EMERGENCY TREATMENT IN SUDDEN ACCIDENTS.

If the author reviews his experience of the last twenty years, he recalls to memory innumerable instances in which the lack of a little special knowledge, in cases of sudden accidents, did not only incur useless physical suffering, but cost lives which otherwise might have been saved. Knowledge of this nature is not intuitive, but must be acquired by study. He therefore offers for the guidance of the intelligent reader, common sense advice on the immediate management of accidents which are liable to occur at almost any moment.

If a child falls any considerable distance to the ground, the system receives a shock varying from the slightest functional disturbance to complete insensibility.

In the former case there may probably be only slight pallor of the countenance, the ideas become confused, there is a disposition to yawn and a feeling of nausea. Young children have a disposition to sleep, older ones rub their eyes, stare wildly around and even vomit, but after a short time they resume their accustomed employment: these symptoms illustrate a slight concussion of the brain.

When the injury is more serious all the above signs become aggravated and it may take several hours before the normal condition is restored.

The proper course to pursue in all these accidents is to lay the patient on a sofa or bed, with his head slightly elevated in a darkened chamber free from all noise and confusion and let him fall to sleep. In ordinary cases reaction takes place after a quiet slumber. If however the patient complains of pains in the head and there is irritability of temper, the advice of a competent physician becomes necessary.

(a) Broken bones or fractures are defined to be a destruction of the continuity of one or more of the bones of the body.

Fractures are divided into simple and compound; a simple fracture is one in which the bone alone is broken, and in which the skin or integument over the seat of the fracture remains perfectly intact. A compound fracture is one in which the skin and tissues over the fracture are lacerated or wounded so that the ends of the broken bones protrude or are exposed to view.

In a case of fracture, no matter of what variety, the first object to be accomplished is to carefully remove the patient to a place where he may be in a comfortable position. If the fracture is in the arm or leg it should be comfortably supported on a pillow so as to relieve the injured limb from all strain.

In compound fractures, the wound should be carefully covered with a soft clean compress which is kept thoroughly wetted with clean cold water until the surgeon arrives.

Sometimes the circumstances make it necessary to remove or transport a patient; then the injured limb must be properly supported so that it will remain motionless on the journey. In case the arm is fractured the above object is readily accomplished by placing it in a sling suspended from the neck. In the case of the lower extremities this object is more difficult. The leg should be wrapped in cotton first, or some other soft clean substance, after which a slat should be placed on the outside and inside of the limb, the same length as the limb; over and around these slats strips of muslin or a bandage is wound so as to keep them in place. This contrivance forms a temporary or improvised splint until the surgeon takes charge of the case.

(b) Wounds are defined as a recent sudden solution of continuity in the soft parts or flesh of the body. For the sake of convenience in description and for practical purposes, wounds are divided into incised, lacerated, contused, punctured, and poisoned wounds.

An incised wound is a clean smooth cut made by a sharp clean-cutting instrument.

A lacerated wound is one in which the parts have been torn asunder or in which the instrument was blunt or dull.

A contused wound is one the result of a bruise or blow inflicted with a blunt object or by a flat surface.

A punctured wound is one in which the flesh is pierced with a sharp-pointed instrument, like that made with a stiletto or bayonet.

Poisoned wounds are such as have become infected any time after the receipt of the injury, or which are the result of a bite or sting from a reptile or insect.

The danger of wounds depends on their extent and depth, and upon the locality or organ in which the wound is situated. The external wounds, that is those which admit of inspection, and situated on the head, trunk or extremities are of most frequent occurrence, and the most amenable to treatment.

