdulgenco in indigestible food. It is characterized by paroxysms of intense puin over the abdomen ; vomiting is sometimes associated with it. The pain is distinguished from that accompanying inflamma- 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 : 5 . Bisinnth subnitratls, Morphia sulph., . Make ten powders. 3j. gr.j. One powder should be given every hour until the patient is relieved. Mustard or hot flax-seed poultices may also be applied over the abdomen. {See Lead Colic.) i ''I ticnt fco be CHAPTER XX. TOXIOOLOOY. NARCOTIC rOISOXfl. Opium, BcUodonnn, IlyoBoyainuH, Aooiiito, Tobacco, Strnnionium, Chloroform, lloailock, Lobclio, Woornra, Ether, Alcohol, etc. OnuM is obtained from the unripe caj)sule3 of the Papa- ver 307)171 iff mm, or poppy. The juice of the capsules is the portion used. The plant is cultivated in India, Persia, Europe, and in this country. It has been employed as a medicine from the time of Hippocrates to the present day, and stands unrivalled as a remedy for the alleviation of pain. In Turkey and China the drug is habitually smoked and cho\ved. 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 fallen 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 i \M Hi ; 212 EMERGENCIES, AND UOW TO TREAT THEM. in ordinary cases are eaten witli perfect impunity by persons accustomed to its daily use. Enougli 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 droj? 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 (S/cae). In the majority of cases larger quantities are required. Oi)iuni kills in from four to twelve hours. Some animals are scarcely affected by the drug. On apes it exerts no perceptible effect. In one instance five hundred grains were given to one of those animals without injury. Tests. — Perchloride of iron gives a red pi-ecipitate with solutions of opium which contain meconic acid. Nitric acid gives a red precipitate with morijhia, the principal alkaloid of opium. The symptoms manifested in persons addicted to opium- eating are readily recognized. The face is sallow, pinched, and parchment-like. The eyes are sunken and glassy. When they are 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. NARCOTIC POISONS. 213 .^1 But in such casca 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 so long as they are allowed to taste and experience its intoxicating effects. Large doses of bromide of potassium will do much 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, drowsy, and unable to resist the tendency to sleep. Gradually the stupor deepens, until there is perfect insensibility. The pupils are contracted, eyes and face congested ; the pulse, at first rapid and small, is 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 1 ■i'^ ^ 214 EMERGENCIES, AND UOW 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-quarters of an hour the nurse in charge informed me that 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- ,.elf, seemed to exert a curative effect on the cholera, and the patient was discharged three days after her admission, cured. 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 medicifies should be fol- lowed by copions draughts 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 {atropia) may be given by hypodermic injections. A solution of one grain to the ounce is made, and fifteen or twenty minims injected, and ^5:1 NARCOTIC POISONS. 215 boi- |y * or will fol- tlie |ina, 'he i>y the and repeated, if necessary. Strong coifee is another antidote. In all cases the antidotes should ho accompanied by stimu- lants. Brandy and ammonia may he frequently given hy the mouth or rectum. Flagellation of the surface hy the hands or towels, and causing the patient to walk about, are important aids to restoration. In connection with other remedies, artificial respiration by Sylvester's method, and inhalation of oxygen, are worthy of a trial. BELLADONNA. The leaves and root of Atropa 'belladonna^ or deadly nightshade, are largely employed for medicinal purposes. All parts of the plant possess poisonous qualities. The leaves 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 hilled an adult. Atropia, the active principle of the plant, given in two-grain doses, has proved fatal. The first symptoms of poisoning are dryness of the throat, constriction of the tauces, diflScult deglutition, indis- tinct vision {amhlyojna), or double vision {diplopia), head- ache, staggering, and confusion of ideas, stammering, etc. The pupils are widely dilated, face sufiiised, lips livid, and pulse rapid and intermittent. Delirium and deep coma soon supervene, followed rapidly by death. In a few r ises 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\ ' •''%[ m m W) \ 216 EMliRGENCIES, AND HOW TO TREAT THEM. Treatment. — An emetic should be administered without delay, and repeated until the Btomach is completely emptied. This should be followed by stimulation, friction to the extremities, and wannth. Some recommend opium as an antidote. It has been successful in one or two cases. Runge advocates the use of lime-water in ]ar: ? \i m \f 224 KMKIUiKNCIKS, AND HOW TO TllKAT TIIKM. Wlioii a i)uiriom>U9 imwlirooin ia taken internally, It causeu extreme niuriculur wcaknoHB, vertigo, mental luilluei- natiunn, htii]i(ir, and in a tew inritaneert violent vomiting and ])urging. lleoovery U not iinfrc(]Uent, oven when largo quantiticB have been eaten. Ti'eatiiient, — The stomach and bowels shonld bo acted upon hy emetics and cathartics, M'horo vomiting and pnrging are absent. Castor-oil, however, may bo given in all cases. Opiates are recommended by some where there is much delirium without 8tni)or. Ether has been used with benetit. If the i)rostration is groat, tho IVeo use of diluted stimulants will bo necessary. YEW-TREES. Tho loaves and berries of this tree arc extremely poison- ous. An infusion of tho loaves is often administered in this country to bring on tho menstrual flow, or to produce abortion. Its action in this respect is not well understood. Children are often poisoned by tho berries. The symptoms are vomiting, convulsions, dilated pupils^ and coma, which usually ends in death. Stimulants are principally to be relied on in tho treat- ment. CAMTnOB Is a concrete substance obtained from tho Camphora officinalis, an evergreen tree of China and Asia. It rarely produces death. Taylor relates tho case of a man who, in twentv minutes after taking tho drug, was seized with vertigo, dimness of vision, and convulsions. Tho pulse became rapid and weak, tho extremities cold. The stomach was emptied by a stomach-pump. lie suffered for a week NARCOTIC rOISONS. 225 flubscquently wltli cxlmuBtion, and from siippi'csHloii of uriiio. In somo cnsea thcro nro pftin in the buck, iind rnpid in- scnBlbility. The breath of a person poisoned by eaniplior eniolls strongly of tlio drug, and thus the diagnoriis is roudily made. Treatment. — Free cmesis shoukl bo procured without dohiy. Stimulants aro always necessary. ALCOHOL. Largo quantities of alcohol, in tho shape of whiskey, brandy, etc., have produced sudden death in young persons unaccustomed to tho poison. Convulsions and coma are not unfrequent accompaniments of excessive indulgence in ardent snirits {Taylor). (For characteristic appearances and treatment, see Convulsions.) Chronic poisoning by alcohol is recognized by tho bloated couL^ouance, blood- shot eyes, general tremulousncss, and delirium tremens. Tho treatment for this condition consists in total absti- nence from liquor, and the administration of bromide of potassium. CHLOliOFORM. This substance is one of the most effective anajsthetics known. Its formula is CJlCla. It is technically known as the terchloride of formyl. It is prepared by the action of chlorinated lime on wood-spirit. When inhaled", it first acts as a stimulant, causing great excitability and intoxication, then mental hallucination and delirium, and finally perfect insensibility and coma. 15 i < 22G r.MERGEXCIES, AND HOW TO TREAT TIIEM. lu the third stage, when the inhalations are carried beyond a certain point, the pulse becomes very small and in- termittent, respiration slow, irregular, and difficult ; face congested, and lips livid. If organic disease of the heart exist, very small quanti- ties may produce death. Sometimes respiration is suddenly suspended, and death ensues rapidly. In one instance I have seen it produce convulsions. Chloroform kills by as- phyxia, syncope, or coma. After death the lungs are con- gested and filled with dark blood. Treatment. — Artificial respiration is the main reliance in the treatment of chloroform-poisoning. Marshall Hall's or Sylvester's method will answer (s^*? chapter on Drowning). Inhalation of pure oxygen is always beneficial. In some cases it may be forced into the lungs through an opening in the trachea. Slapping the patient, and pouring cold water on the surface, are also recommended. Galvanism has been successful in restoring life in one or two cases. Some relv solely on electrical stimulus in the treatment. ETHER (C4H5O) Is manufactured by the action of sulphuric acid upon alcohol. The acid merely removes the water from the alcohol, to form the ether. The action of the vapor of ether is similar to that of chloroform. Its effects are, how- ever, manifested more slowly ; the resulting ancesthesia con- tinues longer, and larger quantities of the urug are required to produce the same degree of insensibility. The symptoms accompanying poisoning by ether are the same as are witnessed in chloroform-poisoning, and a similar treatment must be pursued. NARCOTIC rOlSONS. 