236. Suspended Animation Hanging, Drowning, etc.
DROWNING is the most common cause of suspended animation, though cases of hanging and of suffocation from noxious gases occasionally occur.
SYMPTOMS- There is no breathing or action of the heart perceptible; the eyelids are generally half-closed; the pupils dilated; the jaws clenched; the fingers semi-contracted; the tongue appearing between the teeth, and the mouth and nostrils are covered with a frothy mucus. Coldness and pallor of surface increase.
TREATMENT- Not a moment’s time should be lost. The patient should be attended to immediately, on the spot, while remedial aids are being fetched. All mere spectators and useless helpers should be sent away, as the admission of abundance of pure air to the patient is of first importance. When a drowned man is taken from the water, he should be first turned on his face to allow the escape of water from his mouth and throat. Artificial respiration should then be attempted.
The directions for restoring the apparently dead, recommended by that noble organization, the Royal Humane Society, are so concise and complete, that we cannot do better than reproduce them, with a few alterations.
The points to be aimed at are first and immediately, the RESTORATION OF BREATHING; and secondly, after breathing is restored, the PROMOTION OF WARMTH AND circulation.
Figure I. INSPIRATION.
Figure II. EXPIRATION.
To illustrate the position of the body during the employment of the Method of inducing Respiration.
TREATMENT TO RESTORE NATURAL BREATHING.
To maintain a Free Entrance of Air into the Windpipe. Cleanse the mouth and nostrils from dirt, saliva, etc. open the mouth; draw forward the patient’s tongue, and keep it forward; an elastic band over the tongue and under the chin will answer this purpose. This drawing forward of the tongue is very important, as it opens the windpipe, and must therefore never be omitted. Remove all tight clothing from about the neck and chest.
To adjust the Patient’s Posture- Place the patient on his back on a flat surface, inclined a little from the feet upwards; raise and support the head and shoulders on a small firm cushion or folded article of dress placed under the shoulder blades.
To Imitate the Movements of Breathing- (See engravings.) The operator, standing or kneeling behind and at the head of the patient, should grasp the patient’s arm just above the elbows, and draw the arms gently and steadily upwards, till they meet above the head (this is for the purpose of inspiration, or drawing air into the lungs), and keep the arms in that position for two seconds. He should then turn down the patient’s arms, and press them gently and firmly for two seconds against the sides of the chest (this is with the object of pressing air out of the lungs, expiration).
If an assistant compress with both hands, flat, the lower parts of the ribs and diaphragm, when the patient’s arms are turned down, the expiration will be facilitated. The operator and assistant must carefully act together.
As the process of artificial respiration is laborious, the best qualified assistants should be selected to take turns with the operator; but changing places must be rapid, that not a single respiratory movement may be missed.
Repeat these measures alternately, deliberately, and perseveringly, fifteen times in a minute (the difficulty is to prevent the too rapid movements of over-zealous assistants), until a spontaneous effort to respire is perceived, immediately upon which cease to imitate the movements of breathing, and proceed to INDUCE CIRCULATION AND WARMTH according to Rule 5.
Should a warm bath be procurable, the body may be placed in it up to the neck, continuing to imitate the movements of breathing. Raise the body in twenty seconds in a sitting position, and dash cold water against the chest and face, and pass ammonia under the nose. The patient should not be kept in a warm bath longer than five or six minutes.
To excite inspiration- During the employment of the above method, excite the nostrils with snuff or smelling-salts, or tickle the throat with a feather. Rub the chest and face briskly, and dash cold and hot water alternately on them.
The efforts to restore life must be persevered in until the pulse and breathing have ceased for at least an hour, for well- attested instances of resuscitation are on record, after several hours of suspended animation.
Another method of effecting artificial respiration is by catheterism of the trachea. “The operator inflates from his own chest; but as he is able to drive in much more air than is absolutely necessary, its impurity is of no great consequence. An assistant must empty the patient’s lungs by compression of the thorax between the insufflations.”
TREATMENT AFTER THE RESTORATION OF NATURAL BREATHING.
Rule 5.-To induce Circulation and Warmth- Wrap the patient in dry blankets and commence rubbing the limbs upwards, firmly and energetically. The friction must be continued under the blankets or over the dry clothing.
Promote the warmth of the body by the application of hot flannels, bottles or bladders of hot water, heated bricks, etc., to the pit of the stomach, the armpits, between the thighs, and to the soles of the feet. Warm clothing may generally be obtained from bystanders.