The treatment of wounds has made wonderful progress since the antiseptic discoveries of the eminent surgeon, Sir Joseph Lister, and these sound principles have materially influenced almost every department of the healing art. It was he who first showed how dust-laden air affected injuriously the exposed tissues of the wounds; it was he who introduced all the precautions as to cleanliness of instruments; the disinfection of hands; the change of clothing; and the purification of sponges and dressings. The magnificent results of the practice of modern surgery are not owing to the superior skill of the surgeon of our time, but to the magnificent conception of the idea of cleanliness from which has grown the entire superstructure of antiseptic surgery, culminating in the grand triumphs of surgical art. To the question What to do with recent wounds? The answer now becomes self-evident; Keep them clean. The best dressing for any clean wound is its own secretion carefully protected from the outside world by a fold of clean soft cloth or absorbent cotton, wetted with pure cold water. This is to be kept in its proper place by means of a bandage, and when it is desirable to remove the compress, it must first be thoroughly soaked with water so as not to tear or irritate the wound.

Before Lister’s great antiseptic discovery it was the generally accepted opinion that suppuration and pus were essential to the healing of wounds; this was an error and the opposite is now established to be the truth. Pus prevents or rather delays the wounds from healing, and suppuration in wounds is a fruitful source of blood poisoning.

If sand, earth, dust or dirt has gotten into or near the wound, it must be washed off with clean, fresh water, but never employ soiled or infected clothes for that purpose for these may poison the wound and do a great deal of mischief. After the wound is clean dress it in the manner described in a preceding paragraph.

Poisoned wounds are chiefly punctured. The danger of these wounds lies in the possibility that the poison is absorbed by the lymphatics and veins, and conveyed to the heart, whence the entire blood becomes infected. To prevent this a ligature should be tied above the wound, by means of a strip of muslin or preferably an elastic suspender, so as to check the free return of the blood by the veins and lymphatics. After which the poison should be sucked from the wound, or the wound should be cauterized, with carbolic or nitric acid by means of a sharp-pointed stick dipped into the acid and then applied to the wound, or fired with a red-hot iron, crochet or knitting needle. The poison of snakes and tarantulas is neutralized with an alkali; the most efficient seems to be spirits of ammonia, but a strong solution of washing or even baking soda should be substituted when ammonia is not at hand. I would puncture and enlarge the wound of the sting with the point of a sharp knife or scissors, so that the alkali can come into immediate contact with the injected venom; the patient must be given frequent drinks of whisky, brandy or strong wine until a physician arrives to supervise further treatment.

Wounds inflicted by poisonous insects like the bumblebee, honeybee, wasp, hornet, yellow jacket and mosquitoes produce wounds which are instantly followed by a sharp, pungent, itching pain, and in a few moments after by a pale, circumscribed, inflammatory swelling. Some persons have a peculiarity in their constitution that the poison of an insect gives rise to exceedingly alarming symptoms, such as palpitation, nausea, dizziness, dimness of sight and an indescribable sense of suffocation. The sting is sometimes left in the skin; for this the wound should be carefully examined, and when present drawn out. The most prompt and useful application is water of ammonia, or strong salt water, or strong soapsuds. Turpentine is also a valuable application. If the insect has lodged in the throat, large quantities of warm salt water and mustard must be immediately administered until the patient has vomited freely, and if there is a sense of suffocation leeches and afterwards hot poultices should be applied to the neck. If the system has become poisoned, and some of the distressing symptoms that were above enumerated are present, the internal use of whisky or brandy is called for.

Hemorrhage is common to all wounds, and the loss of the blood depends upon the size and nature of the vessel that is injured.

The bleeding that takes place in ordinary superficial wounds oozes from minute vessels, the capillaries, and slight pressure temporarily applied controls it. When an artery is wounded, the blood flows in intermittent jets, or in a running pulsating stream from the vessel. The venous blood is dark red and flows in a continuous stream and not under the same pressure as that coming from the arteries, hence it is much easier controlled.

The clotted blood with which a wound may be filled, is nature’s means of arresting the hemorrhage, and it must never be disturbed or washed off, lest this open the blood vessels again and thereby renew the bleeding.