227 ClILOKAL. This drug has lately come into general use as an ano- dyne and hypnotic. It is made by the action of chlorine gas on alcohol. It is used in the form of a hydrate. When taken into the system it is changed into chloroform by the action of the soda of the blood. Its poisonous influences are manifested by laborious and irregular breathing, congestion of the face, rapid and feeble pulse, numbness, and insensibility. In some cases there is considerable disturbance of the mental faculties. After death the same lesions are found as exist in poison- ing from chloroform. Treatment. — Some recommend hypodermic injections of strychnia as an antidote. Artificial respiration, inhala- tions of oxygen, and stimulation are mainly to be relied on. Electricity is also beneficial. ired are ,d a nYDROCYANIC ACrO. The common name of this drug is prussic acid. It is obtained from bitter-almonds, peach-kernels, cheiTy-laurel, prunus Virginiana, and bitter cassava. It is formed in bit- ter-almonds by the reaction of a peculiar principle called amygdaline, and water. The change is uxcited by the pres- ence of a nitrogenized body called emulsine. The essential oil of bitter- almonds is employed as a flavoring extract. Almond-water and laurel-water are used for a similar purpose. Prussic acid is manufactured by the action of sulphuric acid upon ferrocyanide of potassium, or by the action of muriatic acid upon the cyanide of silver. n '•I 'm 228 EMERGENCIES, AND HOW TO TREAT TIIEM. The acid obtaii»ed by tliis process is in a dilute form, and contains about two per cent, of the anliydroua vari- ety. It is colorless, and possesses a peculiar odor resembling peacli-kernels or almonds. It is one of the most deadly substances known, killing more rapidly, and affording less opportunity for recovery, than any other poison. Inhalation of its vapor in a con- centrated form has in some instances produced almost in- stant death. Scheele, while pursuing his chemical investi- gations with this drug, died instantly by inhaling his own preparation of it. A single drop of the anhydrous acid placed on the tongue will kill instantly. A drachm of the dilute acid will destroy life in a few seconds, unless im- mediate efforts at restoration are made. The poison acts as rapidly if placed in a wound. In some instances life is prolonged for thi'ee or four minutes when poisonous quan- tities are swallowed. In one or two rare cases a fiital termination did not occur for an hour after the adminis- tration of the poison. Tests. — Taylor mentions three principal chemical tests : 1. Xitrate of silver, which gives a white precipitate of the cyanide of silver ; 2. On the addition of potash, and a solu- tion of the sulphate of iron, there is a brownish-green pre- cipitate, which changes into blue, upon the addition of diluted iimriatic acid. The blue substance thrown down is ferrocyanide of iron, or Prussian blue ; 3. Bihydrosulphate of ammonia, when added to the suspected solution and warmed, makes the mixture colorless, and after evaporation leaves sulphocyanate of ammonia, which is recognized by the " blood-red " color produced by adding a solution of the colorless persulphate of iron. f! NARCOTIC POISONS. 229 "When large closes of the drug arc taken, the patient falls unconscious to the ground, the face becomes congested, respiratory movements labored, and diminished in length and frequency ; pupils dilated, eyes glassy and prominent, pulse imperceptible, skin clammy and cold. Foam collects on the lips, the jaw drops, and death supervenes. If small quantities are taken, and the symptoms develop more slowly, there are difficult and convulsive efforts at breath- ing, the movements occurring at long intervals, vertigo, oppression over the precordial region, muscular weakness, and paralysis {Bacher). The eyes are prominent, and there are sometimes convulsive movements, and loud cries from the patient. ^\\Q jpost-mortem appearances vary. The peculiar almond odor is nearly always exhaled from the body. The lungs, brain, liver, and kidneys, are filled with dark fluid. The eyes are remarkably bright and staring. In some instances the muscles will not respond to galvanic stimulus. The symptoms appertaining to poisoning by almond-oil, cherry-laurel, or cyanide of potassium, are developed more slowly than the preceding. Their main features and treat- ment are alike. Treatment. — Chlorinated lime in solution, chlorine- water, or ammonia in vapor largely diluted, are good anti- dotes. Another method employed is to change the prussic acid in the stomach into Prussian blue. According to the " United States Dispensatory," this is done in the following manner : Ten grains of sulphate of protoxide of iron and one drachm of Tr. ferri chlor. are added to an ounce of water, and twenty grains of carbonate of potassium to one ounce of water in another vessel. The latter solution is swallowed '' m 230 EMERGENCIES, AND HOW TO TREAT THEM. first, and immediately followed by the preparation of iron. Cold water poured from a height npon the face, chest, and abdomen, and artificial n [)iration, are also recommended as eflScacious remedies. • WOOEARA. The source of this poison has been the subject of con- siderable controversy. Schomberg thought it was a product of a plant called Strychnia toxifera. Nothing analogous to the action of strychnia has, however, been found in it, and there is no definite account of its origin. Prof. W. A. Hammond, from numerous experiments made with the drug, believed its action to be exerted mainly on the heart, paralyzing that organ. It was also thought to produce a paralysis of the sympathetic and motor nerves. "NVoorara is employed by the natives of South America to poison the heads of arrows. It exerts its peculiar effects by being introduced through wounds. When ta!:en into the stomach it is often inert. The symptoms attending a wound poi- soned with woorara are sudden stupor and insensibility, frothing at the mouth, raj^id cessations of the respiratory movements and pulsations of the heart. Some writers say that the heart continues its action some mo*nents after res- piration has ceased. Treatment. — When the poison enters a wound, the part should be sucked and excised, and a ligature placed around the limb between the wound and the heart. Brainard and Green discovered that a solution of iodine and iodide of potassium neutralized the poison, and recommend its ap- plication to the wound, and also its internal administration. Chlorine and bromine are also said to have a similar effect. NARCOTIC POISONS. 231 Artificial respiration Las been tried on criminals poi- soned by woorara, and has been followed by good results. CALABAB BEAN. Calabar bean is a seed of tlie Plysostigma venonoswn, a climbing plant of Calabar. It is used by the negroes of Africa as an ordeal-bean — the guilt or innocence of the individual being determined by its action on the system. If a dose is taken without subsequent unfavorable symp- toms, the person is declared innocent. If the contrary, a verdict of guilty is announced. Its action on animals is said to resemble that of woorara. It paralyzes the heai*t and motor nerves. Poisonous doses in man produce vertigo, dimness of vision, great weakness, small, intermittent pulse, contrac- tion of the pupil, insensibility, and death. Treatment. — The stomach should be evacuated, stim- ulants administered internally, and the surface briskly rubbed. Hypodermic injections of strychnia might be tried. Strychnia exerts an entirely opposite effect on the spinal cord. Electricity is also worthy of a trial. UPAS-TKEE. This tree grows in various parts of the East Indies. A resinous exudation, obtained by incisions in the bark, acts on the system as a virulent poison. Like woorara, it is prin- cipally employed by the natives to poison arrow-heads. The vapor of the tree at certain seasons of the year is said to cause eruptions on the skin. When applied to a wound, or taken internally, it causes great muscular weakness, syncope, nausea, and vomiting, ' r I'l I ■I m i' i! :h'--i\ '..i'm iff 232 EMERGENCIES, AND HOW TO TREAT THEM. relaxed sphincters, thready, irregular pulse, and