On the restoration of life, when the power of swallowing has returned, a teaspoonful of warm water, small quantities of warm wine, warm brandy-and-water, or coffee, should be given. In some cases, an enema of beef-tea and brandy is to be preferred to administration by the mouth. The patient should be put into a warm bed, in a room well ventilated, and encouraged to sleep. Great care is requisite to maintain the restored vital actions, and at the same time to prevent undue excitement.
In cases of Suffocation from Hanging, the treatment is much the same, after the body has been cut down, and the ligature removed from the neck.
When a Stroke of Lightning has produced Asphyxia, the body should be dashed for ten or fifteen minutes with abundance of cold water to promote reaction. The body should also be diligently rubbed. But artificial respiration should be resorted to. A current of electricity passed through the chest, from breast to back, may prove beneficial.
237. Concussion of the Brain.
DEFINITION- An interruption to the functions of the brain, from a blow or other mechanical injury of the head; it may vary in degree from a slight —— extinction of life.
SYMPTOMS- Partial or complete insensibility—— face; rapid, irregular, small or imperceptible—–slow, shallow, irregular breathing; cold —– etc. By shaking the patient, or calling his name loudly in his ears (which, however, should never be done), he may give a surely answer, and soon become insensible again. After a time, longer or shorter according to the severity of the injury, reaction comes on, and consciousness returns, with rise of temperature (101 degree to 102 degree F.), and some irritability; often there is vomiting. At first the reaction may be imperfect; it is often several days or even weeks before the power of the mind is restored.
TREATMENT- Arnica. Place two pilules upon the tongue, or moisten it with a few drops of the tincture by means of a feather or quill, and repeat the dose every hour for several times.
Aconitum- Should be administered alternately with Arnica if fever attend the return of consciousness. But if there be danger of cerebral disturbance headache, flushed face, or other head- symptoms Aconite and Belladonna should be alternated. Opi. Stertorous breathing; constipation, remaining after concussion. Hyoscyamus Delirium, low or furious. A dose every one, two, or three hours.
GENERAL TREATMENT- The patient should be placed in a warm bed, with his head at first moderately low, and warmth applied to his extremities and axillae. On no account should he be induced to eat or drink; he must also be kept very quiet, and no attempt made to arouse him. When reaction comes on, the head and shoulders should be raised a little, and cold evaporating lotions applied, keeping the patient at the same time in a cool, quiet room, with the light modified, and noise and conversation shut out. He must be under care for two or three weeks, lest some insidious inflammation should arise within the head.
238. Burns and Scalds.
DEFINITION- An injury produced by radiated heat from any hot body, or by the direct contact of hot solid, liquid, or gaseous substances.
A burn is comparable to roasting and a scald to boiling.
VARIETIES- (1) The Erythematous, producing mere redness, and soon terminating in resolution; (2) The Vesicated, in which the inflammation leads to the formation of vesicles, which, in slight cases, soon dry up and heal; or if the skin has been much injured, may be succeeded by obstinate ulcers. (3) Leading to destruction of the skin and more or less of the deeper tissues. It involves all the dangers of inflammatory fever, and septic absorption. This variety, although usually exempt from pain, is by far the most serious.
The after effects of burns and scalds upon the body generally have been divided into three stages:-
1. Shock and collapse.
3. Suppuration and sepsis.
The stage of shock usually lasts from twenty-four to forty-eight hours, and varies in severity with the “superficial area” of the body involved, the degree of the burn, and the age of the patient. Shock is commonly most profound in infants, though pain is often not marked, even in the gravest cases. The pulse is rapid and frequently imperceptible at the wrist; the temperature is lowered and often to such a degree that the clinical thermometer is unable to register the fall; the surface of the body is cold and covered with sweat; thirst is extreme, and the child constantly cries out for something to drink.
TREATMENT- The majority of patients when first seen are in a state of profound shock, urgently calling for treatment. Every effort must be made to get the patient warm and to restore the failing circulation. In the case of a child as a substitute for the some what inefficient hot-water bottle, a thirty-two candle- power electric lamp is placed beneath the cradle which covers it and the temperature of the air can thus easily be maintained at about 103 degree F., until shock has passed off. “Normal saline solution” ( a teaspoonful of common salt to a pint of water) at l05 degree F. should be very slowly injected into the rectum every few hours in quantities varying from two ounces for a small child to a pint for an adult. Half a drachm to half an ounce of brandy may be conveniently added to the saline, especially when it is difficult to administer everything by the mouth.
