ASPHYXIA AND APNEA.

From Drowning.-Remove the person from the water as rapidly and gently as possible, turn the face downwards for a moment, and depress the tongue, in order that water, mucus, etc., may be removed from immediately over the entrance of the windpipe. Give the patient plenty of fresh air, fully exposing neck and chest to the breeze, unless inclement. Turn gently on the face, one forearm being under the forehead, and raise the body up that the water may have free discharge from the mouth. Place the patient upon the side and apply stimulants (ammonia, etc.) near the nostrils; or the cold douche, in order to excite respiration.

The above measures being ineffectual, convey the body to the nearest convenient spot, strip it carefully and dry it, and place it on a warm bed, with head and shoulders slightly raised, and at once employ one of the following methods, known as Silvester's and Marshall Hall's.

Silvester's Method.-Pull the tongue forward, to prevent obstruction to entrance of air into the windpipe; produce expansion of the chest by drawing the arms from the sides of the body and upwards until they almost meet over the head. Then bring the arms down to the sides again, causing the elbows almost to meet over the pit of the stomach, and thus producing contraction of the chest. This imitation of the act of respiration should be continued at the rate of fifteen or sixteen times a minute, as in health.

Marshall Hall's Method. The person should be placed flat on the face, gentle intermittent pressure being made with the hands on the back, the body turned on the side, or a little beyond, then on the face, and the same pressure, etc., continued as at first. The whole body must be worked simultaneously. The same number and frequency of these artificial processes of respiration should be employed as in the other method.

The Michigan Method.-Lay the body face down, the head upon the arm, and stand astride it; grasp it then about the shoulders and armpits, and raise the chest as high as you can without lifting the head quite off the arm, and hold it about three seconds; then replace the body upon the ground, and press the lower limbs downwards and upwards, with slowly increasing force, for ten seconds; then suddenly let go, to perform the lifting process again.

Whichever process be employed, the effort to restore the temperature of the body must be maintained, the body being well rubbed in an upward direction with the hands, with warm flannels, etc.; bottles of hot water, hot bricks, etc., being applied to the stomach, the axilla, the soles of the feet, etc., stimulants and beef tea being judiciously administered when restoration is about taking place. The attempts at resuscitation must be persevered in for several hours, if necessary.

Laryngotomy or tracheotomy, with or without catheterization, or forced insufflations of air or oxygen, have proved successful, as also electro-puncture (Garratt).

In artificial inflation, always press the larnyx and trachea against the vertebral column, so as to close the oesophagus and thus prevent the air entering the stomach.

After Long Submersion is Recovery Possible?-According to Harley (p. 881), dogs kept under water 11⁄2 minutes always died, if water had entered the lungs. If it had not, the trachea being plugged, they survived a submersion of 4 minutes. When persons rise after sinking they usually get some air, and less speedily come into a state from which recovery is impossible. The greatest period between the last inspiration and the stoppage of the heart is 4 minutes. Some think that no recovery has been made after complete cessation of the heart's action. We infer that after complete submersion for 5 minutes recovery is improbable, unless the person had been previously choked, or in a fainting state, so that no water entered the lungs. But in Anderson's case, the patient had been under water at least 15 minutes, and in Garratt's the time was variously estimated at from 15 to 60 minutes.

When is a Case Hopeless ?-Harley says (p. 892): "If the eyes are open, the pupils dilated, the conjunctiva insensible, the countenance placid, the skin cold, frothy mucus round the nostrils and mouth, no attempt at respiration, and the heart's action inaudible (when the ear is applied to the chest), the case is hopeless."

Signs of Death-The following have been suggested as mehods of deciding whether death has occurred:

(a) Tie a string firmly about the finger. If the end of the finger becomes swollen and red, life is not extinct.

(b) Insert a bright steel needle into the flesh. If it tarnishes by oxidation in the course of half an hour, life may be considered not extinct.

CLINICAL EXAMINATION OF THE URINE.

735

(c) Inject a few drops of Liquor Ammonia under the skin. During life a deep red or purple spot is formed.

(d) Moisten the eye with Atropine. During life the pupil will dilate.

(e) Look at a bright light or at the sun, through the fingers held closely side by side. During life the color is pink; after death a dead white.

(ƒ) After death a dark spot is said to form gradually on the outer side of the white of the eye, from drying of the sclerotic, so that the dark choroid shows through.

(g) Putrefaction is an absolute sign of death. Better delay for it than run any risk of burying alive.

From Foreign Bodies in Air Passages.—If round and smooth, invert the patient and strike on the back; laryngotomy; tracheotomy.

Of the New-Born.-Clean the mucus out of nostrils and throat; catheterize the trachea, and suck up the mucus. "Marshall Hall's method: " by placing child on abdomen, then bringing into lateral posture, repeating slowly and deliberately. "Schultze's method:" by placing the thumbs upon the anterior surface of thorax, the indices in the axillæ, and the other fingers along the back, the face of the child being from you; rotate the child, by swinging upward, so that the inferior extremities turn over toward you. In a moment re rotate to the original position. Do not support head or legs in the forward rotation; their bending upon or toward the abdomen gives a forced expiration.