The arrest of hemorrhage is accomplished by the application of cold or ice water, by hot water and by pressure upon the arteries. Persons fainting from the loss of blood should always be laid with their heads lower than the body; cold water should be dashed into their faces so as to restore them to consciousness. Moderate hemorrhage from the smallest vessels and from the veins generally ceases from slight pressure over the wounds or by drawing or pressing the edges of the wounds together. In a very short time the blood coagulates and forms a temporary plug until the vessels themselves become permanently sealed by a similar process. The pressure must often be continued for a considerable time until the object has been attained. A folded clean cloth or compress is laid over the wound which is the source of the hemorrhage, and this is retained by means of a properly adjusted bandage. If notwithstanding the pressure exerted by the bandage or with the hands, the scarlet blood saturates the cloth and continues to flow, it indicates that a very large vessel is wounded, and thus life may be seriously threatened and in proportion to the magnitude of the wounded vessel, a surgeon should now be summoned to make a further investigation. Hemorrhage from varicose veins of the legs may be checked by a compress fastened over the site of the wound by a bandage, but every constriction around the waist or above the knee by a garter must be loosened. If the patient’s life is threatened from the bleeding, the limb must be elevated, and the pressure of the compress increased, or the pressure should be exerted on the trunk of the bleeding artery above the wound or injury.

(c) Burns and scalds are the most commonly fatal injuries which occur in modern life. The extended use of steam machinery, the universal employment of coal oil, the general use of the phosphorus and sulphur matches, and the flowing manner of woman’s dress has materially increased the liability of this accident. Of all accidents, burns involve the victim in the most agonizing pain and protracted suffering. Burns are liable to serious complications; the obstinacy to the healing of vast ulcerated surfaces, or the lifelong mutilation to which they condemn the unhappy patient, the rapid draft they make on the patient’s strength, and the danger of abscess and ulceration of internal vital organs which eventually destroy life.

These injuries have been classified into three divisions: First degree, superficial skin irritation. Second degree, cutaneous inflammation. Third degree, devitalization of the skin or deeper parts, or carbonization of a member, or the entire body. The first degree is only a superficial redness, fading without any definite edge into the natural skin. This may be produced by the sudden and momentary application of flame over a larger portion of the body, from an explosion of gas. The local injury is not dangerous, and the epidermis remains to protect the surface of the true skin until a new layer is produced, as the injured one peels off. This hardly calls for any other treatment but one or several applications of sweet oil. In the second degree, the local injury has penetrated a little deeper, and the sudden congestion of blood to the surface, raises the epidermis from the cutis in blisters filled with the serum of its vessels. Here there is a more serious condition, and indeed dangerous in proportion to the extent of surface that has become involved. Skirts draped largely with lace, and those made of cheese cloth, swiss, and other gauzy material are of a very inflammable nature, and when once ignited blaze into a flame that is almost sure to consume the material before it can be extinguished, so that it has been deemed advisable on the German stage, to first saturate these materials in a solution of sulphate of ammonia to make them non-inflammable; this does not interfere with ironing, nor with the texture or color of the fabric. Another source of scalds and burns is the wash boiler or tub on the floor, with hot or boiling water in it, so that little children stumble or reach into it. Vessels filled with hot water or other fluids standing on tables or on stoves within reach of little children, who innocently pull the vessel down, pouring its scalding contents over them, is another cause of numerous accidents.

The best course to pursue when skirts or clothing are on fire is to roll the victim, so as to smother the flames; but the patient herself has rarely enough presence of mind to do this. She will run for help, thus fanning the flames, the very worst thing she can do. Take the nearest blanket or quilt, or if that is not at hand, take an overcoat or wrap; wrap this around the burning person and throw her to the floor and roll her until the flames are smothered. Then get some cold water and pour it on the smoldering clothes until they are thoroughly saturated, for the hot charred clothing burns into the flesh. In scalding from hot water or steam the clothing should be cooled off in the same manner. Cold water must be poured over the hot and steaming clothes from head to foot, and thus the further action of the heat is suddenly checked. The patient should now be carefully removed to a warm room and laid in a blanket, on the table or floor. If he complains of thirst give a cupful of warm tea or a warm whisky toddy.