convul- sions. Treatment. — The remedies employed in poisoning by tobacco, or aconite, are applicable to these cases. SPINANTS. Nux- VOMICA {Strychnia). Strychnia is derived from the seed of the StrycJmoa nnx- vomica and the Strychios ignatia, large trees of the East Indies and other Eastern countries. The seeds are embedded in the pulji of the fruit. They are circular in shape, three- quarters of an inch wide, about the thickness of a cent-piece, and are covered with delicate, yellowish-gray hairs. Strych- nia exists in the seed, together with brucia and igasuria. The nux-vomica and its alkaloids possess the same action on the system, the only difference being in the rapidity with which their characteristic symptoms are manifested. Strychnia, which is the most powerful ingredient of the nut, or seed, is found in the shops in the form of a fine, white, crystalline powder, with an extremely bitter taste. Its bitterness is so marked that one part will give a taste to six hundred thousand parts of water {U. S. Dlsj).). Very small quantities suffice to produce a fatal result ; one-tenth of a grain has killed a dog. There are instances recorded where half a grain has proved fatal to human beings. In exceptional cases recovery has taken place after the administration of four or five grains. Strychnia acts specially on the spinal cord, but there is no good reason for supposing that it does not in a measure SPINANTS. 233 affect the brain. I have seen a cortaiii amount of vertigo and rapid utterance follow its use. There are several testa of the presence of this drug. In Mararchard's process, five or bix drops of concentrated sulphuric acid, and one hundredth part of nitric acid, are mixed with the suspected solution ; a little protoxide of lead is then added, and, if the strychnia is present, a blue color appears, which changes to violet, red, and finally to yellow. If the strychnia is in solution in sulphuric acid, the addi- tion of ji bichromate-of-potash solution will give a violet hue. This test will detect the one million five hundred thousandth part of a gi'ain ( U. S. Disj^.). Poisonous doses of strychnia first produce an inability to remain in one position, and a tendency to perform every motion with great rapidity. The muscles seem to be be- yond control of the will, and twitch unceasingly. There are some constriction in the throat, difficult respiration, and feeling of oppression about the chest. Violent mus- cular spasms then appear; they are tonic or continuous in character, resembling those occurring in tetanus. The muscles of the back are often affected more than those of the extremities, and as a result the body is bent like a bow, and rests on the head and heels {opidthotonos). During the paroxysm the jaws are tightly fixed, the face dark and congested from the accumulation of blood in the veins. Contraction of the muscles prevents expansion of the chest, and obstructs the blood going to the thorax, and hence the congestion. Intermissions in the seventy of the paroxysms may occur; they last but a moment. Death takes placj from the spasm of tlie muscles of respiration inducing asphyxia. m r* 234 EMERGENCIES, AND HOW TO TREAT THEM. On jjost-m&rtem examination there are usually a dark color of the face, congestion of the brain, cord, and their membranes, and congestion of the lungs. The right side of the heart contains a largo quantity of dark blood, and the left side is empty. Treatment. — Chloroform taken in a liquid state or by inhalations should in all cases be tried. A relaxation of the spasms will at least prevent or retard the occurrence of asphyxia. Infusion of tobacco is rcconnnended by some. It may be advantageously combined with chloroform; that is, the tobacco-infusion can be swallowed, or given by enema, while anoesthesia is procured by inhalation of chlo- roform. Aconite has been used in some cases with benefit. Thoral employs preparations of antimony as an antidote; it is given in emetic doses. Boudecker experimented upon dogs with chlorine-water and tartar-emetic, giving them alternately. lie claims to have saved the animals from the poisonous eifects of strychnia by this treatment. It will be well in most instances to connnence treatment by an emetic, in order to get rid of the poison remaining in the stomach. The infusion of tobacco, or sulphate of zinc, will answer this purpose. If the patient cannot swal- low the medicine, it can be given through the rectum. CHAPTER XXI. IRRITANT POISONS. tlicm CantbariJos. — Croton-oil. — '/ oratria.- -IloUoboro, etc. A PKCULiAR Spanish fly, called tlio Cantharis veaicato- rut, has long been employed in medicine as a vesicant and as a stimulant to the genito-urinary apparatus. There are several other varieties of cantharides found in the southern parts of this country, which possess properties analogous to the Spanish fly ; they are, however, rarely employed for medicinal purposes. Large doses of cantharides produce tenesmus at the neck of the bladder, inability to pass water, intense pain and scalding with the few drops of urine which are squeezed through {strangu7y), great pain throughout the alimentary canal, and thirst, with profuse vomiting and purging. The vomited matters and the stools contain blood. The extremi- ties are cold. There are great prostration, a rapid pulse, sighing respiration, and a fetid odor to the breath. A. 2'>ost-mortein examination shows signs of inflammation in the stomach and intestinal canal. Treatment. — When the stomach and bowels have been emptied of their contents by emetics, cathartics, or the natural efforts of the patient, ten to thirty drops of liquor potassa largely diluted may be given every hour (Jlulack), m 'A: t i; ! 230 EMEUGEXCIES, AND DOW TO TREAT THEM. m in conjunction with liot npplications to the hypognstric regions. Small pieces of ice nmy be swallowed with benefit. Thalo reconuneiuls animal charcoal as an antidote; a' tea- spoonful of this substance mixed with a little water may be given at a dose. OIL OF BAVIN. The tops and leaves of Jumpcrus sabina, or red cedar, furnish a volatile oil which possesses marked irritant proper- ties. The oil is employed in medicine as a stimulant to the secretions, and as an emmenagoguc. Its action on the uterus is denied by some authorities. It is commonly administered by quacks and others to produce abortion. These cases not infrequently terminate fatally. A decoction and infusion of the tojjs and leaves are also used for a similar purpose. An overdose produces strangury, sharp jjains in the bowels, hot skin, rapid pulse, violent vomiting, and some- times purging. The vomited matters are often of a green color. Great prostration comes on rapidly, and usually ends in death. The jpost-mortem appearances are the same as those ob- served in poisoning by cantharides. Treatment. — Warm fomentations over the epigastrium and hypodermic injections of morphia may be tried with benefit. The patient should be fed through the rectum if possible. Nothing but ice should be allowed in the stomach until the subsidence of the inflammation. CKOTON OIL. Is a product of the seeds obtained from the Croton tiglium, a small tree of Ilindostan. It is a drastic hydra- IRRITANT POISONS. 237 goguo cathartic, acting cfHciently in from a half to one hour after its odniinistration. Applied externally it ju-oduces a pustular eruption. In largo doses it excites intlaninuition of the oesophagus, stomach, and intestines, and gives rise to vomiting, purging, and rapid prostration. Treatment. — Empty the stomach thoroughly, and treat the resulting inflammation in the usual manner. Stimulants diluted with iced milk should also bo used, to sustain tho strength of tho patient. COLCniCUM. The tinctures and decoctions of this drug are not infre- quently taken in poisonous doses by careless persons. Three drachms of tho wine of tho seeds have caused death. Tho poisonous eft'ects are manifested by violent vomiting and purging, great pain, and collapse. Tho treatment is the same as for tho preceding varieties. VEEATRIA. This alkaloid is obtained from the seeds of Veratrum sahadiUa and other plants. It is found in the shops, in tho form of a grayish-white powder. The taste is bitter. It gives a red color with sulphuric acid, and a yellow color with nitric acid. Veratria is a powerful poison in doses of four or five grains. IlaM" a grain has proved fatal to a child. The symptoms of poisoning are vomiting and i)urging, pain in the epigastrium, rapid respiration, small, quick pulse, and spasmodic movements of tho muscles, resembling those which occur in tetanvts. 238 KMKlUiKNCIES, AN'I) IIOW TO TUKAT TIIKM. Tlio mtidotcs nro vinegar, vegotublo astringcnta, Lugol's Bolution, and stimulants. Black and white hcUoboro, nil the drastic cathartics, turpentine, etc., are irritant poisons in largo doses. They present similar symptoms to those irritants previously men- tioned, and require the same treatment. 