CLINICAL EXAMINATION OF THE URINE. NOTE.-Use morning urine, or a sample of all passed during the 24 hours.

Pale (and copious), 1.030+. . indicates Sugar.

Pale (and copious), below 1.018

Of urine and froth, very yellow

66

Hysteria and convulsions,

nervous disease.

Bile, Rhubarb.

{

Of violets,

Quantity (in 24 hours). Normal about 50 fl. oz., from which there may be considerable variation either way, according to the quantity of sweat, the fluidity of food used, etc. Specific Gravity. If possible, take the mixed urine. Normal is about 1.018, i. e., 18 grains of solids in each fl. oz. If sp. gr. is high, suspect sugar; if low, suspect albumen.

Reaction, in health is always acid in 24-hours' urine. It may be alkaline from medicine, or disease, or shortly after a meal. If excessively acid, examine for crystal of uric acid. If alkaline, let the test-paper dry, so as to ascertain whether the alkali be fixed or volatile.

Albumen by Heat and Nitric Acid. With Acetic Acid, or dilute Ammonia, make the urine slightly acid. If a precipitate appear on boiling, it may be Albumen or Phosphates. Add a drop or two of Nitric Acid. If the precipitate dissolve, it is Phosphates; if not, it is Albumen. If a deposit or turbidity disappears on heating, it consists of Urates; if not, add a drop of Nitric Acid. If now dissolved, we have Phosphates; if not, Cystine. Other Tests are the Potassio-Mercuric Iodide, the Sodium Tungstate, Potassium Ferro-cyanide, and Picric Acid Tests; but the above described one, if carefully done, will give as good results as any.

Bile Pigment and Acids, if necessary. Vogel's color-table. Marechal's Test, as follows: Put 3j of urine in a test-tube, and pour one or two drops of Tinct. Iodi. to

trickle down along the side of the tube, held horizontally nearly, so that the two fluids may touch, but not mix. If bile pigment be present, a fine green color will at once be developed below the red Iodine layer. Noel's Test, Pettenkofer's Test, Nitric Acid Test, Oxide of Silver Test. Sugar, if necessary. Urine containing sugar is usually light-colored, froths readily when poured from one vessel to another, and has a high specific gravity. Fehling's Test, as follows: Add to the boiling urine a few drops of freshly-prepared solution of PotassioCupric Tartrate (Fehling's Solution). If sugar be present, a yellow, orange, or red precipitate of Cuprous Oxide will form, 10 cubic centimeters of the solution being reduced by 0.05 gram. of diabetic sugar. To prepare Fehling's Solution, dissolve 34.639 grams of pure, crystallized Copper Sulphate in about 200 grams of Distilled Water; also 173 grams of chemically pure, crystallized, neutral Tartrate of Sodium in 500 or 600 grams of a solution of Caustic Soda, of specific gravity 1.12, pouring the first solution into the latter, slowly and a little at the time. The clear, mixed fluid is then diluted with distilled water up to a litre. This solution soon spoils, and must be kept in a dark, cool place. Much more convenient are Dr. Piffard's Cupro-Potassic Paste, and Dr. Pavy's Cupric Test Pellets (see Tyson on Urine, page 57); and still more handy are Wyeth's Compressed Tablets for preparing Fehling's Solution of Potassio-Cupric Tartrate, U. S. P., 1880, a box of which costs 50 cents, and may be obtained from any good drug-store. The writer has used these Tablets for some two or three years, with extreme satisfaction.

Pavy's Solution is a modification of Fehling's; is equally good for qualitative and volumetric testing, and is intended for those who prefer the apothecaries' weights and measures to the metric system. It is made in the same manner as Fehling's, 100 minims corresponding to 1⁄2 grain of diabetic sugar, and consists of-Copper sulphate, gr. 320; Potassium Tartrate (neutral), gr. 640; Caustic Potash, gr. 1280; and Distilled Water, fz 20.

Other Tests for Sugar are Böttcher's Bismuth Test, the Fermentation Test, Moore's, Trommer's, the Pieric Acid and the Indigo Carmine. They are all useful, but will not be detailed here, as one good method is all that the average practitioner wants.

Chlorides. Add a drop of Nitric Acid, and then Silver Nitrate until a precipitate ceases to form. Thus estimate the amount of Chlorides.

Urea. Place a drop of urine on platinum foil, and to it add a drop of Nitric Acid, and leave undisturbed in a cool place for a minute or two. If the urea is in excess, crystals of Uric Nitrate form immediately.

To ascertain the percentage of urea present, use Parke, Davis & Co.'s Ureometer, employing the Solution of Hypobromite of Sodium, instead of the solution of Chlorinated Soda, the former giving much the best results. This apparatus is simple, reliable, and quite accurate enough for clinical purposes.