Visitors and strangers should now be requested to leave the room and the clothing should be removed from the body with the greatest care. The scissors or a sharp knife should be used to cut away the garments, so as to avoid all possible straining and dragging on the patient. The blisters must not be torn, and where they are very tense they can be pricked with a sharp needle, so as to allow the escape of the serum. The epidermis forms the best protection for the cutis, and where the skin is stuck to the linen do not tear this off, but allow it to remain and cut with a sharp scissors around it. The application of cold water generally increases the suffering, but sweet oil, lard oil, vaseline, castor and china nut oil will answer for the emergency or until a more suitable dressing can be obtained, after which the surface should be covered with cotton batting to exclude the air. A very useful application is a mixture of equal parts of lime water and sweet oil or linseed oil. Carbolized sweet oil is another useful dressing and superior to lime water liniment; it is made in proportion of half an ounce of carbolic acid to one pint of sweet oil; either of the above preparations can be poured over the burned surface and then it should be covered with cotton batting, or small pieces of soft linen cloth can be dipped and saturated in the oil and then applied over the burns. The advice of a physician should be sought in view of the dangerous complications that may occur from extensive burns.

(d) Frostbite is the result of exposure to cold, and in certain regions during the winter months a considerable number are liable to this accident. But extreme cold weather is not alone responsible for frostbite; very often this accident occurs in moderately cold weather, for instance, if persons exhausted from hunger or fatigued from long travels or stupefied by alcoholic drink lay themselves down and fall asleep, and a cold wind blows over them which withdraws the bodily heat, the same effects are accomplished on the system.

The first effect of dry, cold air is a sense of numbness and weight, with a peculiar prickling or tingling, and a rush of blood to the surface, giving the skin a lively reddish appearance. If the cold is maintained for any length of time the blood leaves the surface, which becomes now of a pale and whitish aspect, forming a striking contrast to the previous redness. When the cold is suddenly applied and very intense, the skin exhibits a mottled appearance, which is due to the presence of congealed blood in the subcutaneous veins.

Moist cold has a similar effect on the living tissues to dry cold. If the hand is immersed in iced water the blood rushes immediately to the surface, so that the color of the skin increases, which is followed by a marked degree of numbness, and an unpleasant burning and tingling sensation. A reaction comes on in a short time, the blood quits the surface, and the skin becomes bleached and contracts, the tissues underneath also shrink and become painful. There is no difference in the effect of either moist or dry cold, only that the former is more penetrating and its effects are sooner apparent. Those parts of the body that are more directly exposed and in which the circulation is not much protected by fatty tissue, suffer the most from the effects of cold; after exposure for an unusual length of time the toes, feet, heels, fingers, hands, nose, and ears, together with the lips and cheeks are for this reason oftener affected than other parts of the body. Persons whose constitutions are broken down by intemperance, starvation and other privations which lower the power of resistance are more susceptible to this accident.