9, Lugol'i •atharticB, 3fl. Thoy lusly men- CHAPTER XXII. METALLIC PCISONS. AliSENIO. Every preparation of ftrsenic acts as an irrifant poison. Among the most common varieties arc arscn'ous aciil, arsenito of copper (Sclieele's green) ; yellow sulpluiret of arsenic (orpimeiit) ; and red arsenic, or realgar. Arsenious acid and Sclieele's green arc most fretpiently employed for purposes of murder or suicide. Metallic arsenic is made by heating an oxide of arsenic with charcoal. Arsenious acid (AsOa) is obtained during the sublima- tion of the arseniuret of cobalt and iron. It usually exists in the shops as a fine white powder. If the sublimation has been slow, it will take the form of brilliant octahedral crystals {Taylor). It combines with many of the alkalies, as soda, ammonia, or potash, to form salts. The well-known Fowler's solution is a liquid preparation of the arsenite of potash. Sclieele's green is applied to a variety of purposes. It is the principal ingredient in the coloring matter of green wall-paper, artificial flowers, candy and paper boxes, etc. Nearly all the bright-green colors of household furniture, paper, and " knick-knacks," are made by this poison. This lili hi 240 EMERGENCIES, AND HOW TO TREAT TIIEM. J* indiscriminate and unguarded use has resulted in serious impairment of health and loss of life. Inhalations of the microscopical particles, which arise from the green surface of room-paper, may induce all the poisonous efliects of arsenic. Cases are not rare where this has occurred. Kealgar and orpiment are much used also as coloring matters, but less extensively than arsenite of copper. Arsenious acid (AsOq) is a very powerful poison, but loss of life from its administration is exceedingly rare. Arsenious acid kills in from three to fortv-eiuht hours. The length of time varies with the dose, the condition of the stomach, and age of the patient. Christoson gives the smallest fatal doses of the preparation as thirty grains of the powder, and four grains in solution. Taylor relates a case where two or three grains in powder proved i'atal. Tests. — Ammonia nitrate of silver, added to a solution of arsenious acid, throws down a yellow pfccii)itate, which is the arsenite of silver. Ammonia sulphate of copper gives a green precipitate of arsenite of copper. Marsh's test is the most reliable. It consists in adding sulphuric acici and zinc to the arsenical solution, and form- ing arsenuretted hydrogen. The gas, as it passes out through the tube, is set on fire. The presence of arsenic is known by the garlicky odor, and by the blue color of the dame. In addition, if a porcelain slate is held near the flame, a black ring of metallic arsenic is deposited, and on the outside of this ring a whitish film of arsenious acid appears. To determine whether the deposit is arL.nic or antimony, the plate is subjected to a high temperature, and, if arsenic is present, the substance is immediately vola- tilized ; if antimony, it will remain. METALLIC POISONS. 241 Iding Ibrui- out hie is If the ir tlie »d on acid lie or and, Ivola- Ricnscli's test eonsists in boiling slips of eopper in an aeidulatcd solution of the suspected liquid. The mixture is heated to tlic boiling-point, and a slip of copper dipped in it for five or ten minutes. If arsenic is present, it will bo deposited on the copper, and will appear of a dark-jn^r^/ color. If tlio material thus obtained is heated in a tube, the metallic arsenic is changed into arsonious acid, which is recognized by its peculiar bright octahedral crystals. Schecle's green and other preparatioii<^ of arsenic arc distinguished by the same reagents. In all cases the arsenic may be reduced to arsenious acid by heat, while the latter can be recognized by its crystals. Small and repeated doses of arsenic .aay produce slow poisoning. The constitutional eifects of the drug adminis- tered in this manner are recognized by a pale, waxy look on the face, oidema of the eyelids and sometimes of the extremities, loss of appetite, pain in the stomach, nausea, or vomiting, eruptions on the cutaneous surfiice, feeble pulse, and great weakness. In some cases the urine is loaded with albumen. If the drug be continued, death soon ensues. When large doses of arsenic are taken, there is pain in the epigastric region, which rapidly increases, and is aggravated by pressure. There are nausea and vomiting. At first, the vomited matter consists of the contents of the stomach, with particles of arsenic intermixed. Subse- quently, they contain blood and thick mucus. Purging usually follows the vomiting, in about half an hour after the prominent symptoms are developed. There are sometimes soreness and constriction about the throat. The respiration becomes entirely thoracic, and the movements are short and 16 m :"ii msBsmm 242 EMERGENCIES, AND HOW TO TREAT THEM. f M rapid. The pulse is quick, small, and intermittent. Death may be preceded by coma and convulsions. In poisoning from corrosive sublimate, the symptoms are developed more rapidly than in arsenical poisoning. In the former there is greater pain in the throat, and in the course of the cesophagus, and the tongue, fauces, and throat, present a white appearance. These signs suffice to distinguish the two forms. After death from arsenic, the mucous membrane of the stomach is congested, thickened, and softened. There is more or less redness over the whole organ, but marked in the most dependent portions. Collections of mucus, mixed with blood and arsenic, are found in isolated patches in different parts of the stomach. Arsenic docs not act as a corrosive poison ; it never produces ulceration of the mucous membrane. Treatment. — The antidote for arsenious acid is the liydrated sesquioxide of iron. It ia prepared by adding aqua ammonia, soda, or potash, to a solution of the persulphate of iron. When the alkali is added, a reddish-brown powder forms, which is administered ad libitum both to adults and children. The iron combines with the arsenic, and the insoluble subarseniate of the protoxide of iron is thrown down ( U. S. Disp.). Preceding the administration of the antidote, the stomach should be thoroughly emptied with the stomach-pump, or by emetics of sulphate of zinc, mustard, or ipecac, assisted by copious draughts of warm water. Preparations of magnesia are recommended as antidotes. Lime-water, mixed with oil, and mucilaginous drinks, may bo given also. METALLIC rOISOXS. 243 The antidote for the salts of arsenic is the subacctate of the protoxide of iron {Dufloa). Fcwtrell recommends the administration of a mixture of chalk and castor-oil, made into a thick paste. When the stomach is cleansed and the antidotes given, the treatment should be directed to allay pain, and relieve the gastric inflammation, by hypodermic injections of mor- phia, internal administration of ice, and blisters to the epigastrium. farm )tes. Inay CORROSIVE suBLniATE {Bichlorxde of Mercury). Mercury in the metallic state is inert. "When taken internally it passes through the bowels with scarcely any change. An extremely small quantity may be oxidized, but not suflicient to affect the system. Many of the combina- tions of mercury act as corrosive and irritant poisons. The most deadly is corrosive sublimate. This substance, according to American authorities, consists of two atoms of chlorine united to one of mercury. The British Phar- macopoeia, however, makes it a protochloride, consisting of equal parts of chlorine and mercury. The bichloride is made by subliming sulphuric acid and mercury together, and then adding chloride of sodium. It occurs in small white or transparent crystals, and is exceedingly soluble. Tests. — Iodide of potassium gives a scarlet-colored pre- cipitate of the biniodide of mercury. Ammonia throws down a white precipitate of ammoniated mercury. Lime- water gives a yellow precipitate of the hydrated deutoxidc of mercury. A black precipitate is formed by sulphuretted hydrogen. If a piece of zinc and gold wire be dipped in the suspected solution, which has been slightly acidulat- ii i! f !