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Title: Backwoods Surgery & Medicine

Author: Charles Stuart Moody

Release Date: May 11, 2015 [EBook #48929]

Language: English

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BACKWOODS SURGERY




  BACKWOODS
  SURGERY &
  MEDICINE

  BY
  CHARLES STUART MOODY, M. D.

  MCMX
  OUTING PUBLISHING COMPANY
  NEW YORK




  COPYRIGHT, 1910, BY
  OUTING PUBLISHING COMPANY
  _Entered at Stationer's Hall, London, Eng.
  All rights reserved_




CONTENTS


  CHAPTER                                PAGE

     I. How to Treat Fractures, Sprains
          and Dislocations                  9

    II. Caring for Burns, Cuts, Drowning,
          and Minor Accidents              29

   III. Medical Treatment of Camp
          Diseases                         51

    IV. Serpent Wounds and Their
          Treatment                        73

        The Camper's Medicine Chest        93




  HOW TO TREAT FRACTURES,
  SPRAINS AND DISLOCATIONS




Backwoods Surgery and Medicine




CHAPTER I

HOW TO TREAT FRACTURES, SPRAINS AND DISLOCATIONS


Several years ago I stood beside a cot in a hunter's cabin in the heart
of the Bitter Root Mountains in Idaho, after a three days' ride, and
watched a valuable young life go out as the result of an unattended
compound fracture of the thigh. At another time I amputated a leg to
prevent the spread of gangrene from a simple cut across the instep
while the camper was splitting wood, an accident which, properly
treated, would have resulted at most only in a slight inconvenience.
Once again, I transformed my boat into a funeral barge and conveyed a
young man who had only been in the water three minutes back to his
sorrowing parents dead, because his companions were ignorant of how to
resuscitate him.

These and many other instances that have come under my observation
of the sacrifice of lives from trivial causes, owing to a lack of
knowledge, have impressed me with the value of a few suggestions on how
to treat the commoner injuries and diseases that may befall those who
seek recreation in the remote wilds.

The rules will necessarily be brief and from the nature of things
easily followed. The woods loafer should learn them and be prepared
whenever the occasion arises. Works on first aid, written ostensibly
for the guidance of the laymen, are apt to presuppose a far greater
supply of surgical necessities than the hunter cares to burden himself
with. It is one thing to apply surgical measures, having at hand
a well-filled emergency bag, and quite another to render the same
assistance with nothing to depend upon but your native adaptability.
My intention is to tell in the plainest and simplest manner possible
how to render intelligent assistance to an injured comrade, using only
the fewest appliances and those of the most primitive character.
These hints are the result of over twenty years of life in the West,
in mining camps, cow camps, logging camps, and in the heart of the
mountains, where people did not have forethought enough to provide
themselves with even a bandage, many times hundreds of miles from where
such things could be obtained.

The most appalling accident that can befall a man isolated from skilled
surgical aid is the fracture of a limb, especially of the leg, and yet
this is one of the commonest of all woods misfortunes.

Before proceeding to the discussion of individual fractures, a brief
consideration of the classification and detection of fractures in
general is necessary. Surgeons divide fractures into: simple, those
where there is a simple separation of the bone without injury to the
flesh; compound, where in addition to the separation of the bone there
is laceration of the flesh and one or both ends of the bone are driven
out through the skin; and comminuted, where the bone is in several
fragments. A comminuted fracture may be either simple or compound,
according as it does or does not penetrate the flesh.

The symptoms of fracture are pain, loss of motion, change of position,
change of contour of the fleshy parts, and most important of all, a
light crackling sound when the limb is moved—crepitation the surgeons
call it.

Pain following an injury that _might_ produce a fracture is not
necessarily proof positive of the existence of a fracture. Pain may and
often does follow a bruise, sprain, or dislocation, in a greater degree
than that following a fracture. Loss of motion, too, is quite as marked
in dislocations and severe sprains as in fractures. Change of contour,
unless in the locality of prominent joints, is quite a valuable sign.
The fractured limb, except in certain rare cases, will show a change in
the appearance of its general outline.

By crepitation is meant that characteristic grating sound produced by
rubbing the two ends of the fractured bone together. It is the one
absolute sign of a fracture, and once heard can never be forgotten. It
may be likened to the sound produced by rubbing two or three coarse
hairs between the finger and thumb.

If a fracture is suspected let the patient himself, or some one for
him, grasp the limb above and below the site of the suspected fracture
and turn it in opposite directions. If a fracture is present it will be
manifested by a distinct grating sound, also by a jarring sensation as
the uneven fragments pass over each other.