One of the most satisfactory solutions to employ as primary dressing is Picric acid, 1 1/2 drachms, absolute alcohol 3 ounces, distilled water 40 ounces. Gauze or lint should be lightly wrung out of this solution, and applied all over the burnt areas, which are then covered with antiseptic wool and bandaged. A point to be insisted on is that no water proof covering of any kind should be used. Dryness of the dressing should be aimed at. Picric acid seems to have in some cases at any rate, a fairly marked action in relieving pain. It possesses also the property of encouraging and assisting the growth of the new tissue.
A most important object to be attained is to cover the injured part with some suitable material that shall exclude atmospheric air. This can only be attained when the skin is unbroken. All blisters must be snipped away. One of the following local applications is recommended:-
1. Carron Oil- A combination in equal parts of linseed oil and lime water. Named from the great Carron iron works, where it is used by the workmen when suffering from burns.
2. Carbolic Acid and Olive Oil- One part of the Acid (as prepared for medical use) to twelve parts of Olive Oil, is found to be invaluable in most cases, slight or severe. It is cleaner, more easy of application, and more soothing than most other remedies. One layer of lint put on at first should not be removed; this should be kept saturated by the removal of outer layers from time to time. When the wound is healed it is easily and comfortably dispensed with. As a domestic remedy, it is recommended to be kept always ready for burns and scalds, just as Arnica, Calendula, etc., are kept ready for other kinds of accidents.
The application of a lotion of Urtica Urens (twenty drops of the tincture to an ounce of water) in the simplest cases, or of Cantharides (ten drops of the tincture to an ounce of water) when blisters are forming, by means of cotton-wool, is of great service. Kreas. is also sometimes useful.
3. Soap- Moisten white or brown soap in water, and rub it on a piece of linen so that the soap forms a coating on the linen as thick as a shilling, and larger than the wound it is intended to cover, so that it may the more perfectly exclude the air.
4. Flour or Starch- One of these may be used as a substitute in the event of either of the above not being at hand. Wheaten flour and finely-powdered starch should be uniformly and thickly applied by an ordinary dredger, so as to form a thick crust by admixture with the fluids discharged from the broken surface, thus excluding the air; and repeated when any portions fall off. Flour is, however, inferior to Carron Oil or Carbolic Acid, and its after-management is more difficult.
The points of greatest importance are immediate application of the local remedy, complete exclusion of atmospheric air, and infrequent changing of the dressings not, indeed, until they have become loosened or foetid from the discharges. A complete change of dressing often causes pain, depression, and the detachment of portions of the new skin, and so retards the cure.
When, after the removal of the first dressing, ulcers exist, Boracic ointment is the best dressing. Calendula or Glycerine cerate, or a mixture of Urtica Urens and Olive Oil (one part to six), are also suitable applications. Any discharge should be carefully removed, and the parts kept as clean as possible.
Internal treatment, except in slight cases, is always necessary, and must be suited to the part injured, its extent, and the constitutional symptoms present. As a general rule, Aconite, early, does good, by allaying febrile symptoms, mitigating pain, and moderating reaction. Arsenicum is valuable if ulcers form, or if the burn present a gangrenous appearance. Secale and Carbo V are also useful in the latter condition.
239. Contusion Bruise.
DEFINITION- An injury inflicted on the surface of the body by mechanical violence, without laceration of the skin. It may be either slight, involving only the rupture of minute subcutaneous blood-vessels, and perhaps the tearing of some muscular fibres, or a large blood-vessel may be torn; or even disorganization of the tissues beneath the skin may be caused, as from the dull force of a spent cannon-ball. The remarkable properties of elasticity and toughness possessed by the skin often permit serious damage to its underlying structures while it remains entire.
CAUSES- A blow from a hard, blunt body; forcible pressure between two forces, as a wheel passing over a limb; or, indirectly, as when the hip-joint is contused by a person falling on his feet from a height.
TREATMENT- In the less severe form of bruises which alone are prescribed for here, the object should be to excite, as speedily as possible, the absorption of extravasated blood. To this end the bruised part should be raised, and a warm Arnica lotion (one part of the strong tincture to ten of water) immediately applied by saturating lint with the lotion, and covering it with oil- silk, to exclude the air. The value of this application is undoubted, and happily is now becoming generally recognized. If the patient have a predisposition to Erysipelas, Hamamelis should be used instead of Arnica In contusions involving glandular structures, as the female breast, Coni. is recommended; or when the covering of bone, as of the shin, is involved, Ruta. When pain or tenderness has subsided, a bandage should be applied.
