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Full text of "Emergencies and how to treat them [microform] : the etiology, pathology and treatment of the accidents, diseases and cases of poisoning, which demand prompt action : designed for students and practitioners of medicine"

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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. 





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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<l in the solution and rubbed thoroughly into 
the wound These agents act by coagulating the blood as 
it flows from the vessels, and by contracting the muscular 
fibres around and in their walls. The coagula thus formed 
should not be removed until all danger of a recurring hoem- 
orrhage has passed. 

Torsion can be employed with advantage where the ar- 
teries are small. This method consists in seizing the bleed- 
ing vessel with forceps and twisting it around until a piece 
is torn off, or its orifice completely closed. Some advocate 
merely one or two turns of the forceps ; others believe in 
tearing off a portion of the artery. 

Ligation must be resorted to when pressure, styptics, and 
milder measures fail. The ligatures in general use are silk. 
The bleeding vessel is first seized with an artery-forceps, the 
ligature passed around and tied. "When arteries of mediuin 
size are ligated for aneurisms, or in wounds, the middle and 
internal coats are cut through, and the external wall brought 
in contact. A clot forms on each side of the ligature, per- 
manently closing the canal as far as the next collateral 
branch. When deep-seated vessels are wounded, it is al- 
ways necessary to go down in the wound and tie above and 
below the opening in the artery, as the lower is frequently 



18 



rMEIlOENCIES, AND HOW TO TREAT TIIEM. 



the seat of Rccondnry luiMnorrhago from collateral branches. 
Some advocate complete division of the vessel before tying, 
if it be only partially cut across. An artery is tied in the 
wound, because, in ligating at a distance above, the bleeding 
might continue throngh anastomosing brandies below the 
ligature. If the wound is punctured and deep seated, it 
must be enlarged to enable the surgeon to reach the vessel. 
The wound at first should only be increased enough to allow 
the operator's finger to enter and close the bleeding orifice ; 
afterward it can bo enlarged at pleasure, without danger. 
When branches of the external or internal carotids are 
wounded through the mouth, it is necessary to depart from 
the ride of ligation in the wound, and tie them in the neck. 
{See article on ligation of arteries.) 

Acupressure, as a means of suppressing haemorrhage, 
has not been before the profession a suflicient time to test 
its claimed superiority over ligation. The method was first 
brought into notice by the late Dr. Simpson, of Edinburgh, 
who, in adopting it, almost abandoned the ligature. The canal 
of the artery is obliteraved by means of a sharp needle in- 
troduced at one side of the artery, and passed over the vessel 
into the tissues on the opposite side. Another method is by 
passing a common sewing-needle, armed witli fine wire, be- 
hind the artery, allowing the head and point of the needle 
to be exposed, and then bringing the wire over the tissues 
covering the artery and fastening it to the point of the 
needle. In this case the artery is compressed between the 
wire and needle, and not, as in the former, by the needle 
alone. "When acupressure ia employed to stop bleeding 
from medium-sized ai*teries, the needle can be removed in 
three or four hours with perfect safety, as by that time a 



' 



\ 



HiEMORRIIACE. 



19 



firm coaguluin will have formacl winch closes the canal. 
This method, of course, will give the wound a better chance 
to heal, as the ordinary ligature is necessarily a source of 
irritation. 

In large vessels, such as the femoral, the needle must re- 
main in for fifty or sixty hours at least, in order to insure 
success in the operation. 

Cautery. — Years prior to the introduction of ligation, 
and heforo the discovery of chloroform and ether blessed 
suffering humanity, it was customary, after ampntation of a 
limb, to touch the bleeding stump with a red-hot iron, or to 
plunge it in a vessel of boiling tar, to stop hoemon-hage. 
Happily, modern science, in its advances, has driven this 
barbarous practice almost entirely from the profession. Oc- 
casionally, however, even at this day, the actual cautery is 
made nse of. Iltcmorrhago from the neck of the uterus, 
after removal of tumors, and from other organs not accessi- 
ble to ordinary means, can be thoroughly controlled by the 
hot, iron. 

Position. — "When the bleeding is moderate, simple eleva- 
tion of the wounded limb will retard the current coming 
from the heart, and thus assist in stopping the flow. It is 
always to be employed in conjunction with other measures 
previously mentioned. 

After the cessation of the hasmorrhage, the lost vitality 
of the patient must be restored. Bottles filled with hot 
water are to be applied to the extremities, and the body is 
covered with warm blankets. Tablespoonful-doses of brandy 
and a few drops of ammonia should be administered every 
fifteen or twenty minutes, or at such intervals as the case 
may require, until reaction is thoroughly established. Sub- 



20 



KMEROKXCIES, AND HOW TO TRKAT THEM. 






Bcquont irritability of tlio iicrvoiw Bjutoni in to bo treated 
with opiates. 

When the loss of blood is so j^rcat that reaction is ini- 
posrtiblo through the ordinary methods, resort inust l)e liad 
to transfusion. This operation consists in abstracting^ blood 
from a robust man or woman, and injecting it into the veins 
of the exsanguinated Datient. If an apparatus for tlio pur- 
pose is not at hand, or its use but little understood, a com- 
mon hard-rubber syringe, with a cajjacity of five or six 
ounces, will answer. An opening is made in one of the veins 
of the forearm, and into this a canula, adapted to the point 
of the syringe, is inserted. A bandage tied below the in- 
cision prevents further bleeding. The syringe, warmed and 
charged with the fresh blood, is introduced, and the piston 
steadily forced down until the instrument is emptied. From 
ten to twenty ounces may bo injected at one sitti jg, and the 
operation may be repeated if necessary. Care must be takcu 
to force out all air from the syringe before it is used. The 
efficacy of this operation has been fully proved. Patients 
' have been restored to life under circumstances which were 
Buch as to almost preclude the hope of recovery. 



CHAPTER II. 



ir.EilORRirA <; A"— (Continued). 

Blooding from tlio Nose, Moutli, Liin(f», Stomnt-h, IntostinoH, Kidnoys, Urotors, 
Bliiddor, Urctlira.— Kcoli>-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'<itinvnt. — Tho first od'orts of tlio surgfon uro dlrectod 
to control tho hivinorrhugo, iiud to aronrto tho patient from 
tho state of collai)so by stinudantrt. Wht'ii ihU is dt n, 
foreign bodies, such as pieced of chjthing, bnlietri, Hplintorfl 
of wood or bone, aro to bo extracted. Tho presence of a 
bullet may bo mado out in deep wounds by tho uso of Ne- 
laton's probe. Tins instrument consists of a silver shaft and 
n bulbous extremity formed of porcelain. When tho bullet 
is touched a leaden-colored nuirk is produced on tho porcelain. 
Tho wound is afterward syringed with a weak solution of 
carbolic acid, and covered with cloths dipped in an ico water 
solution of tho acid. Ice-bags arc then fouiul serviceable in 
limiting tho amount of inflammation. When suppuration 
commences, warm fomentations may be used to hasten its 
progress, and tho debris prevented from remaining by fre- 
quent syringing. In the suppurative stage, there is great 
diiUger from secondary haimorrhage. Therefore, when tho 
wound is in tho vicinity of large vessels, it should bo care- 
fully ■watched, and a compress or tourniquet should bo 
placed loosely around tho limb, ready to bo used at a 
moment's warning. 

Gunshot-wounds of viscera aro treated in the same man- 
ner that ordinary wounds aro after extraction of foreign 
bodies. 



CHAPTER V. 



WOUNDS OF ARriJlUES AND FEINS. 

Lijjulion of Inrgo Artorlcn.— Air In Vulnii, etc.— Cousus of SuJJon DeatL.— 

Troatuiout. 

AViiKN liirgo vessels are wounded, there is n p^reat nnd 
iiniiicdiiito (liiii<for to life. The blood may be jjoured out 
externally, or become diffused in the tissues near the artery, 
or dissect up the sheath of the vessel. Efforts should in 
every case bo made to tie both ends of the bleeding 
artery in the wound. {/See article o)i Ila-morrhnge.) If 
this cannot be done, the artery is then tied between the 
wound and the heart. Ligature of large vessels is generally 
followed by complete obliteration of their canals. The 
ligature divides the middle and internal coats, and brings 
the external walls together. The blood coagulates at each 
end of the ligature. The coloring matter of the clot is 
absorbed. Lymph is poured out between each coat of the 
artery, between the clot and the lining membrane, and ex- 
ternal to the vessels, blending all these parts together, and 
becoming ultimately a fibrous cord. The ligature, mean- 
while, makes its way out by a process of ulceration, and the 
s])ace formerly occupied by it is filled up by granulation. 
From ten to fourteen days after the operation the ligature 
comes away, and then there is the greatest danger of sec- 
ondary haemorrhage. 
6 



I' 



I ' 



! 



GQ 



EMERGENCIES, AXD HOW TO TREAT THEM. 



As wounds may involve any of the arteries in the body, 
a short description of the operation in different k)cations, 
upon important arteries, will be necessary in this connec- 
tion. 

In wounds of the common carotid or subclavian, it may 
be necessary to place a ligature on the arteria innominata, an 
operation rarely attended with success. 

When the patient is fully anaesthetized and in ])osition, 
an incision about two inches in length is made alont; the 
inner edije of the sterno-mastoid muscle to the articula- 
tion of the clavicle with the sternum, meeting it with a 
second incision commencing about half an inch from the 
posterior border of the same muscle, and carrying it along 
the clavicle. When the integument is turned back, the pla- 
tysma myoides and sterno-mastoid muscles are divided on a 
director, the platysma being first cut. The handle of the 
scalpel is now used to push aside some thick cellular tissue, 
and the sterno-thj-roid and thyro-hyoid muscles are brought 
into view and carefully divided. A plexus of veins, com- 
posed principally of branches of the inferior thyroid, next 
appears, and must be moved upward and kept out of the 
way. A thick layer of deep cervical fascia is next incised ; 
the fingers can now be carried down, using the conunon 
cai'otid as a guide, until the arteria innominata is reached. 
This vessel is situated behind the right sterno-clavicular ar- 
ticulation of the right side. The right vena innominata, in- 
ternal jugular vein, and pneumogastric nerve, are displaced 
to the right, and the left vena innominata pressed downward 
and to the left. An aneurism-needle, armed with a liga- 
ture, is tlien passed around the vessel from below upward. 

The common carotid artery is Hgated either above or 



WOUNDS OF ARTERIES AND VEINS. 



67 



below the omo-liyoid muscle. When the vessel is ligated 
above the omo-hyoid, an incision is made from tlie angle of 
tlie jaw to the cricoid cartilage. This incision is carried 
three inches farther than this point when the artery is tied 
belo that muscle. The inner edge of the sterno-mastoid 
is tlio guide for both incision^'. The integument, supei-fi- 
cial fascia, platysma, and deep fascia, are cut through (the 
three latter on a director) ; the descendens-noni nerve is 
moved aside, and tlie sheath of the vessels lifted with a for- 
ceps and opened. The internal jugular vein swells up in 
the wound as the sheath is cut ; it shoidd be compressed 
above and below the opening, and drawn outward. The 
pnoumogastric nerve is situated here between the artery 
and vein, and on a plane posterior to both, and great care is 
necessary to avoid it in passing the ligature. The needle is 
carried from without inward around the artery. In ligating 
the carotid on the left side in its lower portion, the jugular 
vein will be found to have altered its relation to the artery. 
Instead of lying external to it, it crosses in front of it. 
Another point to be remembered in connection with the op- 
eration below the omo-hyoid is, that the sterno-mastoid ar- 
tery and the middle thyroid vein run along in the course of 
the incision, and must be avoided. The sterno-thyroid and 
sterno-hyoid are drawn toward the median line of the neck. 
Ligation of the connnon carotid arteries is sometimes fol- 
lowed by hemiplegia. 

The siibclavian artery is usually ligated in the third 
portion. In this operation the shoulder is depressed as 
much as possible, the integument drawn down on the clavi- 
cle, and an incision made throu2;h it, extendinj? from tlie an- 
terior margin of the trapezius to the posterior border of the 



68 



EMERGENCIES, AND HOW TO TREAT TIIEM. 






sterno-mastoid. The fascia and platysma having been di- 
vided, the external jugular vein is seen near the edge of the 
sterno-mastoid muscle, and the supra-scapular and transver- 
salis codi nerves and vessels running across the space. 
These are pushed aside, the deep fascia scratched through, 
and the finge* of the operator carried along tlie edge of the 
scalenus-anticus muscle to the tubercle of the first rib, at 
■\vhicli point the subclavian artery will be found. The aneu- 
rism-needle is carried around the vessel from before back- 
ward, and the ligature tied. 

