anus. These compresses should be changed every few minutes, because if they are permitted to become warm they will act as a poultice and increase bleeding instead of checking it.

HEMORRHAGE INTO THE ABDOMEN.

Severe injuries such as crushes or perforating wounds of the chest or abdomen may give rise to internal abdominal hemorrhage. Symptoms.-Gradually increasing pallor. The pulse gets rapid and weak. There is a peculiar sighing form of respiration. Marked thirst. Pain in the abdomen. The patient vomits and is very restless. Later attacks of fainting may come on.

First-aid treatment.-Send for a physician at once. Place the patient in a recumbent position with the head low. Apply cold to the abdomen and keep the person as quiet as possible.

After treatment.-Keep the patient absolutely quiet in bed. Allow small quantities of warm water for the thirst. Apply an ice bag or cold applications to the abdomen.

SUMMARY OF THE TREATMENT OF HEMORRHAGE.

Ordinary bleeding from the arm or leg can be controlled by raising the part and by pressing a sterile or clean pad firmly on the wound. The pad may be held in the fingers or fastened in place by tying a handkerchief tightly around the limb.

If pressure and elevation fail, apply a tourniquet if medical help can be obtained soon. If the services of a doctor will not be available for four hours or longer, pack the wound with stirile gauze or muslin.

In all cases of very severe bleeding of the extremities or when the blood comes in spurts apply a tourniquet immediately.

In hemorrhage from the scalp, fasten a sterile compress on the wound by a bandage or handkerchief around the head. Failing in this, tie a tight band around the forehead just above the wound.

In hemorrhage from the neck, press the large artery in the side of the neck against the backbone with the thumb. Failing in this, if the hemorrhage is severe, pack the wound immediately with any material available, using the cleanest thing obtainable.

In hemorrhage from wounds of the trunk, apply pressure by a gauze compress, and failing in this, if the wound is bleeding freely, pack it with sterile gauze.

Tourniquets must not be left on for more than two or at the most three hours.

Remember that a man who has lost a good deal of blood may require constitutional treatment after the bleeding has been stopped.

SHOCK.

After a severe accident the patient almost always goes into a peculiar mental and physical condition, which is called shock. This condition may immediately follow the injury or may not develop for some time. Shock may be described as a condition of extreme general depression produced by injury or profound emotion. The state of shock is somewhat similar in some respects to cxtreme exhaustion or collapse. The amount of shock does not always correspond to the gravity of the injury, some individuals being much more susceptible to it than others. Shock is dangerous, and every one who is treating an injured man should bear it in mind and examine him to determine whether it is present.

Symptoms of shock.-The face is pale with a dull expression. The skin is cold and covered with a clammy perspiration. The pulse is weak and rapid. It may be impossible to feel the pulse at the wrist. The patient is usually conscious but is in a peculiar state of mental indifference, lying with the eyes partially closed, and making no effort to move. He may respond to questions, but no dependence can be placed on the truth of his statements. He rarely feels pain and seems to be indifferent to his fate. The breathing is rapid, irregular, and shallow, sometimes gasping. Under suitable treatment recovery from the condition may be expected, but in severe cases shock may continue and death follow.

Shock is a merciful provision of nature to prevent suffering on the part of injured people. It is stated than animals go into shock, and that when carnivorous beasts seize their prey that the victim becomes immediately numb and feels no pain. When a cat plays with a mouse, which she has captured, the mouse is not suffering the torture which the observer would imagine.

When a person makes much continuous outcry after an accident, it is probable that his condition is not dangerous. The seriously injured individual lies quiet and may escape notice on account of his apparent indifference to what has happened. Where a number of persons have been hurt, it is generally a safe rule to give aid first to those who are evidently gravely injured but making the least complaint.

Treatment. The symptoms of shock give a fairly clear idea as to what the treatment should be. The body is cold, hence it should be warmly covered, the patient lying in a recumbent position with the head low. External heat should be immediately applied by means of bottles, jugs, or other containers filled with hot water. These should be placed alongside of and between the legs and around the feet. In emergencies hot bricks or even hot stones can be used. Great care should be taken that the patient is not burnt by these

appliances, however, and they should be well wrapped with towels, old clothing, or similar material, and never placed in direct contact with the skin. The heart is weak, hence stimulants should be given. The best of these for shock is probably a small quantity of very strong hot black coffee. Aromatic spirits of ammonia, one-half a teaspoonful in a half tumblerful of water, is also another excellent remedy. Very small quantities of warm soup or milk are sometimes useful. Atropine sulphate in doses of 1/100 of a grain is highly recommended. Do not repeat oftener than every three hours. Liquor in shock is of questionable value. Shock is sometimes due to concealed hemorrhage, and this should always be looked for with great care. A patient should never be moved while he is in shock, or disturbed in any way, unless it is absolutely unavoidable and necessary to save life. This, of course, does not apply to putting a man in an ambulance and taking him on a short trip to a hospital, where he can receive very much better treatment, or to a man lying on the street a cold winter day, where the dangers of a short move into a warm house will be more than offset by the favorable surroundings which are thus secured.

Unconscious patients can not be given stimulants by the mouth, in which case smelling salts can be held under the nose, or a few drops of ammonia water sprinkled on a handkerchief and the patient allowed to inhale the fumes at intervals a minute apart. The application of external heat is almost always available, and should be conscientiously and thoroughly followed out. There are other forms of treatment for shock, but they are only available to the skilled physician. Raising the feet or legs and rubbing the extremities toward the heart, in order to encourage the flow of blood to that organ, is sometimes useful, but these measures are only applicable when the patient is in a warm room or on a warm day.

One can tell that the patient is recovering from shock by the disappearance of the symptoms. The face recovers its natural color, the skin becomes dry, the respiration is full and regular, and the pulse, as felt at the wrist, becomes stronger and slower. When the patient has reacted in the above-described manner and the symptoms of shock have disappeared, it is then safe to move him or to undertake other measures necessary for his treatment.

In reacting from shock, vomiting often occurs. If an unconscious person starts to vomit, always turn his head to one side, so that the ejected matter runs out of the mouth and does not get back into the windpipe (fig. 188).