rapid-speed, static machine exclusively, after trying it side by side with others. The material condenses very little moisture as compared with glass. It can be completely taken apart and the plates washed with soap and water, the bearings oiled and the whole reassembled in less than an hour. It runs comparatively noiselessly, which is quite marvelous at such speed. During the winter months I remove one set of plates, so as to be able to get the high-speed current without getting too much amperage. During the hot, damp summer months, my laboratory being only two blocks from the Mississippi river, I get about the same output with the four revolving plates as in winter with two plates. The motive power is a direct current, half horse-power motor with a speed-regulating rheostat. With this I can get any speed from 500 to 2,000 revolutions per minute. The latter speed is especially fine for high frequency work with vacuum electrodes, as no condenser is necessary. All who have put in machines in Memphis since I have this combination have flattered me by "following suit."

Randolph Building.

FIRST AID TO THE INJURED.*

E. M. HOLDER, M.D.

MEMPHIS.

Assistant to the Chair of Surgery, Memphis Hospital Medical College; Visiting Surgeon to the City Hospital, and to St. Joseph's Hospital; Consulting Surgeon to the Shelby County Poor and Insane Asylum.

AMONG the many subjects claiming the attention of this association, none can be more important to the welfare of humanity than that of first aid to the injured. An accident, as a rule, creates a panic. Everybody "loses his head," and the young surgeon is often perplexed and embarrassed. When a messenger summons you to such a case do not allow his haste to disconcert you. Compel him to take time to tell you the three following things: 1st, The correct name and address of the injured person, which you must carefully write down; 2d, Whether or not he has been removed from the scene of the accident; 3d, What, as nearly as possible, is the *Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 18, 1903

exact nature of the injury? Sometimes the messenger will tell you he ran off in such a hurry that he did not wait to ask what happened. As a rule, however, he can give you some idea of the condition of things. He can tell whether the injured person is bleeding or whether he is conscious. If he can state how, and under what circumstances the accident occurred, the surgeon can form a fairly correct idea as to the nature of the injury. These questions need occupy but a few moments, and frequently save much time and annoyance. No matter how clear the case may appear or how urgent the demand for your assistance, you should not neglect to obtain what information you can from the patient or from his friends. If called to a case of fracture do not immediately begin to manipulate the injured limb. While removing your overcoat or gloves it is easy to inquire how the accident happened or in what position the patient was standing or lying when he was injured. A few questions of this character will elicit information which may influence your examination, and prove helpful in the diagnosis. For example, a fall upon the outstretched hands is apt to produce a Colle's fracture, or upon the shoulder a fracture of the clavicle, or upon the knee, with a strong effort upon the part of the patient to save himself, a fracture of the patella. A history of an injury caused by jumping from a rapidly moving railway train or street car and landing upon the feet excites our suspicion that a fracture of the fibula has been sustained. In cases which are at all likely to come into the courts these points, although apparently insignificant, should receive close attention and should be jotted down in a note-book at the time, as they may attain great prominence during the trial. A business-like surgeon will always have his satchel well stocked and ready for emergencies.

Finally we come to the examination of the patient. When the patient has not been removed from the scene of the accident before the arrival of the surgeon, a brief examination must be made to ascertain the character of the injury. If hemorrhage be profuse and a vessel of considerable size is wounded, a tourniquet may be applied temporarily until the patient has been removed to his home or to a hospital. If a

limb be fractured or severely lacerated, a temporary splint must be applied. The patient may complain of cold, and no amount of clothing heaped upon him can make him comfortable. A hypodermic of morphin acts speedily and effectually, allaying pain, causing the patient to feel a sensation of warmth and comfort. It is also an excellent remedy for shock, better than alcoholic stimulants. I would advise, however, against its use in profound shock. If the patient be unconscious, place him on his back with the head slightly raised, care being taken to give the lungs free play by unbuttoning the clothing over the chest and removing the neck-wear.

The utmost care should be observed in moving the injured person. In a fracture of the lower extremity the fragments are liable to lacerate the tissues or may even perforate the skin, thus converting a simple into a compound fracture. One attendant should support the fractured limb, and before transporting the patient on a stretcher the two limbs should be tied together to prevent the injured member from rolling outward by its own weight, or a blanket, a coat or a pillow may be rolled up and placed around or against the limb as a support. Arriving at the sick room, the surgeon will find it to his advantage to select two or, if necessary, three of the most intelligent of the bystanders, while he quietly but firmly asks all the rest to retire. This will relieve him of a crowd of critical observers, while the favored few who are asked to remain, feeling that a compliment has been paid them, fall into line as willing helpers.