-i-^*^ w ^ "Jg * •i ^i M |i 1 i ^ 244 EMERGENCIES, AND HOW TO TREAT THEM. ed, a grayish deposit of mercury will take place on the metal. In small doses, continued, it produces ptyalism and other characteristic effects of mercurial preparations. The patient's gums become red, tender, swollen and ulcerated ; saliva is poured out in excessive quantities. There is a strong metallic taste in the mouth, and the breath has a fetid odor. A blue line, in some cases, may be noticed around the edge of the gums. The teeth loosen, and the throat becomes sore and inflamed. The blood loses its plasticity, and the red globules are diminished. If allowed to proceed without treatment, these symptoms are intensi- iied ; necrosis of bone and ulceration of the integument are added, and the patient dies from exhaustion. Corrosive sublimate has been known to destroy life in doses of three grains {Taylo)'). Usually it takes from ten grains to a drachm. In a few cases much larger doses have been recovered from. The symptoms produced by poisonous doses are those common to many corrosive poisons. A burning pain is felt along the oesophagus and in the stomach, a few mo- ments after the drug is swallowed. This is followed by vomiting and purging of slimy mucus, marked with blood. Portions of mucous membrane have been thrown up with the evacuations. The mouth and throat have a white appearance, and a strong metallic taste is experienced. There are thirst, difficulty in swallowing, a feeling of oppres- sion on the chest, and difficulty in breathing. The pain in the stomach increases in intensity, the pulse becomes small and thready, extremities cold ; great prostration comes on, which is soon follo^ved by death METALLIC POISONS. 245 The mucous mcmbrano lining tlie oesopliagus and stom- ach present after death a slate-gray appearance. The mem- brane is softened, and may be ulcerated. Extravasations of blood are found beneath it, and occasionally on the surface. If a piece of the membrane is taken up with a forceps, it is easily separated. There are also redness and tumefaction, particularly marked in the great cid-do-sac of the stomach. Treatment. — "'.T'hen profuse salivation arises from medicinal doses of corrosive sublimate, or other prepara- tions of mercury, iodide of potassium is given as an anti- dote in conjunction with chlorate of potash. A solution of the latter makes an efficient wash for the ulcerated mouth. Carbonic acid, in the proportion of one drachm to four ounces of water, is an excellent application for the same part. "When poisonous doses of the bichloride have been taken, the stomach should be emptied rapidly and completely with emetics or the stomach-pump. The common antidote, albumen, may then be administered, in the form of white of egg, or the glxitcn of bread. The ^^■^ should be beaten up with a large quantity of water before it is given. Milk may also be administered in large quantities. TIic casein it contains, as well as the albumen of the Qg^, forms an in- soluble compound with the mercury. Small rolls of zinc and gold foil have been recommended as antidotes. The subsequent inflammation should be treated in the same manner as that arising from arsenical poisoning {see Arsenic). Calomel is the true protochloride of mercury. It acts sometimes as an irritant poison, but there are few cases of destruction of life from its use. It is recognized by its ■m 246 EMERGEiVCIES, AND UOW TO TREAT THEM. I''t III extreme insolubility. The bile is the only lluid in the body which exerts a solvent action upon it, and that only in very small proportions. Potash and ammonia give a black pre- cipitate ; lime-water gives also a black precipitate. COl'l'ER. The preparations of copper in common use are the sul- phate {blue vltrioV) and subacetate {vcrdajris). The sul- phate of copper is employed medicinally, internally, as an emetic, and externally as an escharotic. Verdigris pos- sesses similar properties, but is little used. Chronic poisoning from copi^cr may be induced by working in alloys of that metal, inhaling copper-dust, or eating from utensils lined with that metal. All the soluble preparations of copper are corrosive poisons, and the effects on the system similarly manifested. The quantity of sulphate of copper which will destroy life is subject to great variation. Leing a powerful emetic, the poison is rapidly thrown from the stomach, and the danger lessened. Nearly an ounce of the poison has been taken and recovered from, while in another instance one drachm has been known to destroy life. Tests. — Ammonia, potash, and soda, give a bluish-white precipitate. Ferroc3-anide of potassium gives a claret-red precipitate {Taylor). "When the system becomes slowly impregnated with copper, there are a rapid loss of flesh and strength, nausea, tendency to diarrhoea, griping abdominal pains, tympanitis, muscular tremors, retraction of the gums, with a purple line around the edge {Corrigan), a dry cough, paralysis, dysen- teric discharges from the bowels, and great prostration. METALLIC POISONS. 247 In acute poisoning tliero arc intense griping pains in the abdomen, profuse grcenisli-colored discharges from the stomach and bowels, metallic taste in the mouth, anxioun facies, vertigo, headache, dimness of vision, muscular trem- ors, a i-apid, small pulse, paralysis, and sometimes con- vulsions. After death, the mucous membrane of the cncsoi^hagus, stomach, and intestines, is reddened and softened. Ulcera- tion and erosion in patches arc found in different parts of the canal. Treatment. — Ferrocyanide of potassium is recommended as an antidote by Schraider. Milk and honey, or white of egg, and milk in copious draughts, are often serviceable. Albumen in any form, or sugar, is considered, by many, an efficient antidote. The resulting gastro-enteritis is treated as in the pre- ceding case? LEAD. Every soluble salt of lead possesses poisonous properties. The carbonate and oxide arc more frequently the active agents in chronic poisoning than any other preparations. Tlic acetate (sugar of lead), and the solution of the sub- acetatc (Goulard's extract), occasionally exert a deleterious effect on the system, when given in ordinary medicinal doses. The carbonate of lead (white lead) is more severe in its action than the other salts. Usually a very large quantity of lead is necessary to destroy life. Chronic poisoning is of frequent occurrence, from using hair-dyes, drinking beer or water which flows through lead pipes, constant handling of the thin foil covering chewing- tobacco, manufacturing or mixing white lead. It is some- 248 EMERGEXCIES, AND HOW TO TREAT TIIEM. Bi^ times produced by wearing Brussels lace, the material of whicli owes its white color to carbonate of lead. Testa. — Sulphuric acid throws down a white precipitate. Iodide of potassium gives a yellow, and sulphuretted hy- drogen a black precipitate. The symptoms of poisoning by lead appear gradually. There arc, at first, colicky pains in the abdomen, and con- stipation. The attack of colic {colica pidomim) may bo very severe, or so slight as scarcely to demand attention. It is paroxysmal in character. Tlio bowels arc constii)ated. A blue line appears aroimd the edge of the gums. There are " thumb-drop " and wrist-drop," from paralysis of the extensor muscles. The right rectus abdominalis is said to be the first muscle affected by the paralysis. The retrac- tion of the abdomen witnessed in these cases is due to paralysis of those muscles. Paraplegia and hemiplegia exist in rare cases. Loss of flesh and strength, and muscular tremors, are also present. When very large doses of lead are taken, there are tliirst, dryness of the fauces, burning sensation in the throat, con- stijpation, and intense colicky pains in the abdomen. If the bowels are moved, the faeces will be found to possess a dark color due to the change of the lead into the sulphuret in the intestinal canal (the same color is also observed after the administration of iron ; the iron is changed into the sul- phuret). Vomiting is sometimes present ; there are difiicult respiration and oppression over the prcecordia. Paralysis and coma precede death. On postrinortem examination there is usually found abrasion of the mucous membrane of the stomach and intestines, with redness and congestion in isolated patches ; METALLIC POISONS. 