The first effect of cold in the general system is bracing and stimulating; an agreeable glow is felt over the surface of the body and one feels strengthened and exhilarated. But if the cold temperature is unusually prolonged this agreeable sensation is changed into one of pain and drowsiness; the brain becomes inactive as if under the influence of a powerful opiate or narcotic, and the desire to go to sleep is so strong that it requires the greatest effort to keep awake. To yield to this inclination to sleep would result in slumber that knows no waking, for the blood would now rapidly accumulate in the internal organs, the breathing would become irregular and spasmodic, the nervous functions would soon be suspended and death would ensue from general paralysis. An individual thus exposed, so as to have become drowsy or unconscious and then suddenly brought into a hot room is likely to die from congestion of the brain and lungs, or if he should revive for a short time, the frost-bitten parts will be stricken with mortification. Professor Samuel D. Gross says: “The treatment of frostbite requires no little judgment and adroitness to conduct it to a successful issue. The great indication is to recall the affected parts gradually to their natural condition by restoring circulation and sensibility, in the most gentle and cautious manner, not suddenly, or by severe measures. The first thing to be done is to immerse them in iced water, or rub them with snow, the friction being made as carefully and lightly as possible, lest overaction be produced, as they are necessarily greatly weakened. If no ice or snow is at hand, the coldest well water that can be procured must be used; and if immersion is inconvenient, wet cloths are applied, with the precaution of maintaining the supply of cold and moisture by constant irrigation. Moderate reaction is aimed at and fostered. All warm applications, whether dry or moist, are scrupulously refrained from; the patient must not approach the fire, nor immerse his limbs in hot water, or even be in a warm room. Attention to these precepts must on no account be disregarded, as its neglect would be almost certainly followed by mortification or other disastrous consequences.”

(e) Drowning or the submersion of an individual until life is destroyed by suffocation is not an uncommon accident. “The immediate cause of death in drowning,” says Dr. Gross, “is suffocation or insufficiency of air. Respiration being thus arrested, the blood is unaerated and consequently unfitted for life, although the circulation may go on for a short time after breathing has completely ceased.”

The Navarino sponge divers whose occupation has accustomed them to live under water the extreme limit, average only seventy-six seconds, while the Ceylon pearl divers seldom remain under water with impunity more than two-thirds of that time.

Dr. Gross says: “The period at which a person after submersion may be resuscitated varies very much in different cases and under different circumstances. In some cases, for reasons not always explicable, recovery is found to be impossible at the end of one minute. The chances are never good after submersion of twice this length of time, especially when the water and the air are both uncommonly cold.

“The treatment of apnoea from drowning must be prompt and decided. Every moment of time is most precious. The body being removed from the water to a dry place, is immediately stripped, wiped, and covered with a blanket, especially in cold weather. The mouth, nostrils and throat are cleared of mucus, froth, and any other substances likely to interfere with the admission of air to the lungs; the tongue is to be pulled out at the corner of the mouth, and prevented from falling back upon the glottis; ammonia is rapidly passed to and fro under the nose; and the body is stretched out at full length with the face downwards, the forehead resting upon one arm, for the purpose of allowing any water that may be in the stomach and air passages to escape by the mouth and nose. If these means do not speedily revive the patient, artificial respiration is instituted. For this purpose, the body being placed upon its back, with the head slightly elevated, the arms, grasped just above the elbows, are carried outwards and upwards from the chest almost perpendicularly, and retained in this position for about two seconds, the object of the procedure being designed to promote the introduction of air into the lungs as in natural breathing. They are then lowered and brought closely to the sides of the chest, where they are held for the same length of time, to expel the air, the effect being aided by pressure applied to the inferior and lateral portions of the chest. These alternate movements of elevation and depression from twelve to fourteen times a minute, and are performed with all possible gentleness. As soon as signs of life are observed, dry warmth should be applied to the extremities, the region of the heart, loins, and abdomen, a little brandy and water being administered, or if deglutition be impracticable, thrown into the rectum.”

(f) Poisons and their antidotes form an important subject for our consideration, because many of the poisons are among the most useful remedies. The daily accounts in the public press of serious and fatal mistakes in the administration of medicines, are always due to carelessness and very often to criminal negligence.

No package or bottle should be kept about the house without its proper label.

Those that contain poisonous drugs or chemical preparations should be plainly marked Poison, besides the name of their contents.

Vials or packages containing poisonous drugs or chemicals must not be kept on the same shelf and near those medicines that are comparatively harmless.

Always look at the label twice; once before the contents are poured out, and a second time, before the dose is swallowed. Never take medicine in the dark, in the belief that you are certain of the right vial and locality; many a sad accident has occurred from this venture.