The third portion of the axillary artery is the most con- 
venient part for ligation. An incision is made about two 
inches in length, over the liead of the humerus, near the 
centre of the axillary space. The integument and fascia 
are cut through, the axillary vein drawn inward, the median 
nerve outward, and the ligature passed from within out- 
ward. 

The hrachial artery, in the upper part of its course, is 
exposed by cutting through the integument and fascia at 
the inr.or margin of the coraco-brachialis muscle. The ulnar 
and internal cutan;;ous nerves, which lie at the inner side of 
the artery, and the median nerve, which is situated exter- 
nally, are separated from the vessel, and the ligature applied. 

The brachial may also be tied at the bend of the elbow. 
The incision is made at the inner border of the biceps nms- 
cle. At this joint the artery lies internal to the tendon, 
with the median nerve still farther inside, close to the ves- 
sel. The median basilic vein passes over the artery, separated 
from it by the bicipital fascia. 

The radial artery should not be tied at its upper por- 
tion, because of its depth from the surface. In the middle 



WOUNDS OF ARTERIES AND VEINS. 



69 



third it is exposed by cutting along the inner margin of the 
Bupinator longus. The radial nerve, a continuation of the 
muscle spiral, is found in close relation with it externally. 
The ligature is passed from the radial to the ulnar side. 

In the lower portion of the forearm, the artery is found 
between the flexor carpi radialis and supinator longus. It 
is superficial at this point, and easily tied by cutting between 
those two muscles. 

The ulnar artery, in its lower portion, is located between 
the flexor carpi ulnaris and the flexor sublimis digitorum. 
The ulnar nerve is found at the inner side of the former 
muscle. The incision is carried through the integument and 
fascia between these muscles, and the artery tied. 

Wounds of tue Palmar Akcu are difficult to manage, 
owing to the numerous anastomoses of the arteries. The 
hremorrhage may persist after ligation of the ulnar, radial, 
and brachial arteries. Some surgeons keep a compress on 
the wound for two or three days, and, if this does not 
succeed, ligate the vessels in the forearm or arm. When 
compression fails, the bleeding vessels should be tied 'in 
the toound, if possible. 

Ligation of the femoral artery is commonly performed 
in the lower portion of "Scarpa's space." The integu- 
ment and fascia are divided at the inner margin of the 
Sartorius muscle. After the sheath is opened, the femoral 
vein will be found at the inner side of the artery. The 
ligature is carried around from within outward. 

After ligation of the femoral artery, the limb should 
be encased in a thick roll of cotton, to keep up its nor- 
mal temperature, until the collateral circulation is estab- 
lished. 



70 



EMERGENCIES, AND HOW TO TREAT THEM. 



I I 



Ligation of the po2>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 



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ii 



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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 Jir<si ^^tvvW, 
from asphyxia or injury to the brain, from extravasatioii of 
blood following the violent efforts to respire. In the second 
])eriod death is induced by bronchitis or laryngitis. If 
weeks and months elapse before its expulsion, abscesses may 
form, and the patient succumbs to exhausti u 

Treatment. — A violent blow on the back, if given im- 
mediately after the accident occurs, will assist the natural 
eftbrts of the patient in ejecting the foreign body. After it 
has passed the larynx, this procedure alone will be of little 
avail. If the first attempt fails, the body is to be inverted 
and held up by assistants, while the physician strikes with 
the open hand between the shoulders, at the same time 
moving the patient rapidly from side to side If this 
method induces violent sufibcatve paroxysms, it must not 
be repeated. Should the urgent symptoms continue, which 



!'!!; Ml, 



EXTRACTIOX OF FOUEKiX IIODIKS. 



89 



they arc liable to do, laryiigotomy or traclieotoniy must bo 
pcrt'oriued without dcliiy. Tho ucuto sensibility of tlio 
larynx hinders tho irritating material from passinjij tlie 
glottis, -vvliieh closed spasmodically every time it reaches 
that point, and, unless an o])ening is made lower down to 
give it exit, death may soon ensue. Some surgeons advise 
the administration of emetics, but such practice is worse 
than useless. 

Trachcotonjy U preferred above other operations by 
some i)ractitioners, especially for children ; but, if circum- 
stances admit, hiryngotomy should bo first performed. It 
possesses many advantages worthy of attention : 

1. Tlie parts are more accessible at all periods of .ife. 

2. It is performed with greater rapidity, and conse- 
quently is peculiarly applicable to cases requiring uistant 
relief. 

3. There is no danger of woumling important vessels, 
or delaying the o])cration l)y hamiorrhago. 

Lanjugotoini/ is performed through the membranous in- 
terval existing between the thyroid and curved cartilages. 
The region is superficial and readily exposed. The only 
vessel to be avoided is the crico-thyroid artery, which passes 
across the upper part of the space to anastomose Avith its 
fellow on the opposite side. 

The patient should be placed in a chair or in the 
recumbent posture, with the head thrown back, and the 
larynx steadied by an assistant. An incision about an inch 
in length is made through the integument over the crico- 
thyroid space, fully exposing the membrane, which is then 
opened by a transverse cut near the cricoid cartilage. By 
keeping close to this cartilage, all danger of wounding the 



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r.MKKCKNCIKS, ANH IIOW TO TIMIAT TIIMM. 












jvrti'rv irf iiv(»i(l('il. Tlio uportiiri! thus iiiadr in llic Imitiix i-t 
now widened by a dilator <»r oi'diimn' tuivcps, and llie 
])atii>iit 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 passa<j;i'ri are entirely deariMl, tho cdi^es of 
the M'ound must ho approxlnuitiMl aud allowed t(» la.'al. 

Ti'di'/u'otomy requires <jjreater care and skill in its per- 
formance than laryny;otomy. The trachea, especially in 
children, is deeply seated, ami covered hy important ])lex- 
lises of veins and close ])roximity to lari:;o arteries. The 
parts to he avoided in tho oi)eration are: 1. 'I'ho anterior 
jui^ular veins. i2. The isthmus of the thyroitl i^huKl which 
lies on tho second and third rinu;s of the trachea; and .'}. The 
inferior thyroid veins. 

It is always safe to administer chloroform to a child 
before commcncinj:^ the operation. It renders material 
assistance to the surj^eon, by relievin<:j si)asm and keepinii; 
the patient from strugj^linu;. Should it bo considcn'od advis- 
able to dispense ■with the anaesthetic, the ehihrs body must 
be enveloped in a siieet, whicli will keep tho limbs motion- 
less. The head is thrown back in the former case, and tho 
larvnx held bv an assistant. An incision is uiado throuiili 
the iutea;umeut directly in the median lino, beirinniui; .". 
short distance below the cricoid eartila2;o, and continued 
clown from one and a half to two inches. J>y 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, <e(lenni j^lottidis, croup, ett;., a curved tid)e is intro- 
duced tlirou^h tlu! openinj^, and allowed to remain until the 
dilllculty which ealle<l for the operation is njmoved. 

Wlicn the oj)eration is concluded an-' the tube inserted, 
the patient must he carefully watched for a day or two, and 
the tid)e kept clear of hlood and mucus. The oM form of 
tnichea-tubo necessitated tho u-ie of a foather in ordcu* to 
keep it clean ; but tho variety now employcil has a second 
tube iltting closely inside the; iirst, whicli can be ri-moved 
and cleaned at pleasure without disturbin/i; the i)ati(!nt. 

FoUEIOX BoDIICS IX THK Ph.VUVNX AND G'^solMIAdlS. — The 

pharynx is that part of the alimenttiry (•■inal which extends 
from the base of the skull to lliu lirth cervi(;al vertebra, 
•where it becomes continuous v.ith tho (osopha!i;us. It lies 
behind tho nose, mouth, and larynx, in the order ni'Mitionod 
from above downward. Its widest i)art is o[)posite the 
liyoid bone, its narrowest portion is wlierc it joins the 




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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 



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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, 



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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 

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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 

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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 



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EMERGENCIES, AND HOW TO TREAT THEM. 



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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- 



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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 



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EMERGENCIES, AND DOW TO TREAT TIIEM. 



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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. 



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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 



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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()niitin<r of fecal matter oxio. tliero i^ littlo room for nii.s- 
take; neither of tlie:4e will bo connected with a bubo or in- 
flamed hernial sac. 

The intestines may bo constricted without leaving the 
abiloniinal cavity. Portions of the colon may twist ui)on 
tlieniselves {lleun\ in such a manner as to cut off the circu- 
lation. The twisting is usually found at the sigmoid iloxure. 
It is recognized as a prominent tympanitic tumoi' over 
the part affected, and by accompanying signs of stranguhi- 
tion. 

A portion of intestine may become invaginatcd or in- 
verted {volvulus), like the finger of a glove doubled in, and 
occasion all the symptoms and danger of strangulation. 
Volvulus may occur at any age, but it is most common in 
childhood. It occurs suddenly, with pain located at the point 
of constriction. In addition to the ordinary signs of strangu- 
lation, there are frequent desire to go to stool, and discharges 
of blood and mucus from the bowels. The invaginatcd 
part may slough off — the two ends of the intestines unite, 
and the patient recover. If allowed to remain until slough- 
ing occurs, a favorable termination is not likely to ensue. 

Treatment. — The injection of air or fluids into the in- 
testines is highly recommended in volvulus. The injected 
material, by distending the gut, forces up the invaginatcd 
part. Some recommend cutting down upon the intestines 
at the part where the pain exists, and drawing out the in- 
verted intestine. A similar course may be adopted in the 
treatment of ileus. 

In ordinary strangulated hernia, eflforts should be made 



STRANGULATED IIERXIA. 



115 



to rodiico it by juiviiipulation {tdxiti). Tho muscles tiro flwt 
relaxed by <>j)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. 






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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 



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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. 



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illi 



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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 



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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 



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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 



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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,' 

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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 



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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 



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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" 



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186 



EMERGENCIES, AND HOW TO TREAT THEM. 



of the muscular fibres, angina pectoris, and pericarditis, with 
effusion. 

Persons of delicate frame and sensitive nervous organiza- 
tions are most subject to syncope. Women are affected 
more frequently than men. Feeble women, with uterine 
disorders, will faint from slight injury, or any unusual 
mental excitement. 

The symptoms of syncope are clearly marked. The 
patient is . luscious of a sinking sensation in tlie epigastric 
region, and about the heart. There are dizziness, dimness 
of vision, and ringing in the ears {tinnitus cnirmm). The 
features are pinched, and the lips and elieeks are pale and 
cold. The pulse, at first small and fluttering, is at last im- 
perceptible. An impulse can scarcely be recognized in the 
prjBcordial region. There is also partial or complete uncon- 
sciousness. Kespiratory movements may cease altogether, 
or a spasmodic, irregular sighing is present. 

The attack lasts from a few seconds to two or three 
minutes. It is very rarely prolonged beyond two minutes. 
Resuscitation would not be possible if the heart's pulsations 
were absent for five minutes ( Walsh). 

Recovery is announced by attempts at swallowing, by 
sighing, movements of the body, restoration of warmth and 
color to the cheeks, and a return of the radial pulse. In 
some cases the attack may terminate with nausea and 
vomiting. 

Although in most cases syncope is easy of recognition, 
mistakes are sometimes made and erroneous opinions given. 
It is therefore well to consider the morbid states for which 
it may be mistaken. 

There is a class of persons called malingei'ers, who, from 



LOSS OF CONSCIOUSNESS, 



187 



sordid or other motives, feign various forms of illness, and 
syncope is sometimes simulated. Prostitutes or disorderly 
characters, in order to escape detention in the station-house, 
or a suhsequent visit to Blackwell's Island, work on the 
sympathies of the police official, until a carriage is ordered, 
and they are conducted to the hospital. Once there, unless 
the doctor in attendance is particularly disgusted -with the 
performance, the patient will likely be discharged the next 
day without trouble. These cases are readily recognized 
by the fact that the pulse is beating with its accustomed 
fulness and regularity, that the temperature of the body is 
normal, and that an announcement of an inteiition to draw 
blood from the arm, or shave the head and apply ice, is fol- 
lowed by an avowal of the patient that she is much better, 
and will not require further treatment. 