A description of all the fractures of the different bones of the
body would be manifestly out of place in a book of this character,
so I shall confine myself to those most liable to be encountered in
the woods—that is, fractures of the leg, thigh, forearm, and arm.
Fractures of the leg or thigh will entail an enforced stay of from four
to six weeks in the woods, or the devising of some means to transport
the patient to a place where he can have proper care, an arduous task
in a country where there are no roads and the trails are difficult. If
a personal experience may be allowed, I will tell how I once treated
a man with fractured thigh and conveyed him with comparatively little
discomfort over sixteen miles of rugged mountain trail and some forty
miles of equally rugged mountain road.

I found the man in a mining camp in the very heart of the higher
mountains, lying in his bunk with a badly fractured thigh. The bone
was separated between the upper and middle third—that is, up toward
the body. The accident had occurred some twenty hours previous and
there was much swelling, which it was necessary to reduce before
anything else could be done. This was accomplished by the application
of cold water by means of strips of blanket, changing the application
as fast as the water became warmed by the body heat.

In the meantime I went out into the timber and felled a small cedar
tree some six inches in diameter. From this I cut a section five feet
in length and removed the bark. Splitting the bark in half, I rounded
up the edges and made a splint for the outside of the limb extending
from the armpit to six inches below the foot. The other half was made
into a similar splint, only shorter, for the inside of the limb,
extending from well up into the groin to a point opposite the outer
splint below the foot.

It was necessary to cut holes in the splints where the bony prominences
came. When all was in readiness and the limb reduced in size, I wrapped
it well in soft cloth, having no absorbent cotton, and applied my
splints. I had a man stand at the feet of the injured man, take hold
of the injured leg, and pull steadily while I manipulated the fracture.

Right here I want to state that it is unnecessary to try to pull a
broken bone out of the socket in order to set a fracture. A persistent
pull of some fifty pounds will soon overcome the contraction of the
muscles and the bone will be replaced. The acting surgeon must at the
same time grasp the limb at the site of the break and knead the two
ends into place. You will know when they are in place by the absence of
inequality at the point of break.

After the bone had been replaced, I placed my splints in position and
bound them on, using strips of sheet torn up for bandages. Any stout
cloth will do as well. They may be placed in the ordinary manner,
each wrap beside the other, or they may be run on in continuous form,
permitting each ascending turn to half overlap the one below it. Care
must be taken that the pressure is equal in all parts of the bandage
and that it is placed tight enough to prevent any slipping of the
splints.

The next problem was to get the man out. Again the cedar forest came
to my relief. I felled another and somewhat larger tree, sufficiently
large to permit placing the injured man in a boat-shaped section of
the bark. This was made longer than his body and a semi-circular board
fitted in each end. When the whole was completed it resembled a rude
trough.

This trough was lined with blankets until it was quite soft. Two poles
twelve feet in length were lashed to either side and the man securely
lashed in the contrivance. When we were ready to start two steady pack
animals were brought out and the litter with its burden swung in such
manner that the animals could wind down the steep rocky trail with the
burden between them. In this manner we jogged down the mountainside all
day, our patient laughing and enjoying his pipe as though he were the
guest of honor in some triumphal procession.

While cedar was mentioned as having been used in the above case, the
reader will appreciate that any sort of timber with a tough bark will
answer equally well.

There is one important fact that should always be borne in mind in the
treatment of all fractures, and that is that at least the two adjoining
joints should be fixed. If it is the thigh that is fractured, the hip,
knee, and ankle should be included in the splint. If the leg, then the
knee and ankle. The same rule holds good with fractures of the forearm
or arm.

If timber with tough bark is not available, or in open countries where
no timber grows, a broken bone may be nicely splinted by using small
round sticks. Never use a clapboard unless it is extremely well padded;
even then it is undesirable from the fact that it is liable to press
upon some bony point and cause trouble. Also it is very liable to slip
and permit your fractured bone to become displaced.

To fix a limb by using round sticks, wrap the limb well in soft cloth;
then, having cut your sticks the right length, place them at regular
intervals about the limb and bind as before. In the absence of anything
better, two leather gun scabbards make quite effective splints.

What has been said with regard to fractures of the lower limb will
apply with equal force to breaks of the upper except, of course, that
the case is one of far less gravity. In cases of fracture of the arm,
either above or below the elbow, the injured person can make himself
quite comfortable by pinning the bottom of his coat to his shoulder
and placing the injured arm in the V-shaped sling thus formed.