240 also, a grayish-whito color in certain portions, from tlio mixing of the mucus with the lead. Treatment. — In chronic poisoning, iodide of potassium is considered the best eliminative. It joins with the lead in the system to form a soluble iodide of lead, which is car- ried out through the different emunctorics. Sulphuric acid is sometimes administered for the same purpose. Tlie patient should entirely change his habits, take active exercise in the open air, cat nourishing food, and keep regular hours. Quinine is a useful tonic in these cases. Tlie paralyzed limbs may be treated by frequent bathing in cold water and by friction. In acute poisoning from lead, the stomach should first be emptied by emetics, or with the stomach-pump. Strong solutions of Epsom salts (sulphate of magnesia), or Glau- ber's salts (sulphate of soda), may then be given in large quantities, as antidotes. If the bowels do not move, castor- oil should bo given imtil free evacuations are j)roduced. Animal charcoal is given by some. Albumen and milk may be used after or before the administration of the salts of magnesia or soda. These are not unfrequently employed alone. Taylor advises a mixture of vinegar and sulphate of magnesia as ar ntidote for poisoning by the carbonate of lead. Imd md les; TAETAKIZED ANTDIONT. This substance is prepared by adding an ounce of the oxide of antimony, and one ounce of bitartrate of potash to eighteen ounces of water, and then boiling for one hour. Tartarized antimony is used in medicine as an emetic, sedative, alterative, diaphoretic, and expectorant. In large 250 EMERGEXCIES, AND HOW TO TREAT TIIEM. ■J'l I: closes is an irritant poison. Tlio ordinary doso for an adult, as an einotic, is from one to two grains ; with young persons very small doses will often produce dangerous cftects. Three-quarters of a grain has been known to destroy life in a eliild {Wilton). Ton grains is the smallest recorded fatal doso in an adult. Although antimony is capable of producing rapid, violent constitutional disturb- ances, yet remedial efforts are generally followed by re- covery. It is not apt to prove fatal, with proper care. Tcsin. — Nitric acid throws down a white precipitate, which is soluble in tartaric acid. Sulphuretted hydrogen gives a characteristic red color to a solution of antimony, and, if muriatic acid is added to the precipitate, it is dis- solved. If the solution is then added to water, a white pre- cipitate appears. Cln'onic poisoning by tartarizcd antimony is distin- guished by gradual exhaustion, nausea, and vomiting, pain in the epigastrium, a small, feeble pulse, pallid surface, and cold, clammy cxtren.ities, sunken eyes, anxious expression of countenance, and metallic taste in the mouth. In largo quantities the drug produces in a few moments profuse bilious vomiting, and the matter vomited is soon mixed with blood. Portions of mucous membrane, of a grayish-whito or dark-brown color, may come away in small pieces {Taylor). Diarrhoea is present if much of the poison has been swallowed. Signs of collapse arc apparent : the skin becomes cold and bathed in a clammy perspiration, the pulse is feeble and rapid, and respiration sighing. A pustular eruption has been observed on the skin in some cases. Before death, the patient sinks into a deep coma. A. ^ost-mortem examination shows signs of inflammation METALLIC POISONS. 251 re- lents [soon lof a in the lent : tion, A lome tion in the throat, stoninch, and intestines. Patches of mucous nienihrano, Boftened and easily detaclied and broken down, are found in the throat and stomach, and occasionally in the small intestines. Peritonitis is found in a small proportion of cases. The lunjjjs arc eonjijestcd. Treatment. — Lar^o quantities of warm water should bo given, to promote the complete evacuation of the stomach. Strong infusions of green tea may be taken at the same time or subsequently ; various vegetable astringents, as tannic acid, etc., arc also tised as antidotes. Attempts should be made to counto'act the collapse by hot bottles and blankets applied to the surface, and by friction of the ex- tremities. ZINC. . Sulphate of zinc, or white vitriol' and chloride of zinc, are energetic poisons ; the former is an irritant, the latter a corrosive poison. Tlie sulphate is employed in medicine as an astringent, nervine, and emetic. Its dose, as an emetic, is from ten to twenty grains. The chloride of zinc in solu- tion is a valuable disinioctant. The tests for zinc are ammonia, ferrocyanido of potas- sium, and sulphuretted 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 stomach, after death, is dark-colored ; the mucous membrane thickened, congested, and perhaps ulcerated. 252 r.MEUr.ENTIES, AND HOW TO TREAT TIIEM. iih ' T/'catincnt. — White of ojjf^, bcntcii uj) with milk niul water, followed by infusioriH of nHtriii},'ciit medicines, is tlio chief remedy fo: Moisoniiig from the sulphuto. In poisoning from the chloride, emeticrt plu»uld firtit bo given ; the albumen in milk can be administci 1 when the Btomach has been emptied. NITKATK OF 8ILVEK. This substance is a corrosive poison. It has powerful cscharotic properties, duo to its affinity for the albumen of tho tissues. In poisonous doses, it produces intense pain, vomiting, and p'lrging. Mucus, blood, and shreds of mucous mem- brane, arc found in tho excavations. If these are allowed to stand, they become dark from exposure to air. Common salt (chloride of sodium) throws down a white precipitate with solutions of nitrate of silver, and it is also given as an antidote. Mucilaginous drinks should bo ad- ministered ad libitum. rnosrnoRus. Phosphorus is largely employed in the manufacture of lucifcr 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 aro peculiar in not developinjr 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 roISONS. 253 Chronic poirtoniiij; usuiilly manlfctttrt itself lirst l>y ordi- nary (lyrti)oi>tic Hyni[)tonirt ; Bucli ii.s loss of nupctito, focl- inj5 of wei;;lit nml lioiit in tlio opij^astriuni, iind by prorttni- tion. Thcro nroalso niiurtca, paralysis of the heart. Christosin states that the mucous membrane after death has a scalded appearance, that dark-colored spots are found scattered through the whole canal, and that the membrane is entirely destroyed in some parts, leaving the muscular coat bare. Treatment — Emetics should be given and followed im- mediately by the antidotes. Lime or magnesia should be ad- ministered in large quantities in water. The lime is usually employed in the form of the carbonate (common chalk). If this cannot be had, the ceiling of the room may be scraped with a shovel or other available instrument, and the substance thus obtained given in the manner prescribed. Lime and magnesia form insoluble salts by combining in the stomach with the oxalic acid. ra- an SULPHURIC ACID. There arc three varieties of this acid, viz., the anhy- drous, SO^; commercial, SO3+II0; and the fuming oil of Nordhausin, SOsIIo+SOs. The commercial sulphuric acid, which is the variety genevally employed for medicinal purposes, is made by burning sulphur and nitrate of potash together in a leaden chamber containing water. It is a powerful corrosive poison, destroying organic tissues when brought in contact with them. It has a powerful affinity for water, and its 250 EMERGENCIES, AND HOW TO TREAT THEM. ■ m \ 11 ' »?.ii caustic effect is due to the abstraction of that substance from the tissues. It makes a red stain on black cloth. Tests. — Chloride of barium throws down a white pre- cipitate. In poisoning from sulphuric acid, the pain is most in- tense in the mouth, tliroat, oosophagus, and stomach. There are great pain on pressure, vomiting of black putrid matter, dyspnoja, small, feeble pulse, anxious expression of counte- nance, cold extremities, restlessness, and sometimes con- vulsions. Treatment. — The poison may be neutralized by mag- nesia, or carbonate of soda, administered in solution, thick Boap-suds, and mucilaginous drinks. Unless these remedies can be given directly after the poison has been swallowed, there is little chance of saving the life of the patient. NITKIC ACID. Nitric acid is made by the action of sulphuric acid on nitrate of potash. It is a powerful corrosive poison. In medicine it is employed as a tonic, astringent, and anti- spasmodic. The vapor of nitric acid is reputed a good dis- infectant. Ir.haling the vapor in a concentrated form has produced death. One to two drachms of the liquid have been known to destroy life. Tests. — A solution of morphia added to nitric acid gives a red color, which afterward changes to a yellow. If the acid is boiled in water containing copper filings, red fumes of nitrous acid are given off. When applied to clothing it gives a yellow stain. The symptoms of poisoning are violent pain, extending CORROSIVE ACIDS. 