Ordinary syncope is readily distinguished from hysterical 
stiipor by the fact that the patient has not lost conscious- 
ness, nor is the action of the heart or pulse specially altered. 

Poisoning from carbonic acid gives a dark, livid color to 
the countenance, the insensibility is continuous, and the 
pulse can be felt in the wrist. Poisoning from urea, or 
Bright's disease, is diagnosed by the accompanying drojisi- 
cal swelling of the lower limbs, urinous odor, and the pres- 
ence of (jasts and albumen in the urine. 

A person in a state of deep syncope may be considered 
dead, but if the characteristic signs of death are understood, 
little difficulty will be experienced in making a correct 
diagnosis. (See article on Asphyxia, page 147.) 

Treatment. — In mild cases, where the patient is only 
partially unconscious, stimulating inhalations of eau-de- 
cologne, vapor of ammonia, sprinkling the head and face 




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138 



EMERGENCIES, AND HOW TO TREAT THEM. 



with cold water, or placing the patient in a cold draught of 
air, will suffice to restore sensibility. 

"Where there is complete nnconscionsness, more urgent 
measures will be necessary. In all cases, the patient should 
be placed in the recumbent position, with the head lower 
than the shoulders. This is done in order that the blood 
flowing toward the cerebrum may have the assistance of 
gravitation, and also to accelerate the current travelling 
from the lower extremities toward the heart. All super- 
fluous clothing should be removed from the chest and throat. 
Collars, neck-ties, and other articles which constrict the 
neck, hinder recovery. The stimulating inhalations of am- 
monia, etc., are of little avail in complete syncope, for there 
is scarcely any respiratory movement ; the nostrils, how- 
ever, may be moistened with tlie liquid. Cold water, 
thrown violently in the face, or sprinkled forcibly on the 
chest, striking the palms of the hands, and rubbing them 
rapidly, are efficacious in all cases. An efficient remedy is 
to dip a plate in hot water and place it over the epigastric 
or precordial regions ; either place will answer. All these 
methods may be combined in the treatment of individual 
cases. Should they fail, galvanism may be carefully tried. 
Too much is worse than too little. One pole of the battery 
may be placed at the upper part of the spinal column, and 
the otli moved up and down over the sternum and prne- 
cordia. The poles may also be applied along the course of 
the spinal accessory nerve. The action of the heart has in 
some cases been renewed by exciting the spinal accessory 
and the four upper cervical nerves ( Yalentln). 

The treatment of syncope resulting from excessive haem- 
orrhage has been discussed in a preceding chapter. 



CHAPTER XII. 



ASPHYXIA. 



Respiratory Apparatus.— Effects of Non-nCration of Blood.— Strangulation.— Com- 
pression of TLoro.x. — Inhalation of Poisonous Gases.- Signs of Death. — 
Drowning. 

The pathological changes arising from defective aeration 
will be better xinderstood if we glance briefly at the pro- 
cesses which regulate the supply of oxygen, and the elimi- 
nation of carbonic acid. To describe in detail these impor- 
tant phenomena would lead us beyond the prescribed limit 
of this work. "We must confine our attention to such as 
have a special bearing upon the morbid actions in question. 

The respiratory apparatus comprises the larynx, trachea, 
bronchi, and lungs. The lungs, the heart, and great vessels, 
are contained within the cavitv of the thorax or chest. A 
large, flat muscle, called the diaphragm, forms the floor of 
this cavity and separdtes it from the abdomen. Each lung 
is composed of bronchial tubes, air-cells, vessels, and nerves. 
The bronchial tubes commence at the termination of the 
trachea. They divide and subdivide, becoming smaller as 
they pass in, until they terminate with a diameter of -^ of 
an inch in the intercellular passages or bronchioles. Around 
these passages and terminal bronchi, the air-cells are clus- 
tered in a manner similar to the arrang-ement of " leaves on a 



140 



EMERGENCIES, AND HOW TO TREAT TIIEM. 



li 






ii 



tree-branch." These cells measure from t,^ to -^^ of an inch 
each in diameter. They are formed of a delicate layer of 
mucous membrane, closely attached to Avhich are minute 
plexuses from the pulmonary artery and veins, and to unite 
the whole there is a quantity of yellow elastic tissue. 

According to the calculation of M. Ivocheaux, tliere are 
17,790 air-cells connected with each terminal bronchus, and 
in the lungs, 600,000,000. Prof. Dalton, of this city, esti- 
mates the amount of surface thus exposed to the action of the 
air, at 1,400 square feet. The capillary vessels of tlic pulmo- 
nary artery and pulmonary veins distributed in delicate 
meshes on the walls of the air-cells are the channels throuijh 
which the blood-changes are eftected. The venous blood, 
loaded with carbonic acid, is carried by the pulmonary ar- 
teries from the right side of the heart to the lungs, where it 
gives up its load of impurity. The capillaries of the pul- 
monary veins, which originate in the walls of the air-cells, 
take up the renovated blood with its load of oxygen, and 
carry it to the left side of the heart, whence it is propelled 
to all parts of the body. 

The interchange of gases and aeration of the blood are 
effected during the respiratory movements of inspiration 
and expiration. During inspiration, the diaphragm con- 
tracts and increases the vertical diameter of tho chest, 
while the ribs are ' 3vated and separated by the action of 
the other inspiratory muscles, thereby making the lateral 
diameters greater. A vacuum is thus formed, and the air 
rushes in. Following immediately is an expiratory move- 
ment, in which the air is forced out : 1. By ihe relaxation 
of the diaphragm, which is pushed upward by tho abdom- 
inal organs resuming their original positions ; 2. The ribs 



ASPHYXIA. 



141 



aro drawn together by tlio external intercostnls ; and 3. Tlio 
lungs, which aro extremely clastic, contract and force the 
air out of the cells. After tlio air entcrsj the bronchial 
tubes, a diffusion of gases takes place, and the impure air 
below passes upward, while the oxygen continues on to the 
air-cells. Aftev reaching the cells, the oxygen passes by en- 
dosmosis threngh to the blood, and is carried off by the cor- 
puscular elements of the circulatory fluid which have pre- 
viously given up their carbonic acid. Allowing that twenty 
respiratory movements take place in a minute, the air in the 
lungs will be necessarily changed 1,200 times in the course 
of an hour. About 17 cubic feet of oxygen are consumed in 
24 hours, and during the same period from 300 to 400 cubic 
feet of atmospheric air are supplied to the lungs. 

Oxygen gas is an essential requirement of a healthy 
organism. It exerts a remarkable influence upon both 
vegetable and animal life. Eight-ninths of the whole mass 
of water, one-third of the earth's substance, and one-fifth of 
the atmosphere, are composed of oxygen : no element is more 
abundant or more important. 

Repair and decay are closely linked in the animal 
economy. Death is a necessary accompaniment of life. 
Molecular disorganization, elaboration, and growth of new 
ihaterial, proceed simultaneously. In health the growth 
keeps pace with loss, in disease waste preponderates. Dur- 
ing the physiological interchange of material new sub- 
stances of a poisonous nature are generated, and are removed 
by the different emunctories. Should the avenues of escape 
be closed, life is speedily terminated. For instance, the 
kidneys eliminate an excrementitious substance called urea^ 
which is formed by the decay of nitrogen i zed tissue. "When 



I ii 



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142 



EIETIGENCIES, AND IIOW TO TREAT THEM. 



i" 



these organs cease to abstract this material from the l)loo(l, 
it accuimilatort and i)roduce8 convulsions, coma, and finally 
death. Carbonic acid, which is specially under considera- 
tion in this connection, is another i)roduct of rctro<i;rado 
metamorphosis. When thronj^h disease or accident it is 
retained, and the blood imperfectly aciratcd, all the nutri- 
tive processes are retarded, or entirely 6toi)pcd. The 
vitality of the body necessarily fails to approximate to a 
healthy standard, and latent germs of disease are impelled 
to an inordinate and even fatal growth. 

The large mortality in our tenement-houses is sufficient 
evidence of this truth. Human beings are crowded together 
in these dens, in a stifling atmosphere, unfit to supply the 
Avants of the system. A family of six and seven will some- 
times be cramped in one or two small rooms, scarcely largo 
enough to accommodate a single person. But it is not alono 
the evil of a diminished quantity of oxygen that these 
people have to contend with ; the surrounding atmosphere 
is rendered doubly poisonous by the animal exhalations 
which naturally accumulate and occasion cholera, typhus 
fever, and other pestilences. In these homes of the poor, 
these monuments to the grasping spirit of the nineteenth 
century, death reaps a rich and continuous harvest. And 
all this must endure until the strong arm of the law compels 
avaricious landlords to construct houses properly ventilated, 
and fit for human habitation. 

As an example of the effects of imperfect ventilation, the 
suffocation of a large number of persons in the famous or 
rather infamous " Black Hole of Calcutta," will be remem- 
bered. One hundred and fifty persons were confined for a 
single night in a room eight con feet square, having but one 



ASPHYXIA. 



143 



pinnll window. In tlio niorninj; only seventeen were alive. 
Art iinotlier cxiunplo of tlio cvilrt attending iiui>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 






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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 an<l 
their treatment. 

Stuaxoulation. — This term is generally api)lied to that 
variety of asphyxia caused by external compression ; but 
any mechanical occlusion of the trachea or larynx, whether 
external or internal, belongs under tho same head. 

Tho strangulation produced by clasping the throat tight- 
ly with the arm or hands is the common method employed 
by garroters. In suicidal attempts, handkerchiefs or ropes 
are generally used, and the rope is resorted to in most civil- 
ized countries in judicial strangulation. All cases of hang- 
ing, however, do not terminate by asphyxia. The neck is 

usually broken by the fall, and death results from pressure 
10 



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146 



EMERGENCIES, AND EOW TO TREAT TUEM. 



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, a 121... 



on the upper part of the spinal cord, and congestion of the 
brain. 

The greatest number of strangulated patients who come 
under the care of the surgeon are those of attempted sui- 
cides, and every stage of asphyxia, from a slight suffocation 
to complete stoppage of respiration, may be found among 
them. 

T'e symptoms arising from mechanical occlusion of the 
air-passages are common in a greater or less degree to all 
other varieties of asphyxia. They are usually so well 
marked as to preclude a possibility of mistake. At the 
same time, the history of the patient should always be in- 
quired into. The patient's countenance presents an anxious 
expression, and is of a livid color, which, in extreme cases, 
is almost black. The .ips are swollen and somewhat evert- 
ed, the eyes bloodehot and prominent, the vessels of the 
head and neck are enlarged to double their ordinary size. 
There is an intolerable feeling of discomfort and oppression 
over the chest, and intense desire for air. The res2)iratory 
movements become rapid, but after a time they are slow 
and prolonged. There is a momentary increase in the pul- 
sations of the heart. As the asphyxia progresses, the move- 
ments diminish in force, until they are totally lost. In the 
beginning, the patient suffers from giddiness, ringing in the 
ear {tinnitus auriiim\ and great general distress. The agony 
gives way where asphyxia results from immersion in water, 
and is succeeded by pleasant visions and droams. In some 
recorded cases, these sensations are said to have been so en- 
ti'ancing as to cause the resuscitated patient to curse his 
attendants for bringing him back to renewed torture. These 
dreams are followed by insensibility ; the pulse is usually 



ASniYXIA. 



147 



absent, but the action of the heart may still he made out 
with a Btetlioscope. So long as an impulse is detected, 
there is chance of recovery. 

In asphyxia resulting from violence, there is often an ac- 
companying condition of syncope. This may resemble death 
to such an extent as to prevent the continuance of treatment. 
However, if the points of difference between death and simple 
insensibility are appreciated, there will be little difficulty. 

When life ceases, the pupils are dilated, the cornea is 
flattened, and the eyes fixed. Tliere are congestion of the 
cutaneous capillaries, especially in the most dependent por- 
tions of the body, and blueness under the finger-nails. (In 
true asphyxia this congestion is not a sign of much impor- 
tance.) All respiratory movements have ceased, and no 
moisture will appear on a looking-glass held over the 
mouth or nose. The pulsations of the heart cannot be 
made out with the car or stethoscope. 