The treatment of compound fractures is one that requires some "nerve"
on the part of the acting surgeon and a great deal of fortitude in the
injured person. A compound fracture of the leg or thigh is the most
terrible accident, short of death, that can befall a man in the woods.
Unless great care is exercised the man will die, either shortly from
septic poisoning, or almost immediately from shock.

First, get your patient into camp if he is away from it. That may be
done in the following manner, which will also illustrate how to carry a
person injured in any manner: take a blanket and lay it at full length
on the ground; place a pole two feet longer than the blanket directly
in the center and fold the blanket over it; lay a similar pole in the
center of the folded half and fold the free side back over; place your
patient on top, and two men can carry him as comfortably as though he
were in a litter. It is, in fact, an emergency litter.

Another emergency litter may be constructed by buttoning an overcoat
its full length and running two poles down the sides, laying the
patient between them. Failing an overcoat, two short coats or Mackinaw
jackets may be made to serve.

Having got your patient with the compound fracture into camp, cut
off all clothing from the wounded limb, but no more. It is a bad
plan to remove too much clothing from badly injured persons. All the
warmth must be conserved, even to the extent of applying artificial
heat. Examine the wound for foreign matter and carefully remove it,
especially bits of clothing, leaves, small sticks, and bits of earth.

While you have been thus engaged, water should be heated in the
cleanest, brightest vessel the camp affords. If there are none bright
enough, one may be sterilized by burning it over a hot fire for at
least ten minutes. It is absolutely essential that the water used to
cleanse a wound of this character should be sterile—that is, without
any germ life whatever; hence the directions for boiling it.

In another clean vessel boil all the cloths, towels, and other
dressings that you intend using. Any soft cloth will do for dressings,
provided it is sterilized and sterilization consists only in thorough
boiling.

One of the articles I shall mention in a very limited surgical kit is a
bottle of tablets composed of bichloride of mercury known as Bernay's
tablets. They are made by all chemical houses and vary in form, but all
contain about the same quantity of the antiseptic agent. Some are white
and some blue in color, the blue being preferable.

One of these tablets dissolved in a quart of water makes a solution of
about the proper strength for dressing wounds. Make your solution and
with your sterilized cloths wash out the wound thoroughly, and that
does not mean to let a little water flow over the wound; it means to
remove every particle of foreign matter in and about the wound.

If the bones have stuck into the earth, as is quite often the case,
they must be exposed and the narrow canal cleaned. Then replace the
bones in as nearly their proper position as possible. Do not attempt
to "set" the bone; just put it back fairly nearly in line. Then cover
with several layers of moist cloth that have been previously boiled and
dipped in the bichloride solution.

Every day expose the wound, wash it out, and dress it. If the patient
is of strong physique and God smiles, he may not have septic fever. If,
however, the limb shows signs of inflammation evidenced by swelling
and redness, accompanied by fever, chills, and thirst, then must you
perform some heroic tasks to save your patient's life.

Remove all dressings and wrap in perfectly clean dressings the entire
limb from the hip to the foot, elevate so that it will drain properly,
and keep cold water running over it in a small stream constantly. This
may be done by making a small hole in the side or the bottom of a
bucket and hanging it in such a way that it will permit the stream to
fall on the limb. If you follow the foregoing directions implicitly,
you have done all that can be done.

It will be understood that what I have said touches upon the subject of
fractures in only a very general way. The methods of treatment outlined
will apply to practically any fracture, and certainly to those most
liable to be encountered in the woods.

The four principal dislocations that are liable to engage your
attention are those of the hip, knee, elbow, and shoulder. Of these,
that of the hip is the most serious. Without going deeply into the
classification of hip-joint dislocation, it will be sufficient to say
that fortunately by far the greater number of these is where the head
of the bone slips out of its socket upward and backward. Those in which
the head of the bone occupies other positions with relation to its
socket are much more difficult, in fact, for the layman practically
impossible.

The signs of a hip-joint dislocation are shortening of the limb, loss
of motion, pain, and the turning of the toes in toward the opposite
foot. You will be able to distinguish it from a fracture of the thigh
by the absence of crepitation (which I have described as the slight
grating sound made by the broken ends of the bone rubbing together),
and the fact that in a fracture the toes are generally turned out.

A friend of mine once reduced his own hip-joint dislocation in a
manner that may prove instructive. He was coming down the steep side
of a mountain in winter on skees. Halfway down the hill, while he was
traveling at a great rate of speed, he ran into a depression, breaking
his skee and dislocating his hip. It was many miles to the nearest
cabin, night was coming on, and it was bitterly cold. Death stared him
in the face. It was a time for the exercise of judgment if ever in his
life.

