b. Bites from scorpions, spiders, and other insects are cases of poisoned wounds, and are treated locally by applying a solution of ammonia or baking soda. Give stimulants if necessary.

SHOCK, FAINTING, POISONING, DROWNING, SUFFOCATION FROM GAS

138. Shock-a. By this term is meant a very severe physical and mental depression following extensive wounds, such as those produced by shell, and ordinary wounds in which the chest and abdomen are entered. You can hardly mistake this condition, for it resembles approaching death. If possible, the patient should not be moved, but kept in position where found, warmed, and carefully stimulated. This will be difficult, perhaps impossible, on the battle field, but it should be attempted unless removal is unavoidable. This condition is a very common one and nearly always follows all kinds of injuries. It is a condition of profound depression of the nervous system or a condition of collapse. It may follow the slightest injury, such as a prick or the scratch of a pin, and is always associated with all severe injuries, such as those resulting from railroad or machinery accidents, severe burns, and gunshot wounds.

The symptoms may be very mild in some cases-in fact, hardly noticeable and require no particular treatment. However, in severe cases the symptoms may be quite alarming and demand most vigorous treatment: otherwise the case may terminate in death.

b. Symptoms of shock.-You may recognize shock by means of a few of the well-known symptoms:

(1) The face is pale and pinched and has an anxious, frightened appearance.

(2) Patient feels weak and faint and may complain of chilly sensations.

(3) The skin is cold and clammy and the surface of the body covered with a cold perspiration, especially noticeable on the forehead.

(4) There may be nausea or vomiting, the pulse weak, rapid or irregular, or may be entirely absent and imperceptible. (5) The breathing is sighing and is irregular.

(6) The person may or may not be unconscious.

The condition closely resembles death and is one which usually causes the bystander or one anxious to help to become frightened and lose his presence of mind.

c. Treatment.-In all severe cases following bad accidents and severe hemorrhage:

(1) Send for a surgeon at once.

(2) Place the injured man in a horizontal position; raise the head slightly by placing a blanket or pillow under the head. (3) Loosen all tight clothing which might interfere with the breathing or retard circulation.

(4) Keep the body warm. The body may be kept warm by wrapping in blankets and placing hot-water bottles at the sides, along the extremities, and over the heart. You may also use hot irons, stones, bricks, plates, or glass bottles filled with hot water. However, it must always be borne in mind that the sensibility of an injured person is blunted or dulled-he may even be unconscious-so that he may not feel the heat, and if applied too hot or directly to the skin without protection very severe burns might result. Always wrap the hot-water bottle or any article used in a cloth of some kind so as to prevent burning. Rubbing the extremities with the hands or hot flannels will aid to restore circulation.

139. Fainting.-This condition is generally the result of severe bleeding or exhaustion from fatigue. The patient should be laid upon his back, head lowered, arms by the side, feet extended, and should be carefully stimulated. This condition is rarely dangerous.

The other important accidents or conditions with which you may have to deal are poisoning, drowning, sunstroke, heat exhaustion, burns, and freezing.

140. Poisoning.-a. Poisoning by way of the stomach may result from swallowing mineral or vegetable poisons. In the military service it often follows the taking of food which has undergone changes resulting in the production of poisonsptomaines, etc.

b. Whenever there is no evidence of caustic action, such as burns on the mouth, an effort should be made to empty the stomach and bowels by the free use of emetics and laxatives, such as a tablespoonful of mustard or common salt in a cup of warm water, as an emetic, and Epsom or Rochelle salts or castor oil as a cathartic. The cathartic should not be given until the vomiting resulting from the emetic has subsided. After the poison has been evacuated, give stimulants and apply heat and rubbing externally.

c. When the lips are burned, give no emetic; give olive oil, cottonseed oil, or castor oil internally, and also the proper antidote, if you know it.

141. Drowning.—a. Resuscitation.—Artificial respiration is required in cases of failure of respiration from drowning, from inhalation of gas, from electric shock, or from concussion of the brain.

Being under water for four or five minutes is generally fatal; but an effort to revive the apparently drowned should always be made, unless it is known that the body has been under water for a long time. It is of the first importance in attempting to revive cases of this character that artificial respiration be begun at the earliest practicable moment, as soon as the patient is on shore or in a boat; and it must be continued, in many instances, an hour and a half or two hours before the case is considered hopeless. After the patient begins to breathe, watch carefully to see that he does not stop again, and when he breathes faintly, assist him with artificial respiration. Do not attempt to raise the patient nor allow him to rise until breathing has become regular. As soon as the patient is removed from the water, lay him face down and, grasping him around his waise, raise his hips so that any water may drain out of the air passages while the head remains low. (Pl. 16, T. R. 112–5.)

Then proceed with the following method of artificial respiration, which can be carried out by one person without great exhaustion for one or two hours.