Another test has been proposed lately by a French gen- 
tleman, who states that, if a bright steel needle be inserted 
into the dead body, it will come out perfectly clean ; if in- 
troduced into the living body, it will become tarnished by 
oxidation. If a preparation of Calabar bean is applied to 
the eye while life is present, the pupil will contract ; if 
death has taken place, no effect will be produced. 

A muscular rigidity {rigor mortis) ensues soon after 
death, and a peculiar, offensive odor is emitted. 

Treatment. — Tlr treatment of strangulation from for- 
eign bodies in the air-passages has been considered in a pre- 
vious chapter. When strangi ""ation results from external 
compression of the throat, a careful examination should be 
instituted to ascertain the amount of local injury. Lacera- 



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148 



EMERGENCIES, AND HOW TO TREAT TIIEM. 



tion or fractui-o of the larynx or rings of the trachea may 
cause pieces of cartiLige to protrude on the internal surface. 
Such obstructions must be removed, in order to render the 
treatment effectual. All superfluous clothing should be re- 
moved from the chest and neck, and the mouth and tliroat 
cleared of mucus. Artificial respiration, cither by Mar- 
shall's, Hall's, or Sylvester's methods, must then bo tried. 
The manner of employing those methods is hereafter fully 
exj^laincd. It is at times necessary to perform tracheotomy 
{see Tracheotomy), and to fill the lungs by forcing in air 
with a bellows, or with the mouth applied to the opening. 
In addition to artificial respiration, tlie surface of the body 
should be briskly rubbed to keep up the circulation, and 
stimulants administered throut!-!! the rectum. As in cases 
of hanging there is congestion of the brain, a few ounces 
of blood can be taken from the arm with benefit. 

CoMi'KESsiox OF TUE TnoRAcic "Walls produccs suffoca- 
tion by preventing the expansion of the lungs and admis- 
sion of air. It usually occurs from jamming, or by being 
crushed beneath embankments or masses of building mate- 
rial. In the former case the sufferer is usually very much 
frightened. The arms are thrown involuntarily above the 
head, leaving the chest exposed to the pressure of the 
crowd. Persons in large crowds can, with ordinary pre- 
cautions, protect the chest by keeping the arms and elbows 
close to the side of the chest, flexing the forearm, and 
bringing it in front, thus making the hands meet in the 
median line. Unless extraordinary pressure is made, this 
method will allow of sufficient respiratory movement to 
sustain life. 

The notorious resurrectionist and murderer, Burke, usu- 



i 



AsrnYxiA. 



149 



ally destroyed his victims by compressing tlie thoracic 
walls. 

With this variety of asphyxia there may be more or less 
bruising and laceration of the chest-walls, but the general 
symptoms and treatment arc the same as given above. 

Suffocation from Ixualation of Gases, — The inha- 
lation of nitrogen or hvdro2;en occasions the same changes 
and symptoms as are witnessed in other forms of asphyxia. 
Nitrogen exists in large qnantities in atmospheric air. 
"When inhaled in a pure state, it destroys life with greater 
rapidity than other gaseous bodies. 

The inhalation of sulphuretted hydrogen, carbonic acid, 
carbonic oxide, carburetted hydrogen, etc., should be 
treated under the head of poisons. As death in these 
cases, however, is usually attributed to asphyxia, and as 
the treatment is the same, they will be considered in this 
section. 

Si(7j)hia'ette(l hydrogen is a product of the decomposition 
of animal matter. It is found in sewers, old drains, and 
stagnant pools. The foul odor of "rotten eggs" is due to 
this gas. When inhaled, it proves rapidly fatal. Accord- 
ing to Flenard, one part in a hundred and fiftieth of atmos- 
pheric air will kill a horse. Men can bear larger propor- 
tions. 

Small quantities of sulphuretted hydrogen, inhaled in 
a diluted form, give rise to nausea, vomiting, pains in the 
abdomen and extremities, vertigo, and a semi-paralytic 
condition of the extremities. In large quantities, it pro- 
duces rapid insensibility, convulsions, and death. The 
body exhales the characteristic odor of the gas. After 
death the mouth and fauces are coated with a dark-brown 



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150 



EMERGENCIES, AND HOW TO TREAT THEM. 



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mucus. Tho muscles and all the internal organs are dark- 
colored, and the blood is fluid. 

Carbonic acid, or di-oxido of carbon, is found in large 
quantities in the bottom of wells, coal-mines, and in all 
dark, damp situations, wliero organic matter is in a state 
of decomposition. In coal-mines it is usually known as 
" choke-damp," and death is often caused by its inhalation. 
This substance also results from the physiological decay of 
living bodies. 

An atmosphere containing one-tenth of carbonic acid 
will produce death. Its eft'oet on the system is that of a 
narcotic poison, although, when death results from its in- 
halations, it is comnaonly said to cause suffocation, or as- 
phyxia. 

The sj'mptoms attending its inhalation, with one or two 
exceptions, resemble those occurring in ordinary asphyxia. 
There is at first marked loss of muscular power, with ten- 
dency to sleep, and the countenance assumes a leaden hue. 
After death the eyes remain bright for some time, and sev- 
eral hours elapse before rigor mortis sets in. 

Charcoai-vajjor consists of carbonic acid, carburettcd 
hydrogen, free nitrogen, and atmospheric air. This vapor 
is often used as a means of self-murder. In France it is 
frequently employed for this purpose. Suicides burn the 
charcoal on a brazier, in a close room, where all the crevices 
for the admission of air are shut oif. The vapor at first 
creates a sensation of extreme languor and general weak- 
ness. This is soon followed by complete insensibility. In 
some of these cases the countenance is pale, and the jaws 
are usually fixed. After death the heart is empty, or a 
little black blood may occupy its right ventricle. 



ASPHYXIA. 



151 



Coal-vapor. — The materials arising from tlio ovdiiKiry 
combustion of coal are sulplinrous acid, carbonic jicid, sul- 
pburetteil hydrogen, and carburcttcd hydrogen. It is im- 
possible to inhale this vapor under ordinary circumstances. 
It possesses such irritating qualities that, unless a person is 
stupefied with alcohol or other narcotics, ho will escape be- 
fore a sufficient amount is taken in to destroy life. Occa- 
sionally, persona are suffocated in holds or cabins of vessels 
from this vapor. A sad instance occurred recently in Xew- 
York harbor. Five seamen shut themselves in the forecastle, 
where a brazier of coal was burning, and in the morning 
were found dead. 

Coal-gas. — This substance is employed for illuminating 
purposes. It consists principall}' of light carburetted hydro- 
gen, carbonic oxide, olefiant gas, hydrogen, nitrogen, etc. 
Its odorous principle is duo to vapor of naphtha. Carl)oniG 
oxide is supposed to be its principal poisonous ingredient. 

If the atmosphere of a room becomes impregnated with 
twelve per cent, of the gas, a lighted candle introduced will 
cause an explosion. Accidents arising from coal-gas are 
generally the rcs^ilt of carelessness or ig: irance. Neglect- 
ing to turn the gas off, and leakage in the pipes, are the 
common causes. The effects produced by its inhalation dif- 
fer from other varieties. There are more or less vertigo, 
nausea, and vomiting, a semi-paralytic condition of the 
muscles, and convulsions ending often in death. After death 
the blood is sometimes of a light-red color. 

Treatment. — In all these varieties of suffocation, inhala- 
tion of oxygen gas will bring about speedy relief. Where 
respiration has ceased, it must be restored by artificial 
methods. If necessary, oxygen may be forced into the 



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152 



EMERr.ENTIES, AND HOW TO TREAT THEM. 



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lungs in the manner previously mentioned. Cold water, 
poured on the surface of the body, is likewise benelicial. 

DROAVXIXO. 

The length of time that persons can remain under water, 
and afterward bo resuscitated, varies according to the cir- 
cumstances attending each individual case. AVhen timid 
persons l)ecome accidentallv submerged, they throw up 
tlie arms, open the mouth to shriek, and consequently fill 
the lungs with water and strnngulate at once. If presence 
of mind is not lost, the arms kept under water, and the res- 
j)iratory movements controlled until the head comes above 
the surface, life may be prolonged a considerable period. 
Again, should the submerged individual faint, the chances 
of resuscitation are good even when several minutes have 
been spent without air. The tit of synco])e is attended with 
a stoppage of respiration and of the heart's action, and, the 
demand for oxygen being diminished, the system docs not 
feel the loss as it woidd under other circumstances. Occa- 
sionally, life is destroyed after an immersion of one minute, 
while in other instances persons remain under water for two 
and even three minutes without receiving injury. Thus 
sponge and pearl divers, Avho spend a great part of their 
working-hours under water, remain deprived of air for two 
or three minutes with but little discomfort. Marac relates 
the case of a German woman m-Iio was tied up in a bag with 
a cock and cat, and throwni into the water as a punishment 
for child-murder. She was submerged fifteen minutes, and, 
when removed from the bag and exposed to the air, imme- 
diately recovered. Such a prolongation of life W'ithout air 
can only be accounted for on the supposition that the woman 



ASPHYXIA. 



153 



fainted on boinf;; ininiersctl, and tlint the state of Byncopc 
lasted until slio was brought to the surface. 

A conimitteu of the Royal Cliirurgical Society, London, 
instituted a series of experiments to ascertain the length of 
time animals could sustain life without a supjdy of oxygen. 
A brief statement of the principal results will be of interest. 
It was ascertained that, when the entrance of air was jn-e- 
vented by submersion, death was more rapid than when 
the trachea was thoroughly closed with a pUig. AYheii the 
trachea was simply plugged, the res])iratory movements con- 
tinued from three to four minutes and a half, and the action 
of the heart was perceittible from six to seven minutes and 
a half. As a rule, the heart's action continued two or three 
minutes after respiration ceased. When animals were kept 
\mder water one minute aud thirty seconds, death followed, 
even when the animal was taken out alive. Xo efforts were 
made in any of these cases to restore life. If respi'-ition 
had been artificially produced, they woidd have probably 
recovered. The striking difierenee in the period of death 
in the two classes is explained by the fact that, in simple 
plugging of the trachea, sufficient air remained in the lungs 
to maintain life for a short time, while in the other, water 
found its way into the lungs and displaced the air which 
might otherwise have been reserved for aeration. Some 
contend that water does not enter the lungs of the drowned, 
but the results of 2>ost-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 



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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/n<mi/7nc8. — Ilcat Apoplexy — Insolation — Sun-Fever. 

"Wo have records of sunstroke iron) the earliest histori- 
cal times. It is fully described by ancient medical writers. 
About the first cases mentioned are the following, from 
biblical history : 

" Manassas was her husband, who died in the early har- 
vest : for, as ho stood among them and bound sheaves in 
the field, the heat came ui)on his liead, and he fell on his 
bed, and died in the city of Bcthuliah." The second in- 
stance relates to the son of the Shunanimite woman, Avho 
was restored to life by the prophet Elisha: "And when the 
child was grown, it fell on a day that ho went out with his 
father to the reapers. And he said unto his father, ' J/y 
head, my hcacV And when he had taken him and brought 
him to his mother, ho sat on her knees till noon, and then 
died." 

Sunstroke is not confined to tropical regions ; Xow York 
and other Northern cities suffer from its yearly visitatioii.-. 
At certain seasons the number of cases, in proportion to 
the population, far exceeds that of the more tropical towns. 
In New York, especially, the mortality has been very great. 



BUNSTHOKH. 



150 



During; tliu rtuinmcrri of 1800 uiid 1S08 iiii iimiiciirto muii- 
hiiV of ciisud wcro rcconlod. 

Visitorri to tlio tr(»i)it'(4 from the colder regions, who uro 
iiiiaccustoiiiod to a liigh tcmpcriituro, uro i)urticulurly siirf- 
coptlMo , while iO nivtivoa, who livo coustiiiitly exposed to 
the heiit, are coiiii»!iriifively sufo. 

Siiiiritroke does not depend upon a short exposure to the 
direct rays of tlio sun; the ex[)osuro must have been con- 
tinued for a day or two; nor does it necessarily arise from 
Bolar heat. I'njlunged coniinement in the heated atmos- 
l>horo 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. 



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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 



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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 



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! . Bill; 



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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 



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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 

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i:Mi;Rr.KNciK.s and how to trkat thkm. 