He crept down to a grove of small pines, selected two that were just a
little farther apart than the length of his body, lashed the foot of
the injured limb to one with his pack strap, lay at full length on the
snow, and clasped the other with his arms. Pulling with all his might,
he had the satisfaction of hearing the bone jolt back into its socket.
The idea suggested will enable the reader to modify the method to suit
each individual case.

In dislocations of the shoulder the old method still in vogue among
some medical men is quite easy of accomplishment. Lay the patient on
his back and seat yourself at his side, first having removed the shoe
from your foot next to his body. Grasp his injured arm and turn it
outward from the body. Place your bare foot well up into his armpit.
While an assistant steadies his shoulder, pull downward upon his arm,
at the same time moving it toward the patient's body.

Make your pull steady, and when you have begun do not relax until you
feel the bone jolt into its position. In the case of muscular persons
the pull must be kept up for a longer period, or until the contraction
of the muscles has been overcome.

Dislocations of the elbow are usually those in which the two lower
bones slip backward and the upper bone forward. They may be reduced by
grasping the injured arm just above the elbow with your left hand, the
fingers just behind the prominence of the dislocation; with the other
hand bend the injured arm well forward, at the same time slipping your
left hand downward.

When the injured arm is fully bent, grasp tightly with your left hand
at the elbow joint and with your right forcibly straighten it. The
fingers of your left hand form a fulcrum for the bone that is out of
place to act upon and thus force it back into position. This maneuver
is somewhat difficult to describe but quite easy to accomplish. One
will be surprised with what ease the bone slips back into position.

Dislocations of the knee are reduced similarly, except that it requires
two to do the work. Then, too, the knee often becomes dislocated
laterally and the pressure must be made in a lateral direction.

A very distressing little accident is the dislocation of the lower jaw.
I once had a patient who rode a long distance with his mouth wide open,
suffering a great deal of inconvenience and no little pain, when one
of his friends could have relieved him in an instant. Wrap both your
thumbs in several layers of cloth, stand behind the patient, who should
be seated, and place your thumbs thus protected, on his back teeth,
grasp his jaws on either side with your fingers, press down with your
thumbs, up with your fingers, at the same time drawing the jaw forward.
The bones will go back with a snap and the victim will spasmodically
close his mouth hard enough to draw blood unless your thumbs are well
shielded.

Dislocations of the joints of the fingers may be reduced by taking
a double half-hitch around the finger below the dislocation with
a handkerchief, placing your left thumb back of the head of the
dislocated bone, and as you pull on the handkerchief with your right
hand push forward and downward with your left. The bone will readily
slip into place.

Dislocations should be kept at rest for several days and any tendency
toward inflammation kept down by the application of water. Severe
dislocations, as those of the hip, should be treated similarly to
fractures.

Sprains and bruises, while not serious, are often very annoying. When
the accident first occurs immerse the limb in cold spring water.
This has a tendency to contract the small blood vessels and keep
down inflammation. If, however, swelling has already set in, hot
water should give place to cold, as hot as can be borne. A consistent
application of hot water to a sprain or bruise will ordinarily cure it
in a few days.

It may be necessary, under certain conditions, to bandage the limb,
especially if one has to make a journey. By applying a roller
bandage snugly about a sprained ankle, for instance, one may travel
in comparative comfort for several miles. Of course, he will pay
the penalty afterwards, but I am speaking now of cases where it is
imperative that a man travel.

In applying any bandage be sure that it has no wrinkles in it. It must
be laid perfectly smooth and drawn reasonably tight. A loose bandage or
one that is placed unevenly is worse than useless.




  CARING FOR BURNS, CUTS,
  DROWNING, AND MINOR
  ACCIDENTS




CHAPTER II

CARING FOR BURNS, CUTS, DROWNING, AND MINOR ACCIDENTS


In speaking of fractures and dislocations I did not dream it necessary
to suggest anything in the way of a surgical kit. The element of
instruments other than bandages does not enter largely into the
treatment of this class of injuries, and the bandages may be improvised
from materials at hand.

In the treatment of such wounds as we shall now take up, however, it
will be necessary to carry a few things with which to work. This outfit
will be limited in its scope, economy of space being imperative. A
convenient instrument roll may be made from a strip of canvas, with a
pocket at the bottom and loops for holding instruments. This can be
rolled into compact shape when filled and tied with tape.