Sulphuric, nitric, and muriatic acid cause great heat and a sensation of burning pain from the mouth down to the stomach. Acids are neutralized by alkalies, hence one teaspoonful of washing soda or two teaspoonfuls of bicarbonate of soda dissolved in a pint of water should be drunk as soon as possible: chalk or powdered magnesia mixed with water will also answer the purpose.

Oxalic acid is frequently mistaken for Epsom salts; lime water, chalk or magnesia mixed with water and taken in large quantities are antidotes: then administer emetics, which act more quickly if the stomach is filled with fluids; sometimes the finger run down the throat will excite quick and sufficient vomiting.

Creosote and carbolic acid benumb the stomach so that emetics usually will not act, and large quantities of sweet oil or castor oil should be first drunk; I prefer the former because from one to two pints of it can be taken; after which lime water or a solution of Glauber salt (sulphate of sodium) should be taken; the latter is especially recommended as neutralizing carbolic acid. When circumstances make it possible the stomach pump or india rubber siphon tube should be at once employed.

Alkalies, for example, caustic potassa, soda, lye, strong solution of ammonia, earths and lime are neutralized by drinking vinegar or lemon or lime juice; afterwards milk in water and flaxseed tea.

Arsenic: Give the white of eggs, lime water or chalk and water; tablespoonful doses of carbonate of iron, mixed with water, or calcined magnesia in the same manner, then evacuate the stomach with an ipecac emetic.

Corrosive sublimate: Give white of eggs, or wheat flour mixed with water; afterwards give an emetic.

Alcohol: First cleanse out the stomach with an emetic, then dash cold water on the head and give frequent doses of aromatic spirits of ammonia in water.

Charcoal or coal gas poisoning: Remove the patient into the open air, dash cold water on the head and body and stimulate by passing ammonia to and fro under the nostrils, at the same time rubbing the chest briskly.

Lead: White lead and sugar of lead should first be treated with alum emetic, afterwards a cathartic of castor oil or Epsom salt.

Nitrate of silver (lunar caustic): Give a strong solution of common salt, and then emetics.

Prussic acid or cyanide of potassium. For this no certain antidote exists, and it destroys life so suddenly as scarcely to allow of use if we had one. When there is time chlorine in solution has been recommended, also water of ammonia and cold affusions.

Opium, laudanum and morphine require the same antidote. If the patient can swallow an emetic should be given; twenty grains of sulphate of zinc and a teaspoonful of powdered ipecac mixed in a draught of water should be given every twenty or thirty minutes until vomiting is insured. A mixture of half teaspoonful of mustard and a tablespoonful of salt dissolved in a pint or quart of warm water is another efficient emetic in these cases. If swallowing is impossible the stomach pump must be used. When the stomach is cleansed out give strong coffee and acid drinks, dash cold water on the head and keep the patient walking.

Belladonna and black henbane: Give emetics, and afterwards a dose of paregoric, and a hot whisky toddy, or a cupful of strong tea.

Nux Vomica and strychnine have no reliable chemical antidote; emetics should first be given, or the stomach washed out with a siphon tube or stomach pump. Chloroform must be employed to control the spasms, then alcoholic stimulants should be freely administered.

Aconite, digitalis, hemlock, lobelia, cantharides, poisonous mushrooms or toadstools, etc., have no certain antidotes. Emetics should be immediately given when any of them are known to have been taken. Animal charcoal is recommended to absorb and render harmless organic poisons in the stomach; teaspoonful doses mixed with water should be given repeatedly, and for those drugs least depressing in their action castor oil is also recommended.

When a prompt emetic is urgently demanded and no drugs of any kind are at hand, large quantities of tepid water should be drunk, say half gallon to a gallon; this distends the stomach mechanically, and by titillating the throat prompt and effective vomiting may be excited; this may be repeated as often as necessary and the stomach thoroughly washed out.