be protected, else severe inflammation occurs. Inhalations of this substance cause destruction of blood corpuscles, and when a worker in these factories shows a loss of hemoglobin and is becoming anemic, he should be prohibited from continuing work in the T.N.T. atmosphere. Another indication that an individual should no longer work in the T.N.T. factories is when bile pigments appear in the urine. Fumes from trinitrotoluene will cause the skin and hair to become yellow.

Absorption of this substance may take place not only by inhalation, but also through the skin, and besides the serious poisoning evidenced by red blood corpuscle destruction and jaundice, gastrointestinal disturbances of all kinds may develop. While at first the liver is enlarged, prolonged poisoning causes atrophy of the liver and degeneration of the kidneys.

Voegtlin, Hooper and Johnson' suggest as a prophylactic against absorption through the skin a varnish made of shellac, castor oil and alcohol, to be applied to the hands and forearms, and then for the worker to use cotton gloves impregnated with a modification of this same varnish. They found the poison could be removed from the skin with sodium hydrosulphite solutions.

The treatment, when poisoning occurs, is absolute rest, fresh air, and a bland, simple diet, with alkaline or mucilaginous drinks to soothe the mucous membrane of the gastrointestinal tract. Plenty of water and large doses of alkali, as sodium citrate or sodium bicarbonate, should be given. If jaundice is present the treatment would be the same as for catarrhal jaundice. The bowels should be kept open with gently acting laxatives. If it is inadvisable to allow meat, small doses of iron should be daily given.

1 Public Health Reports XXXIV, 1919.

PART XI

TREATMENT OF EMERGENCIES

SUDDEN DEATH

When a physician is called to a case of sudden death, or if a patient dies before he has been under his care for twentyfour hours, the death must be reported to the authorities, in most communities to the medical examiner. If the physician finds the patient dead on his arrival, he should remain with the body until the medical examiner has arrived, or at least until a policeman has taken charge of the body. In the meantime, he should allow no one to touch the body, and the physician himself should not disturb the individual except to positively ascertain that he is dead. If he finds the patient is alive, the physician has full charge of the case, and can do whatever he decides is necessary; although if he thinks that death is imminent, or that the circumstances of the injury or illness are suspicious, he should send for the authorities, the police or the medical examiner.

Signs of death are: the absence of heart-beat, with the stethoscope over the heart; absence of befogging of a cold mirror held close to the nostrils; absence of swelling and dark hyperemia of a finger when a string is tied fairly tight around it; absence of dilatation of the pupil within a few minutes if a I per cent. solution of atropine is dropped into an eye.

COMA

If a patient is found in coma, this may be due to: injury; alcohol; apoplexy; epilepsy; uremia; diabetes; sunstroke; illuminating gas; carbon monoxide; or to poisoning from opium (in some form), chloral, or phenol. A quick survey will generally show whether or not there is an injury. The odor of alcohol is not necessarily evidence of alcoholic coma. An epileptic seizure followed by coma can generally be certified to

by the bystanders; or some one may know that the subject is an epileptic; or froth at the mouth or a bitten tongue may give the clue. In an apoplectic attack there may also be frothing at the mouth, and there is generally stertorous breathing. In this condition the face will generally be found drawn to one side, and one arm and leg may not act as the other arm and leg, even though the patient is comatose. Uremic coma may not be preceded by a convulsion. It is rare, however for uremic coma to occur without sufficient premonitory symptoms for the individual to be under medical supervision. Diabetic coma may suddenly occur, and must always be considered as a possibility. Coma from sunstroke occurs only in heated periods when the individual has been exposed to the sun. The surroundings and the odor will diagnose the cause of coma from illuminating gas. The possibility of the coma being caused by carbonic oxide gas must be borne in mind, especially when the individual is at or near a furnace or in a garage, or is found in a cellar.

In drug comas there are always some indications that poison has been taken. Chloral may have been administered surreptitiously in the form of "knockout drops." Coma comes on slowly after most poisoning with opium preparations. Phenol coma is more or less rapid, the lips are generally stained and burned, and the odor is characteristic.

Sudden faintness in the beginning of acute disease may occur in cerebrospinal meningitis, and in some forms of influenza, and sudden paralytic symptoms may occur in botulinus poisoning and in wood alcohol poisoning.