In the pocket place a card of assorted silk ligature, ranging in size
from one to six, half a dozen egg-eyed needles ranging from full to
half curve, one yard of oiled silk or an equal amount of gutta-percha
tissue, one bottle bichloride of mercury tablets mentioned before, half
ounce Squibb's surgical powder in shaker-top can, four ounces absorbent
cotton in carton, two yards sterilized cotton gauze sealed, a paper
of safety pins and another of common pins, one soft rubber catheter,
number 9, one roll adhesive tape two inches wide.

In the loops place one needle-holder (Emmet's), one hypodermic
syringe (all metal), one pair straight shears about six inches, two
hemostatic forceps (Kelly's), one curved bistoury (small), and one
splinter forcep. The metal case for the hypodermic has compartments
for small tubes containing the hypodermic tablets. Take one tube each
of the following: hydrochlorate cocaine gr. 1/4, morphine sulphate gr.
1/4, strychnine sulphate gr. 1/60. With the foregoing rather limited
equipment you will be able to render assistance to a person injured in
any of the accidents likely to occur in the woods.

There are a few surgical principles that should be impressed upon your
mind before the subject of treatment is taken up. The first and most
important of these is that it requires a great deal more loss of blood
than is popularly supposed to endanger life. There is no danger from
hemorrhage from a vein and but little from any of the smaller arteries.

The free flow of blood from a wound instead of being alarming is the
most beneficial thing that can happen. The cleansing power of flowing
blood cannot be overestimated and it is cleansing that all wounds
require. That brings up a second thought. All serious consequences
arising from incised or punctured wounds come from the invasion of
bacteria, and all your efforts should be directed against these
energetic little gentlemen, either those that have already entered the
wound or those that are striving to gain ingress.

A simple cut will, if permitted to seal itself up in its own blood,
generally heal without any further interference. The man who puts
tobacco, flour, soap, or any other of the popular monstrosities on a
wound is little short of a criminal.

While, theoretically, many people know that blood flowing in a steady
stream is coming from a vein and that flowing in jets or spurts
is coming from an artery, few know how to take advantage of that
knowledge. The general rule to make pressure between the heart and the
wound in case of a jet and between the wound and the extremity in case
of a stream is only good as a general rule; there are exceptions and
it is exceptions that make the rule dangerous. There are times when it
becomes necessary to reverse the process.

The proper way is to make compression with your fingers until you
have located the region the blood comes from; then apply your steady
compression in that locality. There are a few great arterial trunks
that lie near the surface and may become injured, the injury causing
death from hemorrhage. The manner of locating the compression point for
these arteries will be given.

The first of these is the great artery that runs down the inside of the
leg, called the femoral. Bleeding from this vessel will result in death
in a very few minutes, and it has been known to be severed by a man
falling on his sheath knife. The bleeding may be controlled by grasping
the leg with the fingers near the body. About half way down the inner
surface of the leg the fingers will fall into a slight depression, at
the bottom of which lies the femoral artery.

Any of the vessels of the lower limb may be controlled by compressing
just behind the knee between the two prominent tendons that will be
found there when the leg is doubled up. Arteries of the forearm and
hand can be stopped by pressing with the thumb at the elbow joint just
to the inner side of the tendon of the biceps which you may feel like
a cord when the arm is extended. If the bleeding is from the upper arm
stretch the whole arm by raising it above the head. Feel in the armpit
and you will locate a prominent ridge on the inner side; press with
your fingers just behind that ridge and you will shut off the blood
supply from the whole arm. These are the more prominent vessels that
lie near the skin.

Certain of these larger arteries require ligation. The ligation of
an artery calls for a certain amount of surgical skill, but if it is
necessary to save life you can do it. Surgeons now use sterilized
catgut for the purpose, but silk can be used as well, taking care to
leave sufficient end hanging out of the wound to remove it by.

After having made compression and controlled the hemorrhage, clean out
the wound and loosen your tourniquet until the blood spurts. Locating
the artery, grasp it in the bite of the hemostatic forceps. Cut off a
short piece of silk and tie it loosely around the forceps. Have some
one pull up on the forceps and at the same time with your forefingers
slip the knot down over the end of the cut vessel. Tie tight and remove
your forceps.

This procedure will be necessary only in case of injury to large
vessels. Smaller arteries can be controlled by the means hereafter
described, or by placing a heavy pad of gauze over them and making
compression with a tight bandage. The blood will become entangled in
the meshes of the cloth and form a clot.