267 from the month to the epigastrium, vomiting of yellowish and greenish-black material, and the emission of fetid ga?, tympanitis, urgent dyspnoea, small, rapid pulse, and collapse. Constipation is usually present. The enamel of the teeth will he found partially destroyed ; the tongue, throat, and fauces, of a yellowish-hrown color, and very much swollen. If poisoning have resulted from inhalations of the va- por, there will he great pain, diiliculty in respiration, and the patient may die asphyxiated from effusion under and into the mucous membrane of the larynx. After death, the mucous membrane of all parts of the alimentary canal which came in contact with the poison is deeply corroded ; in some parts there are yellowish-brown stains, in other parts extensive redness. The mucous membrane is readily broken down ; in many eases there is congestion of the lungs and larynx. Treatment. — Magnesia, olive-oil, and mucilaginous drinks, should be given in large quantities. ves the nes it ing MURIATIC ACID. This acid is made by the action of sulphuric acid on chloride of sodium. It is sometimes called spirit of salt. Cases of poisoning by it are rare. Tests. — If the acid is boiled with black oxide of manga- nese, chlorine is evolved, which is recognized by its odor and its bleaching properties. If a rod is dipped in the acid and held near ammonia, a white vapor of the hydro- chlorate of ammonia is formed. Nitrate of silver throws down a white precipitate of chloride of silver. The symptoms following large doses resemble those 17 258 rMERGENCIES, AND HOW TO TREAT TEEM. produced by the otlicr corrosive acids. They are, however, developed more slowly ; life is not so soon destroyed, and white vapors may be emitted from the mouth. CAEBOLIO ACID, Sometimes called oxide of phenyl, or phenylic acid, is much em])loyed at the present day as a disinfectant. It is obtained by tli) distillation of coal-tar. Yery few cases of poisoning by it have yet occurred. A concentrated solution taken internally excites violent fjastro-enteritis, and destrovs life in a few hours. After death, the mucous membrane of the throat and stomach is intensely congested, and in small sections soft- ened and corroded. The treatment consists in evacuating the stomach, and giving large quantities of magnesia, mucilaginous drinks, etc. CHAPTER XXIV. CORROSIVE ALKALIES. SALTS OF POTASH. Carbonate of potasli (pearlasli) acts as a corrosive poi- son when adtniiiistcred in a concentrated form. It gives a yellowisli-wliite precipitate with nitrate of silver. The symptoms following its administration are intense pain in the throat and stomach, pain on pressure over the abdomen, vomiting of dark materials, which consist of mucus, hlood, and shreds of the lining membrane. Diarrhoea occurs in all cases. On examination, the mouth and throat are found of a dark-red color, and very much swollen. This condition seriously interferes with deglutition. The pulse is small, rapid, and weak, and the countenance anxious. After death the mucous membrane of the throat and stomach is of a dark-brown color, softened, and in some portions destroyed. Treatment. — Taylor advises the use of citric or acetic acid, lemon or orange juice. Oil in large quantities, and mucilaginous drinks, are efficient remedies. Ilydrated oxide of potasshtm, or caustic potash, is dis- tinguished from the carbonate by giving a brown precipi- tate with nitrate of silver. The symptoms produced by poisoning with this drug are 260 EMERGENCIES, AND UOW TO TREAT THEM. 1'/ similar to those which occur after adniinistratiou of the car- bonate, and a like treatment is necessary. Einoxalate of potash, sometimes called essential salt of lemon, is an active poison, resembling oxalic acid in its effects on the system. It is sonaetimes mistaken for cream of tartar. The latter, however, is not precipitated from its solution by the sulphate of lime, while the former is. Ink- stains are removed by the binoxalatc, which furnishes an- other distinguishing point. The symptoms of poisoning are violent vomiting and purging, pain in the stomach, difficult deglutition, and sigh- ing respiration, small, rapid pulse, cold extremities, great prostration, and muscular spasms. Treatment consists in the administration of lime, mag- nesia, and mucilaginous drinks. m Fiji.- i :■;. I V. NFTRATE OF POTASU, Usually known as saltjyetre, is employed medicinally as an antiseptic, diuretic, refrigerant, diaphoretic, and sedative. In doses of from three drachms to an ounce it acts as a corrosive poison. In these doses it causes vomiting and purging of blood and mucus, violent pain in the abdomen ; there are feeljle pulse, rapid prostration, insensibility, and death. Treatment. — The stomach should be emptied by emet- ics, and mucilaginous drinks should be freely adminis- tered ; opium should be given to relieve pain. There is no antidote for the poison. The salts of soda correspond with the salts of potash in their peculiar poison- ous action, and in the treatment. CORROSIVE ALKALIES. 261 AMMONIA. Strong solutions of ammonia, carbonate and muriate of ammonia, act as corrosive poisons. The vapor of ammonia, when inhaled in large quantities, excites inflammation of the mouth, fauces, and air-passages, and may produce asphyxia. Solutions of the carbonate {sal-volatile), or of gaseous ammonia, produce violent inflammation in the oesophagus and stomach, and corrode the mucous mem- brane. The carbonate is said to be more violent in its ac- tion than the other preparations. These substances are recognized by their peculiar pene- trating odor. The symptoms of poisoning are nausea, and vomiting of mucus, mixed with blood and shreds of mucous membrane, pain in the throat and epigastrium. Perforations of the stomach sometimes take place, and are followed by perito- nitis. There is great difiiculty in swallowing and breath- ing. The mouth is tender and swollen, the face is anxious, the pulse rapid and feeble, and the extremities cold. After death the blood is found more fluid than in other cases of poisoning ; there are extravasations of blood in the stomach and intestines, and congestion, softening, and ero- sion of the mucous membrane. Treatment. — Vinegar, acetic acid, diluted milk, and mucilaginous drinks, are usually given ; opium is necessary to relieve pain. INDEX. .f m m 1:1,1 i'S m lit ^ 1 II J] Abdomen, ■wounds of, 50. Acotnto ot loud, poisniiint? by, 217. Aconite, poisoning; by, \ilS. Accidcntiil lucniorrhugo, 42. Acupressure, IS. Air m vcin.s, 71. Air, impure, oll'ects of, 142. Alhuininurin, 124, 184. Alcohol, poisoninp by, 127, 101, 225. Ammonia, poisoninj,' by, 201. Antimony, poisonin^f by, 240. Arsenic, poisoning by, '230. Arteries, ligation of, 05. Arterial liromorrlmgo, diagnosis of, 12. Articulations, wounds of, 02. Asthmftj dyspnoea in, 1G5. Asphyxia, from compression of throat, 145. ofcliest, 148. inhalation of gases, 140. olistructions in nir-passages, 65. drowning, 152. injuries to cord, 157. Atropio, poisoning by, 215. Base of the skull, fracture of, 121. Iklladonna, poisoning by, 215. Bladder, hosmorrhage from, 34. wounds of, CO. Bleeding from the mouth, 23. nose, 21. stomach, 23. bronchi, 20. lungSj 20. intestines, 20. kidneys, 35. uterus, 41. urethra, 85. Blood-vessels, wounds ofj 65. Blood-changes, non-aeration of, 143. extravasation of, into iuterccUidar tissucj 88. into bruin-tissuo, 119. Brain, compression of, 118. concussion of, 130. contusioi. of, 130. intlammation of, 121. Brachial artery, ligation of, 6S. pressure on, i.">, 10. Briglit's disease, convulsions in, 154. coma in, 124. Bronchial tubes, foreign bodies in, 85. Burns, 101. Calomel, poisoning by, 245. Calabar-bean, poisoning hy, 231. Camphor, poisoning by, 244. Capillaries, hremorrliago from, 12. Carbonic acid, poisoning by, 15i). Carbonic oxide, iioisoning by, 151. Carbolic acid, poisoning by ,'258. Carbonate of lead, poisoniiijf by, 247. Carbonate of potosh, poisoning by, 25'.t. Carburetted hydrogen, poisoning by, 151. Carron-oil (see Burns). Carotid arteries, ligation of, CO. pressure on, 15. Cautery in htemorrhage, 10. Centipedes, bites of, 84. Charcoal-vaporj poisoning by, 151. Chloroform, poisoning by, 225. Chloral, poisoning by, 227. Cicatrization of burns (see Burns). Coal-gas, poisoning by, 151. Coceulus indicus, poisoning by, 223. Colchicum, poisoning by, 237. Colic, 210. Cold, effects of, in hnomorrhnge, IG. on the system, 100. Compression of brain {see Brain). Coma from compression, 118. u'oomia, 124. aicohol, 127. embolism, 123. hysteria, 128. INDEX. 263 Coma from cpilopsiy, 130. Congestion of tho lungs (dyspna'a in), 108. Conlum mnculiituin, poisoning by, 210. Convulsions tVoin apoplexy, lUO. urtcinia, 184. epilepsy, 187. liysteriii, I'Ji. runij 1!»1. Concussion of brnin, 130. Corrosive subliiiiuto, poisoning by, 243. Croup, dyspnu'ii in, IfiV. Croton-oil, poisnning by, 230. Coup-Jo-soleii, 158. Donth, signs of, 117. Degoneriition of vessoLs in brain, 110. Dentition, convulsions during period of, 178. Diniilir'ngm, action of, 140. Digitalis, poisoning bv, 221. Dislocation of cervical vertebra, 209. Dissection-wounds, 74. Dog-bites (nee llydrophobio). Drowning, 152. Duodenum, ulceration of, in burns, 105. Dyspnoea in astbnia, IGO. croup, 1(17. cardiac disease, 1G9. pulmonary codema, 170. cedema glottis, 172. Ear, foreign bodies in, 90 Eelampsia, 170. Emboliain, coma from, 123. Eutcrocele (see Hernia). Epistaxis, 21. Epilepsy (see Convulsions). Epiglottis, wounds of, 47. Etber, poisoning by, 2'.'0. Eye, foreign bodies in, 93. Falling sickness (see Epilepsy). Fmccs, involuntary passage of, in com- pression, 120. Femoral artery, lii;ation of, 09. pressure on, 10. hernia, operation for, 110. Fits (see Convulsions). Fibrinous coagula after ligation, 05. Food, indigestible, ell'ects of, 177. Foreign bodies in eye, 98. nose, 95. larynx, 85. bronchial tubes, 85. lungs, 83. pharynx, 91. oesophagus, 92. urctlira, 99. rectum, 100. Fracture of skull (sec Compression). (iastritia, from poisons (see I'oisons). Genitals, wounds of, 00. bleeding from, 99. (ilottis, oedema of, 172. Ulo))Us hystericus, cause of, 128. Gunshot-wounds, 03, Ihvmatemosis, 23. llaMnatliorax, 55. lliuinoptvsis, 29. Iliuinorrliage, general, 9. internal (si-e BletdiiiK). Ilwmorrliagic diathesis, 13. llieiuorrlioids, bleeding from, 27. llaut-mal (see Epilepsy). Heart, wounds of, 60. Hematuria, 85. Hemlock, poisoning by, 210. Hemiplegia, 120. Henbane, poisoning by, 217. Hernia, strangulated, 112. Hospital cases, 5, 9, 10, 11, 02, 79, 86, 102, 128, 213. Hysteria, 128, 192. Hydrophobia in animals, 78. in iium, 78. Hydrochlorio acid, poisoning by, 257. Hydrocyanic acid, jjoisoning by, 227. Ice in hmmorrhago, 10. Heus (see Hernia). Infantile convulsions, 177. InL'uinal hernia, 115. Inhalation of oxygen (see Aspliyxia). Innominata artery, ligation of, 00. Insolation (see Sunstroke). Insect bites, 83. Intercostal vessels, bleeding from, 54. pressure on, 54. Internal mammary artery, ligation of, 54. Joints, wounds of, 02. Jugular veins, relations of, 07. Kidneys, disease of, as causes of coma and convulsions (see Coma), htemorrliago from, 35. Laceration of perinojum, CO. Larynx, wounds of, 47. foreign bodies m, 85. Laryngotomy, 89. Laryngismus stridulus, 109. Lead, poisoning by, 247. Ligation of arteries, 05. innominata, OB. subclavian, 67 carotid, 00. axillary, 08. brncliial, 08, radial, 03. ulnar, 09. 