Mucus and Pus resemble each other so closely under the microscope, that it is almost impossible for any one, except an expert, to distinguish between them thereby. Mucus is more cloudy and flocculent to the naked eye than Pus, which latter is generally of a stringy consistence and thickish yellow appearance at the bottom of the vessel. The supernatant liquid being poured off, and an equal bulk of Liquor Potassæ added, the deposit, if containing much pus, becomes gelatinized, and so tough that it cannot be poured If Mucus, Acetic Acid added coagulates it, forming delicate molecular fibres. Other Deposits are best examined with the microscope, and compared with good plates, rather than with printed descriptions. The plates in Hoffmann and Ultzmann on Analysis of the Urine, will answer the wants of most general practitioners, but the text follows the metric system. The urinary deposits may be classified thus:

out.

ETHICS.

737 Necessary Apparatus. A dozen test tubes. Alcohol lamp. A small porcelain dish. 2 watch-glasses. A sheet of platinum foil, 3/4 inch square. 3 pipettes of different sizes, to be used only for urine. A 2-oz graduate. Urinometer. Blue and red litmuspaper. The reagents mentioned above. A little Grape-sugar, for use in testing the Fehling's solution. Ureometer (Parke, Davis & Co's).

The foregoing directions comprise all that the average practitioner will usually perform in the matter of urinary analysis. For fuller directions, the reader is referred to one of the numerous manuals on the subject, among which may be mentioned Da Costa on Medical Diagnosis, Chapter VII,-Tyson on the Practical Examination of Urine,—and Sir Henry Thompson's Clinical Lectures on Diseases of the Urinary Organs, Lecture

XXIV.

A "Physician's Pocket Reagent Case," intended for urinalysis at the bedside, is put up by Parke, Davis & Co., and sold at the low price of $1.50. It contains a set of Dr. Oliver's Test Papers or Pellets (the latter preferable), a color scale, specific gravity beads, two test tubes, a pipette, and full directions for the use of the reagents, which are to be absorbed by the test-papers.

ETHICS.

The Hippocratic Oath.-I swear by Apollo, the physician, and Esculapius, and Health, and All-heal, and all the Gods and Goddesses, that according to my ability and judgment I will keep this oath and this stipulation:-to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this Art, should they wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipu lation and oath, according to the law of medicine, but to none others. I will follow that system of regimen which according to my ability and judgment I consider for the benefit of my patients, and abstain from what is deleterious and mischievous. I will give no deadly medicine to any one, if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and holiness I will pass my life and practice my art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. In whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice, or not in connection with it, I see or hear in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this oath unviolated, may it be granted me to enjoy life and the practice of the Art, respected by all men, in all times. But should I trespass and violate this oath, may the reverse be my lot! [Adam's Genuine Works of Hippocrates, Sydenham Society, London, 1849 ]

EXTRACTS FROM THE CODE.

Consultations should be promoted in difficult cases. During them no jealousy or rivalship should be indulged. Candor, probity, and all due respect should be exercised toward the physician in charge. The attending physician should first question the patient, the consulting one afterwards putting such other questions as may seem fit to further elucidate the case. The discussion should take place in a private place, and no opinions delivered which are not the result of concurrence. In discussion the attendant delivers his opinion first, the others in the order in which they have been called.

A Regular Medical Education furnishes the only presumptive evidence of professional abilities and acquirements, and ought to be the only acknowledged right of an individual to the exercise and honors of his profession. No one can be considered a fit associate in consultation, whose practice is based on an exclusive dogma, to the rejection of the accumulated experience of the profession.

Punctuality should especially mark the keeping of these engagements; if one of the parties be delayed, the other should wait a reasonable time, and then, if the attendant, prescribe; if the consulting, he should retire, unless the case is urgent or he be called from a distance, when he should prescribe for the emergency or leave a written opinion under seal. All theoretical discussion should be avoided. Should diversity of opinion

prevail, the majority should rule; should the numbers be equal on each side, the decision should rest with the attending physician. The consulting physician should always justify, as far as may be consistent with truth, the course pursued by the attending one, and no hint impairing confidence in him, or his reputation, should be thrown out. A double fee should be expected in all consultations.

Interference. A physician should not visit or prescribe for a patient who has been under the care of another for the same malady, unless in, Ist, a case of emergency; 2d, of consultation; 3d, of relinquishment, by the physician, of the case; 4th, or a regular notification to him that his services are no longer desired. When the case is assumed by another, he should indulge in no insinuations against the former attendant. If called because the family physician is not at hand, or is sick, he should resign the case to him on his arrival. In case several physicians are simultaneously called, as in accidents, the first arriving should take full charge of the case, unless the family attendant be present, when he should assume the charge; if not present, he should be sent for, and the further treatment resigned to his hands.

Miscellaneous. A case should never be abandoned because it is supposed to be a hopeless one.

Contumelious and sarcastic remarks relative to the Faculty, as a body, should always be avoided. It's a foul bird that fouls its own nest.' ""

66

It is held unprofessional to resort to "public" advertising, to hold a patent upon an instrument, or to dispense or prescribe a secret nostrum.

Gratuitous services should be given to an afflicted brother practitioner. If compelled to temporarily suspend his practice, on account of sickness, the physician who has been invited to take charge of his cases should turn the accruing fees over to the sick one, save in surgical or obstetrical cases.