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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 



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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 




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170 



KMElKiENClKS, AND HOW TO TIIEAT THEM. 



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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. 



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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 <j;reatest amount of codcma will be found in the ary- 
teno-e])iglottidoan folds, situated at the sides of the sui)erior 
aperture of the larynx, and at the base of the i'pi<,dottis. 
The aryteno-cpiglottidean folds are i*edu[)lications of mucous 
mcndjrane which loosely cover the cuneiform cartila<;es. 
Lar^'o, irrej^ular pouches, which are hero developed by the 
infiltration of serum, hang over the laryn<j;eal aperture. 
These bags are forced in with each ins])lration, making the 
opening still smaller, and seriously obstructing the ingress 
of air. 

ffiuKMA (Irxrrrinis occurs more frequently in adults than 
in children ; the reasons for this are — 1. That in early life the 
nmcous membrane of the larynx adheres more intimately to 
the adjacent tissues. An exudation of any kind from the 
blood-vessels would therefore appear on the free surface of 
the membrane, and not on its attached portion ; 2. The 



f 



(i:drma glottidih. 



178 



disoa)'('rt wliicli ((cciibioii (I'doniii uro mon; cnimnoii in ml- 
Viuu;c>(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 



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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. 



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CIIAPTEK XVI. 



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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 



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•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 



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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 



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180 



EMEUGFAX'IKS, AND HOsV TO TREAT THEM. 



W. til 



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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 



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182 EMEIIGENX'IES, AND UOW TO TUEAT THEM, 

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Amaurosis and deafness also occur. Very little can l,o 
done to relieve them. 

T/vati/ient. — The preventive treatment consists in ut- 
tendin<j to the general health of the child, and ]»lacing it 
under proper hygienic iiiUuejices. Its food slioukl he of 
good qualiry, its nurse liealthy, the sleeping-ai)artnient well 
ventilated, the clothing loose and not heavy. • If worms are 
present, they must he removed hy anthelmintics. Indiges- 
tion should be relieved immediately hy the ordinary means. 
Sores or ulcers of the integument are treated with emollient 
ap])lications, and with sedatives internally. 

During the ])aroxysm, cflbrts are made to relieve the 
severity.^ and as far as possible prevent a recurrence of the 
attack. 

The child should at once bo stripped and immersed in a 
hot bath. A tablespoonful of mustard added to the water 
will increase its etiicacy. The child nuiy remain in the 
bath from two to four minutes at a time. Some recommend 
firm pressure around one arm and leg on ojiposite sides of 
the body. This procedure is of benefit in that variety of 
spasm called by Trousseau ^t'^a?iy ; but in this affection it 
would be of little service. As soon as the paroxysm has 
ceased the bowels should be emptied with castor-oil, or by 
injections of warm water. After the evacuation the follow- 
ing may be administered, by enema — 



5. Mistura assnta'tida 
Aqua . 



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= i. M. 



and repeated when necessary. Bromide of potassium, in one 



CONVULSION'S. 



183 



or two jfvd'in doscrf, is nko a valuublo remedy. Tlie dose uf 
tliia may l)u increased if desired. Should the coiivulsiuiis 
Lo violent, protracted iidialations of chloroform may bo em- 
ployed, unci repeated with benciit. 

Convulsions arising from cerebral lesions, such as inllam- 
mation, etc., will not give way to the treatment recom- 
mended. This variety might as well bo let alone, as it 
usually terminates f\atally. 

In all convulsive attacks a ri-^id investigation into the 
cause of the convulsion should be instituted, and treatment 
directed to its removal should be commenced without 
delay. 



iM 



I 



CONVULSIONS IN THE ADULT. 

Convulsions in the adult acquire an importance which 
they do not possess during infantile life. In many cases 
they indicate the presence of constitutiomd lesions, which 
may bring about a fatal termination in a short period. An 
extended description of the diseases which give rise to these 
convulsions 'is, with the limited space at command, inad- 
missi V\ All the prominent features of each condition, and 
especially the different signs which lead to a correct diag- 
nosis, will, however, be fully considered. These points of 
difference cannot be too closely observed, and they should 
be studied more carefully than the points of resend)lance. 

These convulsions may be classed under five separate 
heads : 1. Those which arise from the retention of urea in 
the blood in disease of the kidneys, viz., urremic convulsions ; 
2. Convulsions which characterize epilepsy ; 3. Those 
arising from affections of the brain, such as extravasations 
of blood in its substance, O'* upon its surfticc ; 4. irystcrical 



184 



r,Mi;u(iF,xcii:s, and now to tkkat tiikm. 



coiivulriioiin, and 5. Convulsions due to the I'xcussivo use of 
iilcoliol. 

1. I'u.KMui (\)Nvri,si()Ns. — In tlu! fli!i|it('i' on uni'inic 
c'oinii, tlio P(tiirc'0 and cliariujtor i»l' l\w itoisoii (i/na) wliich 
accMiniulatfrf in tliu Mood in l>ri>;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(Mc<l 
or (liliitt'd, UHUiill}' tliu liittcr. I''rotli, iiuximI somciimcrt witli 
blood, t'ollectrt around tlio moutli, and in cxcopfional cases 
tlio tonguo nniv \m Itittcn. Tlioru is u slronjx urinoiiH odor 
cinatnitin;^ iVoni tlio ix-rspiralion. Wlicn lliu convulsiotm 
cease, the j)atient riinks into a deep ('((niii, wliicli usually 
ciidn in death. There may he only one (•onvid>ion, 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<idneys ; 
in epilepsy a history of previous convulsions, with perfect 
licaltli during the intervals. The tongue is generally bitten 
in true epilepsy, rarely in a nricmic convnlsit)n. Following 
the latter, there is deep coma ; in the former merely a deep 
sleep, from wliicli the patient may be aroused. In cerebral 
extravasation there ii paralysis -with irregularity of the 
pupils, which is not present in urrcmia. In the former also 
there is sometimes rigidity of the muscles following the 
attack; in the latter, this is rarely manifested. The trcat- 




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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 



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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- 









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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 



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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 



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194 



EMERGENCIES, AND HOW TO TREAT TllEM. 



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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 



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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. 



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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 <lc- 
giMieratioii of tlie uterino fibres, arc liable to cause rupture, 
if there is the slightest ovcr-distention or obstruction to the 
free passajj^e of the head. Great distention from multiple 
fmti or monsters, even where the uterine walls arc of nornuil 
thicluiess and structure, is an exciting cause. 

Defornutics of the pelvis, by obstructing the passage of 
the child, and increasing the internal pressure on the walls 
of the uterus, introduction of the hand or instruments into 
the uterus, are not uncommon causes. Rupture of the uterus 
may also arise from blows on the abdomen, or from violent 
straining efforts. 

The dangers froni rupture of the uterus arc shock or 
collapse, bremorrhagc, peritonitis, or mctro-i)eritouitis, and 
strangulation of intestines. 

The principal and immediate danger arises from hem- 
orrhage The flov of blood from dilated vessels of the 
uterus may put an end to life in a few moments. If the 
contractions of the uterus continue after the accident, there 
will be less danger of bleeding. In connection with the 
eiFects of loss of blood on the system, there is more or less 
danger from shock. In all injuries to internal organs this 
peculiar sudden loss of vitality is present. Sometimes the 
loss of blood ia slight, b'lt the shock is so great that the 
patient never rallies. 

When immediate danger from haemorrhage and shock 
has passed, peritonitis or metritis is apt to supervene. If 
the inflammation of the peritonaeum be of any great extent, 
if it involve more than that portion covering the uterus, a 
fatal termination may be expected. 

After the rupture has occurred, a portion of intestine 






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200 



EMERGENCIES, AND HOW TO TREAT THEM. 



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may pass througli the opening, and be tightly strangulated 
by the contracting uterine walls. If this complication have 
not been recognized by the hand in the uterus, it will soon 
manifest itself by violent vomiting, at first of the contents 
of the stomach, and then of fecal matter, and by obstinate 
constij)ation, pain and tendernrss over the abdomen, and 
finally collapse. 

At the time of rupture the woman shrieks loudly, and 
complains of an agonizing pain in the hypogastric region. 
If the physician be near the bedside, a distinct " tear " may 
be heard. There is a gush of blcod from die vagina, and 
the presenting portion of the child immediately recedes. In 
many cases the child can be felt in tlie abdominal cavity 
outside of the contracting uterus. The patient's coun- 
tenance becomes excessively anxious and pallid. The pulse 
is rapid and very feeble. In severe cases the patient may 
succumb at once. If the patient survives the combined 
effects of shock and hajmoiThage, there is still very little 
chance of escaping metro-peritonitis or other complications 
of the accident. 

Treatment. — In every case the child should be delivered 
at once. If the head is within reach, the forceps can be 
used, or version performed to effect that object. When the 
child has passed completely out of the uterine cavity. Prof. 
T. G. Thomas, of this city, recommends the performance 
of gastrotomy, and abstracting the child through the oper. 
ing in the abdomen. lie believes that the danger to the 
mother's life from the operation is not so great as when the 
child is taken out through the natural passage, because in 
this latter case some portions of the intestine are almost 
certain to be caught in the opening and strangulated ; and 



I 



COMPLICAflONS OP LABOR, ETC. 



201 



the 

•of. 
ance 
per. 

the 

the 
se in 
most 

and 



also that an opening in the ahdomen, besides obviating this 
danger, gives an opportunity to clean the cavity of all blood 
or portions of placenta which would excite peritonitis. 
Other authorities recommend the introduction of the hand 
in all cases without exception, and the delivery of the 
child through the natural opening. In so doing, great cure 
should bo taken to prevent portions of the intestine from 
being dragged through the hole in the uterus. 

Stimulants are to be freely administered to couT'.teract 
the effects of the collapse ; styptics, to prevent ha3mor- 
rhage, and opiates in quantities sufficient to relieve pain, 
are always necessary. 

Pkolapse of tue Funis. — "When the umbilical cord 
enters the vagina in advance of the child's body, it is said 
to be prolapsed. If labor proceeds under such circum- 
stances, the cord is compressed against the walls of the 
pelvis, and the aerated blood coming from the placenta 
cannot reach the child. If this pressure is maintained 
fur many minutes, the child dies asphyxiated. 

Prolapse of the funis occurs once in every two hundred 
and fifty cases {Thomas). It is caused by unusual length of 
the cord, sudden escape of liquor amnii, excessive quantity 
of liquor amnii, transverse presentations, and obliquity of 
the uterus. 

If the membranes have ruptured, the cord can be recog- 
nized by its isolation from surrounding structures, and the 
rapidity of its pulsations. The pulsations are synchronous 
Muth the movements of the foetal heart. 

Treatment. — If a diagnosis is made before the head is 
engaged in the superior strait, the patient should be placed 
on her chest and knees ; the hand of the attendant should 






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202 



EMERGENCIES, AND HOW TO TREAT THEM. 



1^1! I ;' 
•I: I 

:if ... 'i 



then be inserted into tlie vagina, and the cord grasped and 
gradually returned to the uterus at the point where it made 
its exit. These efforts should ho made while the uterine 
fibres are relaxed. The cord is retained inside the cervix 
by the finger of the physician until the uterus is firmly con- 
tracted. The woman should remain on her chest and knees 
until the head of the child is engaged in the superior strait. 

This method of replacing a prolapsed cord has super- 
seded all others. It was first introduced by Prof. T. G. 
Thomas, of this city. 

If the child's head passes the superior strait before the 
prolapsus has been discovered, the forceps must be applied, 
and the labor completed without delay. 

Short Cokd. — ^The length of the umbilical cord is sub- 
ject to considerable variation. Schneider reports a case in 
whi ' the cord measured over three yards, and Cazeaux 
speaks of one which was only nine inches in leng:h. It 
usually measures from eighteen to twenty-four inches. 

A short cord retards '' .". progress of labor. It may also 
give rise to haemorrhage by causing premature separation 
cl' the placenta, or rupture of the cord. When the cord is 
shortened by winding around the child's body, similar con- 
scvj^aences may ensue. 

A short cord cannot be recognized until the commence- 
ment of labor. At this time the fundus of the uterus will 
be found depressed or " dimpled " with each contraction. 
The cervix is soft and dilated, but there is no advance in the 
labor. If the index-finger is applied to the child's head it 
will be found to recede during the relaxation of the uterine 
fibres. IlfBmorrhi/ge more or less profuse may also be 
present. (See Placenta Praevia.) 