Schaefer method.-The man is laid on his stomach, face turned to one side so that the mouth and nose do not touch the ground, his arms extended from his body beyond his head. (Pl. 17, T. R. 112–5.)

In this position the tongue does not obstruct the air passages, but falls forward of its own weight, and the removal of any foreign body, tobacco, chewing gum, or false teeth, or of mucus, blood, or vomitus is facilitated.

The operator kneels, straddling one or both of the patient's thighs, facing the patient's head, and places his hands, with the thumb nearly parallel to the fingers, so that the little finger curls over the end of the lowest rib. The lower margin of the hand must be free from the pelvis and resting on the lowest rib. The ribs can be more easily located and the pelvis avoided by operating on the bare back of the patient.

The nearer to the ends of the ribs the heels of the hands (thenar and hypothenar eminences) can be placed without sliding off the better the position. Thus the hands are far removed from the spine and the fingers nearly out of sight. The fingers help some, but the chief pressure is exerted by the heels of the hands, the weight coming straight from the shoul

der. To bend the arms and shove the hands in at the sides, in addition to the vertical pressure, is a waste of energy, being less beneficial than the vertical pressure alone. The operator's arms should be held straight and pressure exerted from his shoulders by bringing his body and shoulders forward. This weight is gradually increased until, at the end of three seconds of vertical pressure on the lower ribs of the patient, the force is felt to be sufficient to compress the parts; then the weight is suddenly removed; if there is danger of not returning the hands to the right position they may remain lightly in place, but it is usually better to remove the hands entirely.

With an overweight patient a light operator can utilize over 80 per cent of his weight by raising his knees from the ground and supporting his weight entirely on his toes and the heels of his hands; the latter properly placed on the ends of the floating ribs of the patient. In this manner he can work as effectively as a heavy man.

A feather or a few fibers of absorbent cotton held near the patient's nose will indicate whether or not air passes with each forced expiration and spontaneous inspiration. The rate of compression should not exceed 12 or 15 times per minute, the lungs being thoroughly emptied by 3 seconds of pressure and allowed 2 seconds to refill.

There are liable to be evidences of life within 25 minutes in patients who will recover from electric shock, but where there is doubt the patient should have the benefit of it. In drowning, recoveries after 2 hours or more of unconsciousness are on record.

Aromatic spirits of ammonia on a handkerchief may be placed continuously within 3 inches of the nose; no liquid will be given a patient while unconscious; apply warm blankets and hotwater bottles as soon as practicable.

Due caution should be observed not to bring force to bear too violently on the ribs lest fracture occur.

b. Precautions.-As a great many cases of drowning occur in connection with swimming, a few simple precautions are noted herewith for men who enter the water:

(1) Don't go in swimming alone unless you are an expert. (2) Don't swim immediately after eating; wait at least two hours.

(3) Don't swim if overheated.

(4) Don't swim if you have heart trouble.

(5) Don't continue swimming when exhausted.

(6) Don't wade into water with your arms above your head. You will not be in readiness to stroke should you step into a hole.

(7) Don't struggle if caught in a swift current or undertow. The force of the current will bring you to the surface.

(8) Don't fight or struggle to swim if you swallow water; clear your windpipe of water first.

(9) Don't cry for help in fun; you may need help some time and not get it.

(10) Don't dive without knowledge of the approximate depth of the water.

142. Suffocation from gas.-During the World War many men on the battle field were subjected to gas poisoning. It is important, therefore, that you should be familiar in a general way with the following rules pertaining to gassed cases:

a. Have on your mask and gloves, if possible, when you handle a gassed man. This precaution will probably save you from being gassed yourself. If you have no gloves, be sure and wash your hands with soap and water following the handling of such cases, or better, rub them with dry lime.

b. Don't forget that all gassed cases require-first, rest; second, warmth; third, fresh air; and, fourth, attention.

c. Don't forget that articles of clothing, blankets, equipment, etc., remain for a long time impregnated with mustard gas. A good method for removing gas, etc., from clothing, equipment, etc., is by permitting them to hang in the open in a pure atmosphere for 48 hours, or, if possible, boiling or steaming will remove the effects of gas.

d. Remove the patient's equipment, but not his mask, if the air is permeated with gas.

e. If mustard gas is used, the essential treatment is, first, removal of clothing; second, neutralization of acid gas with an alkaline substance, if possible; third, avoid contact with soiled clothing; fourth, treatment of the eyes or lesions of the mucous membrane, of the respiratory tract, the digestive tract, and of the skin with a mild alkaline solution or water.

f. Don't bandage the eyes. Pressure bandage over the eyes locks up the lids and retains the secretions, which after a term of hours may become purulent and pussy.

g. Don't forget that it is often difficult to tell the difference between slightly gassed cases and malingerers. Symptoms of gas poisoning generally show up within 24 hours. If possible, remove all gassed cases from woods or low ground to little knolls or hillsides, and, above all, do not carry them into dug