The pupils are contracted in all forms of opium poisoning; they may be contracted in uremia and in head injuries. They are generally dilated in alcohol and chloral poisoning, and in diabetes; one pupil may be dilated and the other contracted in apoplexy and in a head injury. The intensity of the coma will decide whether or not the pupils react alike.

In most cases of coma it is advisable to catheterize and quickly test the urine, as an aid to diagnosis. The treatment for these various conditions depends on the diagnosis of the

cause.

ILLUMINATING GAS POISONING

Carbon Monoxide Poisoning

Illuminating gas, generally by accident but often by suicidal intent, is one of the most frequent causes of poisoning.

Individuals found comatose from inhaling illuminating gas generally have an increased temperature (although in some instances the temperature is subnormal, especially in convalescence), the pulse is generally rapid, and there is often a leucocytosis. If the coma is not profound, twitchings of the muscles and sometimes convulsions occur, and in some instances there is muscle rigidity. Prolonged coma is always serious and generally shows that the outcome will be fatal. Rarely, gangrene of the hands and feet may follow carbon monoxide poisoning.

Yandell Henderson,1 who has made so many investigations of various kinds of asphyxias, finds that artificial respiration properly done with the individual prone (Schäfer method) will accomplish more for resuscitation from drowning, electric shock, and asphyxia than is possible by means of any apparatus. But whether apparatus is used or manual artificial respiration is done, it is most important to remember that every minute's delay makes recovery more doubtful (ten minutes of complete asphyxia is probably fatal), hence if breathing has stopped artificial respiration should be begun immediately.

In a later article2 on carbon monoxide poisoning, Henderson states that carbon monoxide is responsible for more deaths than all other gases put together, and that this gas is the chief poison in suffocation from the smoke of burning buildings, from the fumes of furnaces and explosions, in the "after damp" of explosions of methane and coal dust in mines, and from mine fires either of timber or coal, and of course it is the important factor in poisoning from illuminating gas. Illuminating gas is composed in varying amounts (depending chiefly on the price of petroleum) of "water gas," "coal gas," and the vapor from superheated or "cracked" petroleum. So-called "water gas" contains about 30 per cent. of carbon monoxide. It is compara'Journal A. M. A., July 1, 1916, p. 1.

2 Journal A. M. A., Aug. 19, 1916, p. 580.

tively cheap to manufacture, and is produced by blowing live steam over hot coal. The gas formed by the destructive dry distillation of coal, technically called "coal gas," contains only about 6 or 8 per cent. of carbon monoxide. It is therefore far less poisonous than "water gas." At the present time water gas is the chief ingredient of the illuminating gas of American cities. Henderson states that the poisonous activity of carbon monoxide is due to its avidity for hemoglobin with which it forms a combination similar to the combination of hemoglobin with oxygen, but with an attraction approximately 250 times as strong. The poisonous effects are largely due to prevention of the oxygen-carrying power of the blood. He also says that it is a mistake to believe that this carbon monoxide combination with hemoglobin is permanent, and that as soon as an adequate amount of pure air enters the lungs, the hemoglobin combination with carbon monoxide begins to break up, and the higher the percentage of oxygen in the air inhaled, the sooner the carbon monoxide is displaced and the sooner the oxygen-carrying capacity of the hemoglobin is restored. He believes that for half an hour it is beneficial to administer pure oxygen, or air enriched with oxygen, to the individual, and that practically all the carbon monoxide is eliminated and the hemoglobin fully restored in three or four hours. Recent investigations of Henderson and Haggard' indicate that inhalation of oxygen plus about 8 per cent. of carbon dioxide greatly accelerates recovery. The carbon dioxide augments breathing and the oxygen thus drawn in increases the rapidity of the elimination of the carbon monoxide.

Although a patient may die unconscious even though he lives a day or two, it is not the condition of the blood that causes his death, nor is the prolonged coma due directly to the carbon monoxide, but to the oxygen deficiency which it causes in the blood, hence bleeding and transfusion of blood or of saline solutions are not indicated, and certainly there is no indication for such treatment after the first two or three hours. The patient will recover as soon as he receives plenty of fresh air if the asphyxia has not been too intense or too prolonged, although 1 Journ. Pharmacol. and Exp. Thera., Aug., 1920, p. 11.