ECCHYMOSIS- This is discoloration of the skin following a bruise, and is produced by extravasated blood under the skin. It is first of a reddish colour, but speedily becomes black. During recovery, the parts change, first to a violet colour the line which defined the bruise becoming indistinct afterwards to a green, then yellow; and thus, sooner or later, according to the health of the individual, or the quantity of blood poured out, the discoloration disappears. Black-eye is a common instance of ecchymosis.
Arnica lotion has great power in preventing this condition if used immediately after an accident. When extravasation has already occurred, Hamamelis lotion (one part to six of water) is more appropriate.
240. Sprain Strain.
DEFINITION- An overstretching of the ligaments and tendons generally with a rupture of some of their fibres.
TREATMENT- The immediate treatment consists in the application of hot water, as hot as can be borne, until the pain is considerably modified, followed by a compress of cloths moistened with the lotion of Aconite, Arnica, Rhus, Ruta, or Hypericum and covered with flannel. The remedy used for the lotion may be also taken internally.
Aconite in alternation with Rhus, may be administered when the joint becomes swollen and painful; and when constitutional disturbance attends the injury.
When the swelling and pain subside strong adhesive plaster is applied to support the injured parts, and do away with the necessity of lying up. It should be worn for two or three weeks as the injury may easily be re-induced and then cure becomes both difficult and tedious.
DEFINITION- A forcible solution of continuity of the soft tissues.
Wounds are termed incised, when made by clean-cutting instruments; punctured, when the depth exceeds the breadth, as stabs; lacerated, when the parts are torn and the lips of the wound irregular; contused, when effected by bruising (see Section 227). We may also add that a gun-shot wound is termed penetrating, when the shot is lodged in the part; perforated, when it passes through it; and, according to law, burns.
For poisoned wounds, see Section 216.
TREATMENT- The following are the chief points:
1st- To arrest the bleeding- In most cases, the elevation of the part, keeping the bleeding surface uppermost, and pressure, will suffice. A Calendula lotion tends to arrest haemorrhage and checks suppuration. In severe wounds involving arteries, the parts should be laid open by a surgeon, and the wounded vessels ligatured.
2nd- The removal of foreign bodies- Dirt, hairs, glass, clots of blood, etc., should be speedily removed by forceps, or allowing clean water to trickle over the wound.
3rd- To bring the injured parts into nice apposition- Any muscular fibres likely to prevent complete union should be relaxed or divided, and after the sides of the wound have been accurately adjusted, they must be kept so by strips of adhesive plaster, first applied to that side of the wound which is most movable, and then secured to the other. But, in extensive wounds, where plaster would be insufficient, stitches should be employed.
4th- To promote adhesion- To secure this, the part should be elevated and kept at rest, and if the injury be severe, the patient should remain in bed.
5th- When a wound is dressed, say once in every twenty-four hours, a rag or sponge wetted with warm water should be laid over the dressing, so that it may be removed without the risk of disturbing the surfaces which may have partially united. Lotions may often be renewed by removing the oil-silk only, and dropping lotion on the rag or lint, or pouring it on by means of a spoon, and then replacing the oil-silk.
6th- To control dangerous bleeding, as from a sharp-cutting instrument. When blood flows in a steady stream, and is dark- coloured, it is from a vein, and can generally be checked by elevating the part and applying pressure, such as a pad of gauze or lint held firmly in position by a bandage. A few thicknesses of material, with steady compression, are more efficient than heaping on a large quantity. Bright-red blood, flowing in jets, is arterial, and similar means must be adopted as just pointed out, unless the bleeding be excessive, in which case a hand- kerchief should be tied round the limb, near the wound, and between it and the heart; a stick inserted under the handkerchief and a firm compress over the course of the blood-vessel; the stick should then be twisted until it stops the circulation, and, consequently, the bleeding. But such means are only temporary, as wounded arteries of size require to be ligatured by a surgeon before bleeding can be permanently arrested. If no surgeon can be obtained, a clever manipulator should grasp the wounded artery with a pair of forceps, and draw it slightly and gently forward, so that it may be securely tied by means of a strong ligature of silk; or haemorrhage may be arrested by twisting the end of the artery round and round until it will not untwist itself. The latter method is designated torsion.
7th- Should a wound or bruise be followed by constitutional disturbances fever, chills, and throbbing in the parts internal medicines should be administered.