In removing the clothing the sound arm or sound leg should be slipped out of the sleeve or trousers leg first, after which the injured arm or leg can be liberated without much trouble. In cases where much pain is suffered a pair of scissors may be used to rip up the seams and remove the garments with the least disturbance possible.

It is possible in many injuries to take in the situation at a glauce, and instantly decide upon a plan of treatment. I will take occasion to say here, it not being irrelevant, that at least a returning reaction from pronounced shock should be established before any capital operation is done. Some injuries do not differ markedly, however, from surgical diseases wherein

every known method of diagnosis must be employed. The most serious consequences sometimes arise from failure to recognize the nature of an injury.

A young physician is called to attend a man who has sustained an injury. He makes a hasty examination, employs a hypodermic of morphia with assurance that the injury is only trivial in character and that the patient will be all right the next day. For some time the condition steadily grows worse. Another physician is called, who recognizing a dislocated limb, sends the man to a hospital. An operation is performed, the dislocation is reduced. There are few surgeons of large hospital experience who have not seen cases with this unfortunate history, a mistake in diagnosis, which is disastrous in its effect upon the practitioner who first had charge of the case, and distressingly unfortunate for the patient.

The discovery of one injured member should not end the investigation. Every part of the body should pass under review, so that there shall be no possibility of any important points being overlooked. None but those who have suffered thereby can realize what it is to have treated such a fracture of the humerus and to be confronted months afterward with a dislocation at the elbow that was overlooked at the first examination.

The practical question of what constitutes first aid to the injured is to alleviate pain and guard against immediate danger from hemorrhage and shock. For the alleviation of pain the hypodermic administration of morphin and the putting of the patient in the most comfortable position are indicated.

Hemorrhage should be controlled as quickly as possible by a tourniquet or by compression. The ligation of bleeding vessels in an open wound is best, if practicable, before the patient is moved; this insures more positively against recurring hemorrhage when reaction sets in, and the patient is safer while in transit. Blood from a wounded internal organ, when poured out into the peritoneal cavity, produces constitutional symptoms which are difficult to distinguish from the symptoms of shock, which may be due to an innocent trauma of the body. Not until a considerable amount of blood has been extravasated can its presence in the cavity be

detected by palpation or succussion; if there be hemorrhage, we would expect to find such symptoms as extreme pallor, small, rapid pulse, yawning, sighing, thirst, and jactitation. Of course severe intra-abdominal hemorrhage demands an immediate laparotomy.

SHOCK. Shock in these cases is due to the physical injury, and is manifested by cardiac depression, impairment of the respiratory and sensorial functions, and by the reduction of surface blood pressure and temperature. It not infrequently happens that the patient is found with a weak, thready pulse, sometimes imperceptible at the wrist, and the whole body surface is cold and clammy.

I wish to make complimentary mention here of a most interesting and instructive paper upon First Aid in Railroad Injuries, read by Dr. G. B. Thornton, of this city, at a recent meeting of the Memphis and Shelby County Medical Society, and published in the October (1903) number of the MEMPHIS MEDICAL MONTHLY.

While dangerous shock may exist without hemorrhage, loss of blood certainly augments the degree of shock. An apparently slight injury may be attended by profound shock. On the other hand a very severe trauma of the body may be accompanied by an inappreciable degree of shock. Therefore shock is of no special diagnostic value when taken alone in estimating the nature of an injury; still, while shock per se is no guide, its behavior is of diagnostic value.

Uncomplicated shock, or shock from a trivial injury, is generally sudden in its outset, and should pass away in a short time, in a few hours. On the other hand delayed shock or progressively increasing shock points significantly to intraabdominal bleeding or to some visceral lesion. Shock delayed for ten or twelve hours will usually point to a rupture of some hollow viscus with escape of its contents and the advent of septic peritonitis. Shock and hemorrhage, strange to say, do not, as a rule, occur simultaneously.

Profound shock is one of nature's most potent hemostatics. Hemorrhage, however, induces shock, but shock restrains. hemorrhage. In no field of surgery is the diagnostic value of shock beset with more difficulties of proper interpretation than in the case of injuries.