Incised wounds inflicted with sharp instruments will be found to
comprise practically all the injuries occurring in the woods. The
method of treating one will illustrate that of dealing with all. Let us
suppose that in cutting firewood the camper has had the misfortune to
drive a sharp ax into his instep (a quite common accident). The blood
spouts at once in a very alarming manner. He hobbles to the camp and
removes his shoes. An ugly gaping wound appears, from the bottom of
which blood is jetting, indicating that an artery has been severed.

The first thing necessary is to stop the blood. Take a handkerchief or
other cloth and tie it about the ankle rather loosely, place a small
stick or a table fork beneath it and twist. In a few turns you will
note that the blood is flowing with less force and shortly will cease
altogether.

When the bleeding has been entirely controlled get out your surgical
kit and throw a pair of the hemostatic forceps into the boiling water.
After they are sterilized wash the wound free from blood with pure
water. I will add in this connection that spring water in the mountains
is practically sterile and can be used for washing wounds without any
danger of infection.

After the wound is clean have some one slightly loosen the tourniquet.
As he does this watch sharply for the jet of blood that will locate the
cut artery. As soon as you see it grasp it with the forceps, lock them,
and leave them in place. The compression of the forceps while you are
getting ready your other instruments will seal up the vessel so that
when you remove them it will not bleed any more.

Take two of your full curved needles, at least two inches long, and
thread them with quite coarse silk, cut off a piece of your gauze
and run the needles through it. Place the needles thus prepared, the
needle holder, shears, and the other pair of hemostats in a vessel and
boil. In the meantime make up a solution of the bichloride, using the
antiseptic tablets for that purpose.

Wash your hands well and rinse them in the bichloride solution. Clean
out the wound, taking great care to remove all clots. With one of the
threaded needles in the grasp of the needle holder begin at the upper
angle of the wound, about half an inch from the end. Pass the needle
down through the flesh one-fourth of an inch from the edge, carrying it
well toward the bottom and making it enter the wound near the bottom
and re-enter the flesh on the opposite side, pass up through and out an
equal distance from the edge. Cut the thread off and lay the two ends
out of your way, leaving, of course, sufficient to tie with when the
time comes.

Place your row of stitches half an inch apart all down the wound. When
all the stitches are in place you may begin to tie. Take the two ends
of the first stitch in your hands and lift up on them; this will bring
the edges of the wound together. Tie the thread, turning the first knot
under twice to prevent its slipping. After all the stitches have been
tied take the handle of your scalpel or the forceps and raise the edges
of the skin, which will have rolled in, until they meet each other.
This is necessary, as where the skin is rolled in it will not heal
readily and leaves an opening for the entrance of bacteria.

Sponge off all the free blood and dust well with surgical powder. Place
a pad of gauze that has been soaked in the bichloride solution over the
wound, cover that with a wad of cotton and the cotton with a piece of
oiled silk, bandage over all, and do not molest for at least three days.

After five days you may remove your stitches in this manner: Cut the
stitch near the skin on one side, grasp the knot in the bite of the
forceps and pull it out. Be careful not to try to pull the knot through
the flesh, and do not leave any end on the part you do pull through
the flesh, as it may carry infection down into the wound.

It is a fact not generally known to the laity that a solution of common
salt and water will take the place of blood when introduced into the
system. Surgeons resort to this practice in performing all very bloody
operations. Their method of hypodermoclysis could not be carried out
in the camp, of course, but a very good substitute for it can be used.
The lower bowel is very receptive of this solution, which by the way,
is made by dissolving a teaspoonful of clean common salt in a pint of
water. The solution, maintained at blood heat, is introduced into the
lower bowel with a fountain syringe. Persons who have lost a great deal
of blood, so much in fact that their pulse can hardly be felt at the
wrist, will receive great benefit from this procedure. Use at least a
gallon of the solution and do not permit it to flow too rapidly into
the bowel.

Certain cuts may be dressed without stitches. Proceed as before up to
the point of putting in the stitches, then roll up two pieces of gauze
as long as the cut and about the size of a lead pencil. Lay these on
either side of the wound quite close to it. With adhesive tape half an
inch wide and four inches long begin two inches on either side of the
wound and carry across, bringing the edges of the wound together. Place
these strips half an inch apart until the wound is brought into line.
Dress as before, except that you will have to omit the moist gauze,
dressing with the powder entirely.

I want to add here that should you run out of sterilized gauze at any
time you can make it from any soft cloth by boiling it for ten minutes
in the bichloride solution and hanging in the air to dry.