COMPLICATIONS OF LABOR, ETC. 



203 



Treatment. — If the labor has not progressed beyond 
the first stage, the membranes should be ruptured, so 
as to bring the uterus in more immediate contact with 
the body of the child, and thus increase its power of ex- 
pulsion {Cazeaux). 

When the child's head has passed beyond the cervix, 
and is prevented from advancing fartlicr by tlie short cord, 
the delivery must be terminated with the forceps. Some 
obstetricians advise the performance of version as soon as 
the cervix is dilatable. 

Ikregulae Presentations and PosrrioNS. — In ordinary 
cases of vertex presentations the occiput rotates anteriorly 
under the pubes. Exceptionally, it rotates in a contrary 
direction into the hollow of the sacrum. In th's position 
the head can only be delivered by extreme flexion. In 
some instances the efforts of Nature are sufficient to termi- 
nate the labor ; the majority of cases, however, require the 
aid of the forceps. 

When the patient is fully anaesthetized and in position, 
the male blade of the forceps, which is usually held in the 
left hand of the operator, is introduced on the left side of 
the vagina, and applied to the right of the child's head. 
The female blade is introduced on the right vaginal wall, 
and passed up to the left side of the head. When the for- 
ceps are locked, the handles should be raised toward the 
pubes, in order to produce greater flexion of the head. At 
the same time traction is made, and the head brought down 
to the vulva. When the head reaches this point, some 
obstetricians prefer to remove the forceps, and let the labor 
proceed naturally. 

Pkesentations of the Arm ok Leg, together with the 






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EMERGENCIES, AND HOW TO TREAT THEM. 






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II: H 



head, may cii'ectually iinpodo the progress of labor. As soon 
as discovered, efforts should ho made to return the pro- 
truding limbs to the cavity of the uterus. Sometimes the 
presenting parts are so firmly wedged in the pelvic cavity, 
that they cannot bo replaced ; in such cases embryotomy or 
craniotomy must bo performed. 

In TiJANsvERSE Pbesextatioxs it is not unusual for the 
arm and shoulder to present at the superior strait. The 
arm should be replaced and the head brought down {cephallo 
version). If the head cannot be brought to the superior 
strait, one of the lower limbs .nay bo seized and the child 
delivered by j^odalio version. In the performance of ver- 
sion the following rules must be observed : 1. Oil the hach 
of the hand and fingers only; 2. Introduce the hand during 
the relaxation of the uterine fibres ; 3. Introduce the hand, 
which when in the cavity of the uterus will have its palmar 
surface in relation with the anterior portion of the child's 
body; 4. Do not rupture the membranes until the hand 
Las reached the part of the child to be brought down ; 5. 
The necessary manipulations in the uterine cavity should 
be made between the pains. 

Face Pbesentatioks occur once in two hundred and fifty 
labors {Thomas). The most frequent position is the "right 
mento-iliac transverse." In natural labors the chin is car- 
ried forward under the pubes and is finally delivered by a 
process of flexion. Should the chin rotate posteriorly into 
the hollow of the sacrum, the longest diameter of the 
child's head (occipito-mental) is brought in relation with 
the antero-posterior diameter of the pelvis. The former 
measures five inches and a quarter, the latter four inches 
and a quarter. It is impossible, therefore, for the labor 






COMPLICATIONS OP LABOR, ETC. 



205 



to teniiiniitc naturally. Operative procedures arc always 
necessary. 

Treatment. — If a diagnosis is made before tlio head is 
engaged, the face-presentation may be converted into one 
of the vertex by flexing the head. If this cannot be done, an 
attempt should be made to change the position of the face 
and rotate the chin under the pubes. Either the hand of 
the physician or the vectia may be employed for this pur- 
pf^se. When the movement of rotation cannot be accom- 
plished, the perinajum may be incised and the child delivered 
by means of forceps. This method is recommended by 
Dr. Taylor. Other authorities advise craniotomy when 
milder measures fail. 

ArrLicATioK of the Tampon. — Tlie tampon is employed 
for the suppression of hjemorrhage occurring in abortion, 
placenta prajvia, ulceration and laceration of the vaginal 
walls, etc. It should not be resorted to in jposi-partuin 
hoeniorrhage. 

The tampon may be made of sponge, picked lint, cot- 
ton. India-rubber bags filled with water or ice, or a surgi- 
cal roller-bandage. The latter was lirst emi)loved in tam- 
poning by Prof. I. E. Taylor. lie claims that the bandage 
is more readily introduced and removed than any other ma- 
terial. 

Any of the substances employed may be wet in astrin- 
gent solutions previous to their introduction. The operation 
is performed with or without a speculum. Tlic patient 
should be placed in the recumbent posture and the thighs 
flexed on the abdomen and abducted. A speculum is then 
introduced into the vagina, and the lint or other materials 
passed up and packed tightly around and rpon the cervix, 






if' ' Til 

I'lf 'I II 



( 



i ll 



206 



EMERGENCIES, AND HOW TO TREAT TIIEM. 



increasing the quantity until the vagina h completely filled. 
A T-bantlagc ia afterward employed to maintain the tam- 
pon in position. Tlie tampon should bo changed at the end 
of twenty-four or tiiirty-six hours. 

AVhen the patient desires to micturate, a portion of the 
plug at the entrance of the vagina must bo removed. At 
this point the plug presses on the urethral canal, and its 
removal is necessary before the urine can pass through. 



CHAPTER XIX. 






RETENTION OF UEUIE.— DISLOCATION OF TUE NECK.— INJURIES 
FROM LIGHTNINO.^COLIC. 

Retention of Urine. — Retention of urine may arise 
from spasmodic contraction of the muscular fibres of tho 
neck ot the bladder, organic stricture of the urethra, en- 
larged prostate, stone in the bladder, paralysis of the blad- 
der, abscesses in the perinajum, fracture of the pubic bones, 
with laceration of the urethra, and injuries to the spinal 
cord. 

Retention "which is produced by spasm of the muscular 
fibres accompanies exposure to cold, or acute inflammation 
of the urethra. It occurs suddenly, and is not connected 
with chronic disease of the genitals. There is pain in the 
perinoeum and hypogastric region. If the bladder is dis- 
tended with urine, a large area of dulness will be found on 
percussing along the pubes. Febrile excitement is also pres- 
ent if the retention follows inflammation. 

The patient is readily relieved by the application of hot 
fomentations over the hypogastrium and genitals, hot baths, 
and by the internal administration of opium. Leeches to 
the perinaeum are useful in some cases. 

In retention from organic stricture the patient will have 



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Ml' 



208 



EMERfiEXCIES, AND HOW TO TREAT THEM. 









had, for a vnrinblo period previous to the attack, great dilli- 
culty in micturition, a Binall, twis^ted stream of urine, and 
some degree of pain. An exph)ration with sounds or bougies 
will show an obstruction at some point between the meatus 
and membranous portion of the urethra. 

If the stricture cannot be dibited rapidly, and if the 
condition of the patient will not permit of urethrotomy, the 
distended bladder may be temporarily relieved by i)unctur- 
inj; through the rectum. At the base of tlio bladder there 
is a space imcovered by peritoiULMun, which is bounded on 
each side by the vesicula) seminalis, behind by the recto- 
vesical fold of the peritonrcum and in front by the ])rostate 
gland. The operation at this point is performed by insert- 
ing the left index-finger into the rectum and carrying it 
half an inch or an incli beyond the prostate, and then in- 
troducing a large, curved trochar (using the finger as a 
guide) ami plunging it into the bladder at that point. The 
stylet is now removed, and the urine passes out through 
the canula. If fluctuation cannot be detected by the finger, 
the operation should not be performed. 

Retention from enlarged prostate occurs in advanced life. 
The hypertrophied gland may bo felt by a rectal examina- 
tion. If the ordinary large curved prostatic catheter can- 
not be passed over the obstruction, an instrument with a 
shorter curve may be forced through the enlarged lobe into 
the bladder, or the bladder may be opened through the rec- 
tum in the manner previously described. 

Habitual distention of the bladder may induce a semi- 
paralytic condition of the walls of the organ and ]>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 



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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\ 






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m 



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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<re quantities 
as a neutralizer of the poison. Bouchard has employed the 
ioduretted iodide of potassium Avith benefit. All the strong 
alteratives are said to possess more or less remedial power ; 
but experiments have not proved their efficacy. 

Brandy by enema, and opium by ^'.ypodermic injection, 
in conjunction with large doses of lime-water, constitute the 
most reliable remedies that have yet been fixed upon. If 
the coma appear rapidly and without convulsive move- 
ments, electricity may be used with benefit, and cold water 
may be poured on the chest and face. 



HEMLOCK. 

There are five varieties of hemlock which possess poison- 
ous properties, viz., Coniimi maculatiim, Cicuta virosa, 
(Enanthe crocata, Phcllandriiim aqnaticvjn, and ^tlmsa 
cynapium. Conium maculatum, or spotted hemlock, is much 
used for medicinal purposes. It was a preparation of this 
drug which caused the death of the i)hilo5opher Socrates. 
All parts of the plant are poisonous. To inhale the air in 
the vicinity of this plant in the hot months of summer is 
said to be followed by slight narcotism. Its poisonous 
effects are manifested within half an hour after entering the 
stomach, and death results in from one to three hours. 

The symptoms are dryness of the throat, muscular trem- 
ors, dizziness, difficult deglutition, and a feeling of great 



^v 



NARCOTIC rOISOXS. 



217 



prostration and faintness. The limbs are rendered power- 
less, sometimes being completely paralyzed. The pnpils 
are dilated, the pulse is rapid and small. Deep insensi- 
bility rapidly supervenes, and tliere may be convulsions 
preceding the fatal termination. 

The roots of Cicuta virosa, or water-hemlock, are some- 
times mistaken for parsnips, and eaten in large quantities. 
The symptoas of poisoning resemble those of the preceding 
variety, with the addition of vomiting, and pain in the epi- 
gastrium ; convulsions are also more frequent. 

Tlie leaves and roots of the (Eaaiithe crocata are more 
deadly than any other species of hemlock. The plant grows 
at the sides of ditches and other moist places ; it resembles 
celery. 

When taken internally, it always produces violent and 
protracted convulsions, in conjunction with the symptoms 
previously enumerated {Tayloi'). 

yEthuaa cyiiapium, or fool's parsley, does not kill so 
rapidly as the other varieties. It resembles ordinary pars- 
ley, and is sometimes eaten by mistake. The symptoms 
commence by intense pain in the abdomen* followed by 
vomiting and purging, and a tendency to coma. 

Treatment. — Empty the stomach of its contents, and use 
diffusible stimulants in large quantities. If there are much 
pain and vomiting, bromide of potassium, in ten-grain 
doses, may be given at short intervals. 



■It 

I ''k 



, 1 



IIYOSCYAMtJS. 



Hyoscijamns niger, or henbane, is a European plant, 
cultivated in this country. The leaves and seeds are largely 
employed in medicine. All parts of the plant are poisonous. 






r 






m 5! 



ai8 



EMERGENCIES, AND HOW TO TREAT TUEM 



rbc sccda are more powerful than other parts. Its alkaloid 
{hyoscyaviia) is a deadly poison taken in minute quantities. 
Animals, such as horses, goats, cows, etc., are exempt from 
its injurious influences, and eat it without receiving harm. 
Dof^s and cats are soon killed by it. 

Poisonous doses of the seeds or leaves are followed 
rapidly by dilatation of the pupils, dimness of vision, mus- 
cular twitchings, inability to articulate plainly, and a ten- 
dency to sleep. In a later stage there are vomiting and 
purging, abdominal pain, delirium, convulsive movements 
of the extremities, small, intermittent pulse, and coma, 
which is often followed by death. 

A post-mortem examination shows evidences of inflam- 
matory action in the stomach and intestines, and in a few 
cases congestion of the brain. 

Treatment. — Common charcoal has been stronglv rccom- 
mended as an antidote by Dr. Gar. The substance lapidly 
absorbs the alkaloid upon which the poisonous properties of 
the plant depend, and prevents its peculiar action. Solu- 
tions of caustic alkalies are said to neutralize the poison. 
In every casc^timulants should be employed, as in the otlier 
varieties of poisoning. 