264 INDEX. F!>r Litlgntlon of iirti'iiin, fuinoral, Z'> I'onlitfiil, 70. tibluls, 7u. Light, ciirburctted liydrn^rcn. poUoninj< liy, IT)!, Livor, rupture of, flO, Luiiff, wouihIh of, fio. Lohelin, poisoning l)y, 222. Mad nniinnla (wo irydrophobia). Mnld'nii, '-'7. Miirsliiill Hull's iiiL'thod of nrtlflcinl roHpinUion, IM. MntcliuB, poisoning by {gee Plio»plio- rug). Alunorrlingin, 41. Mi'trorrhajriii, 41. Mercury, 243. Morpliia, poisoninjf by (ni'e Opium). Mouth, luuiuorrlingo tVoin (me Blocd- infr). Mushrooms, poisoning by, 223. Narcotics, poisoninfr by, 211. Narcs, plugging of, 23. Neck, wounds of, 48. Nitrogen, effects of inhalation, 140. Nitrate of silver, poisoning by, 2J2, potash, ])oisoning by, \li',i). Nitric acid, pois(Uiing by, 250. Nose, bleednig from, 21. foreign bodies in, U5. Nux-vouiica, poisoning by, 232. Obstruction in air-passages [sec Foreign Bodies). (Edema glottis, 172. ffisophiigotoniy, 1)5. CEsophagus, foreign bodies in, 02. Opium, poisoning by, 211. Oxalic acid, poisoning by, 254. Pain, effects of, in burns {gee Burns). Palmar arch, womids of, CO. Paralysis in compression [etc Couiprcs- sion). Paracentesis thornci-i, 55. Pericardium, wrunds of, 58. Pericarditis (see Wounds). Penetrating wounds of chest, 51. abdomen, 57. Penis, htcmorrhago from, 33. Peritoiiteum, wounds of, f)7. Pharynx, fo-eign bodies in, 02. Phosphorus, poisoning by, 2r)2. Pia mater, sjmsms of vessels of. 180. Piles, bleeding from, 27. Placenta proevia, 42. Pneuraocele, 63. Pneumothorax, 53. Poisonous w^ounds, 74. Poisons, vegetable, 211. metallic, 239. Poisons, corrdcivo, 254, Irritiitinir, 2.J."i. ropbliid Hpai'i', jirciisure in, 15. rost-iiartiiiii bu'miiri'hiigt', 43. Poliisii, nn'l)(iiiato of, poisoning by, 2B9. nilnitu of, 2(10. binoxaluti^ of, 20O. oxi.lu of, ilM. I'retnntuio labor, induction of, IRd. Pressure in gcMLrul hu'riinirbiige, 14, Prussuro on carotid artiry, 1,"). Bubclaviaii, 15. axillary, 15. l>rachlal, 10. ulna, I'l. on abdoniiiud aorta, 1(1. femoral artery, 1(1. popliteal, 15. Presentations, abnormal, 203. Kabies (wa Hydrophobia), Kadial artery, ligation of, 08. K'attlesnake-bites, hi. Keaction in concussion (tea Concus- sion). Keady method of artificial resiilration, Rospiriitionj suspension of (gee Ab- pliyxia\ 15il. Retention of urine, 207. Rui>turo of liver, (10. bladder, 00. cerebral vessels, 119. Salivation from mercury {sfe Mer- cury). Savin, oil of, noisonlnif by, 230. Secondary asidiyxia, 154. * Serju'iits, l)ite8 of, 81. Shock (nfc Syncope). in burning (nic Hums). Soda, poisoning bv, 20o. Spasms, tonic ami clonic (sec Convul- sions). Spontaneous combustion, 103. Stramonium, ]uiisoiiiiig by, 221. Stomach, bleeding from (nee Bleeding). Stertor, causo vt' (gee Coma'*. Sudden death (gee Syncope). Suli)Iiato of zinc, poisoning by, 251. of copper, ]>oisoning by. 240. Sulphuretted hydrogen, poisoning liy, 140. Sunstroke, 158. Sulphuric acid, poisoning by, 255. Sylvester's metliod of urtificiul respira- tion, 150. Syncope, 133. Tapping of chest, 55. of bladder through rectum, 20S. Tampon, application of, 205. Tarantula, Ditos of, 84. INDEX. 205 TiIXIh (-«.■ IIlTIllft). 'rttunuM, lu3. 'i'lioriix. wouiuU of, fill, 'I'lioriiuio vinoLTii, wouikIm of, Bl, 60, TlirombuH (*<'« Coraii). Til)'ml arturiuH, lif(ationof, 70, Tiiiiriiiquut, 14, Tobacco, I'oIhoiiIii>{ by, '2\{>. Trnohun, torulKii bodies in, 87, Triichootomy, DO, Trniwfimloii, lio, Traiisversu i)n.'8ontatIon8, 2ii4, Ulnar artery, I'ufatioii of, (19, Umbilical cord. HhortnortM if, 20ii, l>rolap8o ot, 201, Upas-troo, jioinoniiiK by, 231, Uroiinia (wtf Coma and (Junvulsions), Urea, poisoulriff by, 125, Urutlira, blocdiii;^ from, 35. Urino, blood in, 85, Uturiw, rupturo of, 102, Vnginn, tamponing of, 205. Vt'iim, wounds of, "1. air in, 71, Vuratria, imlHoniii;; by, 237. VcsscIh, woundn i>l', (1,'>. VunuHi'otion ill apoplexy {ni^ Coiu- iire.'islon I. VolvuIuH, Hi. Wounds of throot, 47. thorax, M, lun^H, 51. jiericardluin, 50. lieart, M. abdomen, 57, intestines, 57, bladder, Oo. nri'tlini, 01, arteries niul veins, C5 gunshot, ("I. iierinieuMi, 00. joints, C.L'. Woorara, puisuningby, 230, Zluo, 251. d- T II E END. c' tl 6( PRESS NOTICES OF NIEMEYER'S PRACTICAL MEDICINE. A TEXT. BOOK OF PRACTICAL MEDICINE, Wirn PARTIOVLAR RinUENCI TO PnTSIOLOOT AND PATEOLOOIGAL ANATOMY. By Dr. FELIX VON NIEMEYER, Proftisor of Pcuhology and Therapeutics ; Direclor of tlie Medical Clinie of the Univernty of Tdbinffen. TniXIUTBO FBOX TnS REVBNTn OEnVAlf EDITION, BT (PBCUL rERU.SSlOX Or TUB iLUTnOU, By GEORGE H. HUMPHREYS, M. D., and CHARLES E, HACKLEY, M. D, In 9 eoI«.| oetavo. IfSOO pp. Priee, in eloth, $0.00 f tn sheep, $10,80. FUBLISIIBD BT ID. A-PFLETOlSr & CO., ff'lO St ffftl Ilroad-way, Now Torlc. From the London Medieal Times and Gazette. "TJinvEnsiTT of Oxford. — The following announcement has been made: ♦ Regius Professor of Medicine, Henry T7. Acland, D. M. Subject : Clinical and General Medicine. Text-book: Niemeyer's Text-looh o/ Practical Medicine. (New York ed.,16'59.)"' F>om the Dublin Qtiarterly Journal of Medicine. "The task of the reviewer is an easy and gracious one in reviewing such a work as this. Il is at once comprehensive and concise ; it Is characterized by clearness and orij^inality, and it differs from many German works on medicino in the sagacious appreciation of the value of therapeutics manifested by the author. " The translation on the whole Is very creditable, an>l the volumes are hand- some and well broug'ut out." ( ;'i J). AVVLETON & CO:S MEDICAL PUJiLICATJOSS. Letterman — Medical Recollections of the Army of the Potomac. By Jonathan Lettkkman, M. D., late Surgeon U. S. Armv, and ]Mo(lical Director of tlic Army of the Potomac. 1 vol., 8vo, pp. 194 Clotli, $2.00 "Snrscon LcttPrmnn hns Bnccccdcil in Riving a very intcrcftlng, not to sny fnscinatin); hook. Uc writes in n perppicuons, oli't'iiiit style, nnd we venture to nsscrt tlmt but few wlio open liis volume ofnieilical annnli'. pregnant ii» tliey nro witli instruction, will cure to Uo otlicrwiso tlinn llnisli them nt n gitttug.''— jl/erficai Ikcont. " The whole book (which mny bo considered a graceful and n''.c'lonnte tribute to the zeal and al)ility of the many •vho ' evinced their devotion to their country and to the cause of luunanity without hope of promotion or expectation of reward') is written in a i)leasiiii; style, and will awakeu many kindly aesoci.".t!o::s in the meinorles of those who slinred with our autiior tlic varving fortunes of the 'dear old Army of the Potomac' "— ^V. 1'. Meilkai Journal, Sept., 18ti«. It.' Davis — Conservative Surgery. Conservative Surgery as exhibited in rcmali/iitij some of the Mechanical Causes that operate injurious!)/ both i?i Jiealth and Disease. By IIenuy G. Davis, M. D. Elegantly printed on tinted paper and handsomely illustrated. 1 vol., 8vo, pp. 314 Cloth, $3.00 Dr. Davis has enjoyed rare facilities for the etiiiiy and trcntmcnt of certain classes ol disease, and in this line has achieved a well-deserved reputation. The now approved methods of treating of liip-joint disease are all based upon Dr. Davie's method and appliances, In this volume lui brings together the result of his experience, and has made a book both interesting and valuable to the Surgeon. '•Dr. Davis, bringing as he does to his specialty a great aptitude for t' > solution ol mechanical problems, takes a high rank as an Ortliopoedic Surgeon, and his very practical contribution to tiie literature of the subject is both valuable and opportune, we deem 't worthy of a place in every piiysician's 1il)rary. The style is unpretending but trencliant, graphic, and, best of all, quite intelligible."— J/«dtfa//i'ctW'