The pain attendant upon any surgical manipulation can be prevented by
the hypodermic injection of a solution of cocaine. When you get your
hypodermic have the instrument man show you how it works. He can show
you much better than I can tell it. Insert the needle half an inch
from the wound and inject a few drops of the solution into the skin.
Proceed thus entirely around the wound and by the time you are through
the wound will be perfectly painless. Before replacing the instrument
in its case always dry it out and replace the small brass wire that you
will find in the needle.

It is somewhat difficult to approach the subject of punctured
wounds, which also include those resulting from gun shots and powder
explosions. The rule among surgeons is to meddle with these injuries as
little as possible, provided they do not penetrate the abdomen. In the
case of penetrating wounds caused by falling on a sharp stick or other
sharp pointed instrument, it is well to clean out the wound, removing
all foreign substance that may be present, searching diligently for
pieces of cloth, rust, charcoal, bark, or other foreign matter. These
things in certain localities contain the germ of lock-jaw, and many
contain it anywhere.

This is particularly true of felt wads from shotgun shells. All
diligence should be exercised to clean out a wound resulting from such
a cause. Shotgun wads are manufactured from the most filthy kinds of
old hair, often reeking with the bacillus of tetanus.

If the wound was caused by a sliver of wood and the sliver still
remains in the wound remove it by making an incision with your
bistoury. Do not be afraid to cut. A little cut is worse than none; go
deep enough to liberate the sliver so that it may be removed with the
splinter forceps. Then wash the wound from the bottom with hot water
and dress as before, using the bichloride.

Experience has proved that the less one attempts to do with gunshot
wounds the better. Nature has a tendency to wall off foreign bodies
that are in the main sterile and will ordinarily do so with a bullet if
given a chance. Keep the patient quiet, prevent infection from entering
the wound, and trust to Nature to do the rest.

An incident will illustrate what takes place when Nature is given an
opportunity to throw out her plastic wall material around a foreign
body. Some years ago a party of Eastern people were camping in the
heart of the Bitter Roots. Among the party were two boys of the age
when boys are prone to try experiments. They bored a small hole in a
spruce tree and drove into it a high power 30–30 cartridge. Then they
stood off some fifteen feet and fired at the cartridge with a small
rifle. One of them hit it.

The 30–30 shell came back and penetrated the abdomen of the juvenile
marksman, burying itself and driving pieces of clothing into the
abdominal cavity. The messenger who came for me was thirty-six hours
on the trail and I was an equal length of time reaching the camp.
The people had had sense enough to keep the patient quiet and I found
him resting fairly easy. So deeply had the missile penetrated that it
required a considerable incision to remove it.

When I reached the bottom of the wound I found that Nature had thrown
about the wounded area a wall of protective lymph and all the pus that
had accumulated was in a pocket. I laid the pocket well open, evacuated
its contents, and removed the bits of cloth that I found, dressed the
wound, and had the satisfaction of seeing the youngster recover.

Burns are classified according to degree of injury. Those of the first
degree are where the skin is reddened, but no blister formed. The
second degree includes those where there has been decided blistering,
and the third, where the flesh has been charred. Those of the first and
second degrees are the most common in about the proportion of 99 to 1.

A burn of the first degree can be best relieved by the application of
cold water. This is contrary to the teachings of a few years ago, but
is in full accord with that of to-day. The water should be changed as
fast as it becomes warm.

Burns of the second degree require more care. In the first place, do
not interfere with the blister. The primary object in treating burns is
to exclude air and the skin remaining intact will do this much better
than any artificial means.

The Indians of the Northwest prepare a dressing for burns by cooking
deer suet with balm of gilead buds. This is the most effective
application for severe burns I have ever seen. If deer suet is not
available, any fresh tallow that has been cooked will serve as well.
Throw a handful of the buds into a vessel and cover them with the suet,
boil for thirty minutes, and strain. When nearly cold apply to the burn
and cover with a soft cloth. The pain ceases almost immediately.

It seems singular after all that has been written on the subject, but
few people know how to restore a drowned person. The matter is really
quite simple, yet it requires great attention to detail. Spasmodic
efforts are useless. The thing has to be gone about methodically and
the method persisted in for a long time, often in the face of seeming
certain defeat.

In the first place, statistics show that no person who has been
submerged in the water for a period of seven minutes was ever
resuscitated. It is extremely doubtful if after five minutes' immersion
anything can be accomplished, still it is worth the effort.

The first thing to do when a person is rescued from the water is to
remove all clothing from about the chest and neck. Do not take the time
to draw the garments off, but rip them off with a knife. Turn the body
over and stand astride it. Grasp it about the middle and lift up so
that only the head and feet are touching the ground. This is done in
order to free the lungs and air passages from water and mucus. Do this
several times.