AcoNrrE. 

This drug is obtained from the leaves and root of the 
Aconitum napellus (monk's-hood, or wolfsbane). Prepara- 
tions of the leaves and root are used in medicine. The root 
is said to have ten times greater strength than the leaves. 
The plant has been mistaken for horseradish. In small 
doses it acts as an arterial sedative, diminishins: the heart's 
action, and lowering the pulse. It diflfers from all other 



NARCOTIC POISOXS. 



219 



the 
)ara- 
root 
laves, 
small 
jart's 
)tlier 



narcotic medicines in producing a peculiar numbness and 
tingling sensation in the mouth and fauces. 

Cases of poisoning generally result from careless over- 
dosing with the tincture of the root. Thirty drops of Flem- 
ming's tincture have caused death, but there are instances 
of a drachm or two having been taken by mistake without 
fatal results. The active jmnciple {aconitia) is one of the 
most active poisons known ; one-twelfth of a grain has 
jjroved fatal. 

Poisonous doses produce immediately the characteristic 
numbness and tingling of the mouth and fauces. The same 
feeling is experienced in the extremities. There are sore- 
throat, pain over the stomach, and vomiting. The pul^c is 
extr'^mely weak and compressible. The pupils are in some 
cti .es dilated, at others contracted. As in poisoning by 
other narcotics, there arc dimness of vision, vertigo, great 
prostration, general loss of sensibility, delirium, and coma. 
Death is said to take place from syncope, asphyxia, and 
coma. 

Treatment — Emetics are first employed. Complete 
evacuation of the stomach is sometimes all that is required. 
Brandy in tablespoonful doses, given in ice-water every 
half-hour, is a useful method of stimulation. Preparations 
of nux-vomica are said to neutralize the action of aconitia. 
The tincture of nux-vomica has been used with apparent 
benefit. It may be given in ten-drop doses, every fifteen 
minutes, until the alarming symptoms have subsided. 

TOBACCO. 

This plant was first discovered in America by the 
Spaniards. The English are indebted to Sir "Walter Ra- 



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220 



EMElUiEXCIES, AND HOW TO TREAT TnEM. 



leiffli for fnrnij^hin}' tlicm with tlio " weed." The leaves 
are employed medicinally as poultices to painful swellings, 
and for their emetic properties. Five grains of the powder 
will produce emcsis. In the form of snuff it has been 
employed by keepers of immoral houses to drug their vic- 
tims. A teaspoonful of snuft'in a glass of ale will give rise 
to delirium, vomiting and purging, and faintness. The 
active principle {iiicotia) is a deadly poison. One drop will 
kill a rabbit {Taylor). It causes death in two or three 
minutes. 

The effects produced in persons of nervous temperament 
by long-continued use of tobacco are well marked. An 
examination of the heart shows that it is intermittent in its 
action, and its pulsations more rapid than normal. The 
pulse is weak. Shortness of breath and palpitation of the 
heart are complained of in going up-stairs. Slight excite- 
ment induces great tremulousness. There is often impair- 
ment of the mental faculties, ruch as defective memory, etc. 
The countenance has a sallow as[ ?X. Some impairment 
of the digestive functions is almost always present. 

The effects of large quantities of tobacco on the system 
are well known to smokers and chewers. Early efforts in 
acquiring the habit are characterized by poisonous symp- 
toms. There are intense nausea and vomiting. The nausea 
is said to resemble that occurring in sea-sickness. Vertigo, 
muscular weakness, and intense prostration verging on syn- 
cope, are also present. Later the extremities become cold 
and clammy, and convulsions sometimes precede death. 

Treatment. — Hot bottles and blankets sliould be applied 
to the body. Brandy by enema is always required if the 
liquid cannot be retained on the stomach. Sub-nitrate of 



NARCOTIC POISONS. 



v5321 



bismuth in ten-grain doses, continued with onc-fiftcenth of 
a grain of morphia, will do much to allay the distressing 
nausea. 

DiaiTALIS 

Is a product of the Digitalis purpurea, or purple fox- 
glove. It exerts a powerful sedative effect upon the heart, 
acts on the kidneys as a diuretic, and on the brain as a nar- 
cotic. Some ascribe its influence in diminishing the pulsa- 
tions of the heart in febrile diseases to a stimulating effect 
on the heart's fibres, which gives them renewed vigor. 

It is dangerous on account of its accumulative effect. 
It may be administered for several days without apparent 
action of any kind, when suddenly the patient is prostrated 
with all the symptoms characterizing poisoning by this 
drug. The alkaloid digitalia, vflien boiled with sulphuric 
acid, is changed into glucose, or grape-sugar (Kinsman). 

The symptoms produced by poisonous doses are loss of 
strength, feeble and fluttering pulse, faintness, nausea and 
vomiting, and stupor. The body is bathed in cold perspira- 
tion, the pupils are dilated, the breathing is sighing and 
irregular, and convulsions are sometimes present. 

Treatment. — Ammonia, given internally in frequently- 
repeated doses, is an admirable remedy, when the patient is 
in a state of syncope.. The medicine should also be applied 
to the nostrils. Brandy internally, and warmth to the sur- 
face, are followed by good results. 






STRAMONIUM. 

The common name of the plant is thorn-apple, or 
Jiinicstown weed. It grows all over this country, particu- 
larly along the roadsides and in moist grounds. All parts of 



;i:.'i 



222 



EMERGEKCIE8, AND HOW TO TREAT TIIEM. 






f 



I'il 



the plant aro poisonous. Tho Bcetls aro not unfrcqucntly 
eaten by children. These seeds aro recognized by their 
dark, almost black color, their flat, roughened surface, and 
kidney-shape. Tho drug is much used in asthma and other 
spasmodic affections. Cigarettes made of tho leaves aro 
smoked by asthmatics with great relief. Tho active prin- 
ciple (datiiria), given in small doses, proves ra})idly fatal. 

The symptoms of poisoning are dryness of the throat, 
thirst, delirium, convulsive movements, swelling of the face, 
dilatation of tho pupil, suffusion of the eyes, small, rapid 
pulse, hurried breathing, and hot skin. In some cases there 
are pain over the stomach, and vomiting. Convulsions aro 
nearly always present, and are liable to bo mistaken for 
those arising from urtemia or epilepsy. On examination of 
the vomited matters, the seeds of stramonium will probably 
be discovered, which will make the diagnosis clear. 

Treatment. — Opium, stimulants, and alkaline medicines 
are employed in the same manner as after poisoning by 
belladonna. 

LOBELIA INFLATA 

Is used in medicines as an emetic and antispasmodic. 
The common name is Indian tobacco. It is often adminis- 
tered by quacks who style themselves " vegetable doctors," 
and is sometimes given in dangerous doses. Taylor recites 
several cases where death resulted from improper quantities 
administered by those men. 

In large doses it induces excessive vomiting and purging, 
pain in the bowels, contraction of the pupils, delirium, 
coma, convulsions, and death. 

The post-mortem appearances consist in congestion of 



NARCOTIC POISONS. 



223 



the membranes of tlio brain, and evidences of inflammation 
of the Btuinach and intestinal canal. 

The treatment is confined to stimulants, and counter- 
irritation over the stomach. 



CO0CULU8 INDI0U8 

Contains a peculiar active principle, called jncrotoxla^ to 
■which its poisonous character is due. The drug is some- 
times given to certain kinds of fish in India to render their 
capture an easy matter. The seeds are small, and about 
the size of a pin-head. The active principle is said by 
Glover to produce the same class of convulsive movements 
witnessed after lesions of the corpora quadrigemina and 
cerebellum, viz., tonic spasms, and wheeling and backward 
movements of the body. 

The symptoms and treatment are the same as in other 
varieties. 

MUSHROOMS. 

This plant is eaten in largo quantities in all parts of the 
civilized world. There are numerous varieties of the plr.nt, 
some harmless in their nature, and others highly poisonous. 
Strangely enough, many which arc regarded as deleterious 
in one part of the world are eaten with impunity in others. 
Mushrooms which arc Considered dangerous in England and 
in this country, are used as food in Russia; and some which 
are eaten in England are thought poisonous at Rome. 

The poisonous mushrooms may be recognized, according 
to Chrystosin and M. Richaud, by their dark color, acid, 
bitter taste, pungent odor, and by the fact that they gener- 
ally grow in damp, dark places. 



^■1 






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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 



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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, 



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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. 






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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), 



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230 


EMEUGEXCIES, AND DOW TO TREAT THEM. 



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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 



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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 



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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, <Uarrli(ua, rcritlcssnesrt, inaliility 
to sloop, pains in tlio bones, nnd fobrilo excitement, which 
is worse toward nij^ht. If tlio exposure to tho poisonousj 
vapor have been of jjn^ duration, necrosis of the lower jaw, 
low {grades of inflaunnntion in various parts, and congestion 
of the lungs, will bo found, in addition to tho other symp- 
toms. 

In ncuto poisoning there are vomiting and purging of a 
greenish-colored substance, which soon becomes mixed with 
blood and mucus. The ejections and breath have a '!;arlieky 
odor. If brought to a dark place, they exhibit a pcciiliar 
luminous appearance. There are intense pain in the abdomen, 
and tympanites. The face is anxious, skin cold, and tho pulse 
is rapid and small. A fatal termination does not, usually, 
take place until a day or two has elapsed from tho com- 
mencement of the symptoms, and in some cases life has 
been prolonged for a week. 

After death the stomach presents signs of gangrenous 
inflammation. The mucous membrane is intensely red, and 
easily detached and broken down. There may be perfora- 
tions in the wall of tho intestines, passing into tho peri- 
toneal cavity. Congestion of tho brain and serous elFusion 
into tho ventricles arc also present. The viscera have a 
garlicky odoi-, tmd, when exposed in a dark place, become 
luminous. 

Treatment. — Phosphorus has no direct antidote. Taylor 
recommends hydrated magnesia, and the free use of demul- 
cent drinks, and albiuuen. 



CHAPTER XXIII. 

aOBBOSIVE ACIDS. 



i 



'\ : 



Ml 



OXALIC ACID. 

Tni3 substance exists in comLination with potash in 
sorrel, witli lime in rhubarb ; it is found also in a free state 
in the chick-pea. It is made by the action of nitric acid on 
sugar; or upon rice, gum, starch, etc. Chemically, it is 
composed of one atom of carbonic oxide, and one atom of 
carbonic ucid, making its formula C2O3. 

The prystals of oxalic acid are sometimes mistaken for 
those of Epsom salts. The crystals of the former are dis- 
tinguished by having a sour taste, and by being clearer 
and more transparent than those of Epsom salts. The 
crystals of the latter have a bitter taste. 

Oxalic acid is a deadly poison, acting ■with great ra- 
pidity, and causing death in from five minutes to half an 
hour. 

Tests. — Chloride of calcium gives a white precipitate of 
oxalate of lime ; sulphate of copper, a bluish-white precipi- 
tate of oxalate of copper ; and nitrate of silver, a white pre- 
cipitate of oxalate of silver ( Wood (& Bache). 

Oxalic acid, when given in a concentrated form, pro- 
duces pain in the throat, oesophagus, and stomach. The 



CORROSIVE ACIDS. 



255 



vomiting is associated with violent retching. There arc 
rapid prostration, syncope, and death. 

If largely diluted, its corrosive action in decreased, and the 
symptoms are not so violent. There are less pain and vomit- 
ing, Imt stupor and prostration are more distinctly marked. 
Death may result fron> 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' 
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yond a smatteriiis of doirmatlc psycholoav learned at coUei;e. To effect a reconciliation be- 
tween the I't-ycholoiry and the Pathoioify of the mind, or rather to construct a basis for both 
iu a common science", is the aim of Dr.' Maudsley's book.'"— /.o«(/o;t Sat. Jiev., May 25, IsliT. 

"The flr-;t rliiiptor is devoted to the consideration of the causes of insanity. It would bo 
well, wo think, if this chapter were publishod in a separate lorm and scattered bromlcast 
throughout the land. It is so full of^ sensible rellectlons and sonnd tnitlis. that their wide 
dissemination could not but be of bcnellt to all thinkin<' persons. In takim; leave of IJr. 
Maudsley's volume, we desire again to express our jTralincalion with the result of his labors, 
and to express the hope that he has not yet ceased his studies in the important field which 
ho has selected. Our thanks are also dne to the American publishers for the very hands<mic 
manner in which they have reprinted a work which is certain to do credit to a house already 
noted for its valuable publications."— f^Mar. Journal of J'fycftolo'jkal MtdiciM and Medical 
Jurisiirudence. 

"Then follow chapters on the diamosis, prognosis, and treatment of insanity, each 
characterized by the same bold and brilliant thoniiht, the same clmrmins; style of composi- 
tion, and the eamo sterlini; sense that we have found all through. We lay down the book 
with admiration, and we commend it most earnestly to our readers, as a work of extraordi- 
nary merit and originality — one of those pn.. ictloils that are evidved only occasionally in 
tlie lapse of years, and that servo to mark actual and very decided advances in knowledge 
and science.*'— -V. Y. Medical Journal, January, 18(W. 

" This work of Dr. Maudsley's is unquestionably one of the ablest and most important, 
on the subjects of which it treats, that has ever appeared, and does inllnite credit to his 
philosophical acumen and accurate observation. No one has more successfully exhibited the 
discordant results of mctaphywical., physiological, and pathological studies of the mind, or 
demonstrated more satisfactorily the uselessiiesH of an exclusive method, or the pressiu;' 
need of combined action, and of a more philosophical mode of proceeding."— J/edicoJ 
Record, ^ov. 15, 1867. 

"In the recital of the causes of insanity, aa found in peculiarities of civilization, of roliff- 
Ion, sex, condition, ana particularly iu the engrossing pursuit of wealtli, this calm scientidc 
work has the solemnity of a hundred sermons ; and after going down into this exploration 
of the mysteries of ourboing, we shall come uj) into active life a^'ain cliastened, thoughtful, 
and feeling, perhaps, as we never felt before, how fcarfirily and WDtidcrlulIy we are made."— 
Evening Gazette. 

"Dr. Maudsley's treatise is a valoahlo work, and t'eserves the careful consideration ot au 
who feel an interest, not only in general inctaphvsical facts, but In those manifestations 
which mark the boundaries De';ween health and disease in the luiman mind."— iYtni/rfcne* 
(if. 1.) Journal. 



m 



D. APPLET ON & CO:S MEDICAL PUBLICATIONS. 



Flint's Physiology. 



The Physiology of Man, designed to represent the existing Stale oj 
Physiological Science as applied to the Functions of the Human 
Body. By Austin Flint, Jr., M. D., Prof, of Physiology 
and Microscopy in the Bellevue Hospital Medical College, 
Fellow of the New York Academy of Medicine, etc., etc. 

Vol, I. Introduction. The Blood ; Circulation ; Respiration. 8vo. 

Cloth (tinted paper). $4.50. 

Vol. II. Alimentation ; Digestion ; Absorption ; Lymj)]!, and Cliylc. 

Cloth (tinted paper). $4.50. 

" Before tlio Issue of the first rinrt we entertained the opinion in common with others that 
there was no room for a toxt-book on pliygiolojry, and tliat a pliyslclan of his (Dr. F.'e) learu- 
Ini; anil acijniremeiits conld more advantageously employ his time in experimental research 
than in wntinp; a Bystcmatic treatise. Dr. Flint has convinced us that we were mistalieu la 
this view. Wc accept the two volumes already issued as evidence of wliat wo may exnect 
In the rcmalninppart of tlie series. Wo reijard them as tlio very best treatises on humiiu 
pliysiology which the Kiifilish or any other liin<;uai;e affords, and wo recommend them witli 
tlioroufrli confldence to students, practitioners, and laymen, as models of lilcrury and scien- 
tific ability."— X Y. MeUical Journal, Oct., 1807. 

" The treatise of Dr. Flint is as yet incomplete, the flr.st two volumes only having: been 
published ; but if the remaining portions are compiled— for I'vcry physiolot;lcal worlc em- 
bracing the whole subject must be In a great measure a compilation- with the fame care and 
accuracy, the whole may vie with any of those that have of lute years been i)roduccd in our 
own or in foreitjn languages."- ii/vYisA unil Foreign Medico- C/drurgical Ittview. 

"The second of the series has just been published, and is now before ns. It treats of the 
great function of Nutrition under the several heads of Alimentation, Digestion, Abr^orjition, 
tlie Lymph, and Cliyle. Upon these topics the author bestows the same judicious caro and 
labor which so eminently characterize the first volume. Facts are selected with discrimina- 
tion, theories critically exaiiilnc<l, and conclusions enunciated with comniendahlo clcaruess 
and precision."— .dwenca/i Journul of the Medical Sciences. 

"Judginfj fl-om the able manner in which this volume is written, the series, when per- 
fected, will 1)0 <me of those publications without which no library is ccmipleto. As a book 
of general information, it will be found useful to the practitioner, and as a book of reference, 
invaluable in the hands of the anatomist and physiologist."- Z/uWi/i (Quarterly Jownal or 
Medical Science. 

"The work is calculated to attract other than professional readers, and is written with 
sufllcient clearness and freedom from technical pedantry to be perfectly intelligible to any 
well-informed man."— London Saturday lieciew. 

"From the extent of the author's investigations into the best theory and practice of the 
present day the world over, and the candor and {jood judi'ment which he brings to bear upon 
the discussion of each subject, we are Justified in regiiruing ills treatises as standard and 
authoritative, so far as in this disputed subject authority is admissible."- *V. 1'. 'limes. 

"The complete work, judging from the present instalment, will prove a valuable addil inn 
to our siystematic treatises on hiiman physiology. The volume belore us is executed with 
conscientious care, and the stylo is readable and clear. It is a volume which will be wel- 
come to the advanced student", and as a work of reference."- Zo/irfwt Lancet. 

"These excellent monographs offer the most complete summary of the pliysioloi.'icai 
knowledge of our day yet written in America, They are brought down to the most recent 
advances of the science, and include the results ol a number of original experiments. ".- 
PhUadelptda Medical Jie^wter. 

"The leading subjootfl treated of are jjrescntcd in distinct parts, each of which is do- 
elgned to bo an exhaustive essay on that to wliieli it kUgk."— Western Journal of Medicine. 

" The interesting feature of the work is a recital of typical experiments, which a.'c timely 
and judiciously introduced to imprees the facts upon the mind of tho reader. It is printed 
In elegant style, and may be considered a model in the typographical line."— J/f(/. Jiecord. 

" We have found tho style easy, lucid, and, at the same time, terse. Tlie practical and 
positive results of physiological investigation are succinctly stated, without, it would seem, 
extended discussion of disputed po'mte."— Boston Medical and Surgical Journal. 

" To those who desire to get a concise, clear but at tho same time sufllciently fnii re- 
sume of the existing state of physiolopcal science, we heartily recommend Br. Flint's work. 
Moreover, as a work of tvpogra'phlcal art, it deserves a prominent place upon our library 
Biii:\vci"— Medical Gazeite, \. r. 



I 



X» APPLETON & CO:S MEDICAL PUJiUCATIOXS. 



W\ 



ii 



Pi 



Elliot's Obstetric Clinic. 

A Practical Contribution to the Study of Obstetrics and the Dis- 
eases of Women and Children. By George T. Elliot, Jr., 
A. M., M. D., Prof, of Obstetrics and the Diseases of Women 
and Children ii' tlio BcUcvuo Hospital Medical College, Physi- 
cian to Bellevuo Hospital and to the New York Lying-in Hos- 
pital, etc., etc. 8vo, pp. 458. . . Cloth, $4,50 

This voliiiiie, by Dr. Elliot, is based upon a largo experience, including fourteen 
years of service in the lying-in department of Bellevue Hospital of this city. Tho 
book lias attracted marked attention, ond has elicited from tho medical press, both 
of this country and Europe, tho most flattering commendations. It is justly be- 
lieved that the work is one of the most valuable contributions to obstetric literature 
that has appeared for many years, and, being eminently practical in its character, 
cannot fail to bo of great service to obstetricians. 

" Tho volume by Dr. Elliot has scarcely loss value, althonsh In a ^ilfferont direction, than 
that of the Edinburiili phy." icinn (Dr. Dimcan, lienearches in ObMelrlcs). Tlio matorkils com- 
prisina; it liave hcon principally {jatlicrcd thronsih a pcrvico of fourteen years In the Bulluvuo 
Ilospltal, New York, during tho whole of which time tho author has been eniraired in clini- 
cal teachius. The cases now collooted Into a handsome voliiuio illustrate faithfully the anx- 
ieties and disappointraents, as well as the fatli^ues and bucoosscs, which are iiiseparablo 
from the rospousihle practice of obstetrics— a line of practice which, under difllcultlcs, de- 
mands tho greatest moral coiira^o, the highest skill, and the power of acting promptly on a 
sudden emergency. Dr. Elliot's favorite subject appears to bo operative uiidwitery; hut 
the chapters on tho relations of albuminuria to pregnancy, ante-partum hminorrhage, tho in- 
duction of labor, and tho dnngors which arise from compression of tlie funis, are ali'dcsorving 
of careful perusal. Tho ploasnre we feel at being able to sneak so favorahly of Dr. Elliot's 
volume is enhanced by tlio circumstance that lie was a pupil at the Dublin Lying-in Hospital 
when Dr. Shekelton was master. We can certainly say that his teachings roiled groat credit 
upon Ills Alma Mater."— J^iidon, Lancet, April 11, 1808. 

" This may bo said to belong to a class of books ' after tho practitioner's own heart.' In 
them he finds a wider range of cases than comes under his observation in ordinnrv practice; 
in them he learns the application of tho most recent improvements of his an ; In tliem he 
finds tho counterpart of cases which have caused him tho iloepest anxiety ; in tliom, too, ho 
may And consolation, for the regret— tho olTspring o. limited experience, wliicli has always 
cast a shadow on the remembrance of some of his fi^tal cases— will pass away at- lie reads of 
similar ones In which far greater resources of every kind failed to avert a fatal torininntion. 

" There are not many books of this kind In our language ; they can probably all bo num- 
bered on tho lingers of a single hand. ♦ * * Many circumstances concur, therefore, to intlu- 
ence us to extend to this work a ciieerfnl welcome, and to commend it as fully as possible. 
We do tlms welcome it; as the production of a gentiemanof great experience, acknowledged 
ability, and high jiosition— as an emanation from one of tho leadinij schools of our country, 
and as an honomble addition to our national medical literature.''— ^l»»€r/ca» Journal qf 
Medical Science, April, 1808. 

"As the book now stands, it Is invaluable for tho practitioner of obstetrics, for he will 
hardly ever in practice find liiinsclf In a tight place, the counterpart of which he will not 
find in Dr. Elliot's book."— New York JfeUicalJournal, February, 1808. 

" The book has tho freshness of hospital practice throushout, in reference to diagnosis, 
pathology, thoraixnitical and oporativo proceedings. It will be found to possess a great 
amount of v.aluahlc information in the department of obstetrics, in an attractive and easy 
style, according to tho most modern and improved views of the profession." — Cincinnati 
Lancet and Observer, April, 1808. 

" As a whole, wo know of no similar work which has issued from the American press, 
which can be compared with it. It oiifjht to be in tho hands of every practitioner of mid 
wlfery in the country."— Z/osto« Medical and Surgical Journai. 

" One of tho most attractive as well as forcil)ly instructive works we have had the 
pleasure of reading. In conclusion, we recommend it as one having no equil in the English 
language, as regards clinical instruction in obstetrics."— -Iffi. Jour, of Obstetrics, Aug., 1803. 
Many ripe, elderly practitioners might, hut few young could, write a book so distin- 
jjuished '"y candor, want of prejudice, kindly feeling, soundness of judgment, and extent of 
erudition. While we do not say the book Is faultless, we say there is no book in American 
obstetrical literature that surpasses this one. • ♦ * ♦ The work now under n^vicw is 
his flrst-bom book or volume, and shows how fine opiiortnnities ho has liad, cliielly at Belle- 
vue Hospital, for acquiring experience, and bow diligently ho has availed himself of them. 
But his book shows much more. It Is tho work of a physician of hlL'h eiiiication. a qualifi- 
cation m which ohstetric autliors are often del'nient— it shows qualities of mind and ekUl 
of hand rarely attained by so young a ma.a.'"— Edinburgh Medical JoumcU, Feb., l.-iiw.