With a handkerchief wipe out the mouth and as far down the throat as
you can reach. Lay the patient on his back with a folded coat under his
shoulders. Kneel at his head and grasp both arms at the wrists and pull
them well up over his head, hold for an instant, return to the sides
and press them against the ribs, hold for an instant and repeat. Do
this about twenty times each minute.

The tendency is to work too fast. The movement should be about as
fast as a man breathes, the object being to simulate the ordinary
respiratory movements as nearly as may be. While this is being done
another person may grasp the tongue and pull it up and out of the
mouth, keeping time with the movements of the arms. When the patient
begins to show signs of life wrap him well in hot blankets, place hot
stones at his feet, and administer hot water, brandy, or strong hot
coffee.

As before suggested, the efforts at restoration should be persisted in
for a long time, until either success rewards your efforts or the body
becomes quite cold and rigid. It may be that there is a little spark of
life left and you may fan it into flame after hours of effort.

There are many minor accidents for which it is well to be prepared. For
example, to remove a fish hook: Do not try to pull it back; push it on
through, file or break off the barb and it can be removed readily.

To remove foreign bodies from the eye: First cocainize the eye by
dropping a few drops of a solution made by dissolving one of the
cocaine tablets in a half teaspoonful of water, then turn the lid back
over a match telling the person to look down at the same time, and
brush the substance off with a soft cloth. If it is under the lower lid
place your forefinger on his cheek just beneath the eye, pull down, and
tell him to look up. If it adheres to the eyeball, as in the case of a
cinder or a small piece of steel, after cocainizing the eye remove with
a sharp knife by brushing.

Insects sometimes crawl into the ear and make a lot of commotion. Place
the patient on his side with that ear uppermost and pour plenty of warm
water into the ear. By plenty I mean several quarts. The bug will crawl
out or be washed out by the returning stream of water.

Burns well characterized toothache as "Thou hell of a' diseases." If
the tooth has a cavity (as it probably has), a small crystal of cocaine
dropped dry into the cavity and covered with a little pledget of cotton
will give immediate relief.

For bleeding from the nose, place a pledget of cotton in each nostril,
lay the patient on his face, and pour cold water over the back of the
neck. Leave the cotton there for several hours. The idea is that the
fibrin in the blood becomes entangled in the fiber of the cotton and
sets up a clot that seals the bleeding surface, while the cold water
closes the blood supply by its action on the artery supplying the parts.

Hiccough is a distressing and sometimes a dangerous complaint. Many
times a swallow of water will stop it. If simple measures fail, the
following has been found very efficacious. The nerves that produce
hiccough are near the surface in the neck. They may be reached and
compressed by placing two fingers right in the center of the top of the
breastbone between the two cords that run up either side of the neck
and pressing inward, downward, and outward. A few minutes' pressure of
this kind will stop the most obstinate hiccough.

Certain injuries are attended with what is known as shock. Usually
the degree of shock is proportionate to the extent of the injury,
though not always so. Often seemingly trivial injuries produce a fatal
shock. The symptoms are cold, clammy skin, face very pale and pinched,
eyes widely dilated and staring, pulse rapid and irregular, little or
no pain, even from severe injuries. The patient retains his mental
faculties but loses the power to originate, answering when spoken to
but usually volunteering no statements of his own.

The treatment consists in lowering the head and elevating the
extremities. Wrap the patient in hot blankets and place hot water
bottles about him, give brandy, or what is as good, hot water; inject
1/30 gr. strychnia every fifteen minutes for three doses.

The symptoms from loss of blood are very much the same as from shock
and luckily respond to the same treatment. In addition, if there
chances to be a fountain syringe in the camp, give rectal enemas of hot
normal salt solution, which can be made by dissolving a teaspoonful
of common salt in a quart of sterile water. In some way this solution
seems to take the place of the blood lost. A hot application over the
heart is also valuable, as are mustard drafts to the spine.




  MEDICAL TREATMENT OF CAMP
  DISEASES




CHAPTER III

MEDICAL TREATMENT OF CAMP DISEASES


In this day of compact pharmaceuticals one can carry a complete
equipment of medicines in a vest pocket almost. The old day of
ponderous powders and nauseating liquids has passed. The physician now
who prescribes for his patients immense bottles of "shotgun" mixtures
writes himself down a back number. This manner of administering drugs
can be taken advantage of by the man who wishes to carry with him upon
his outing a supply of remedies for the relief of such ailments as may
befall him.

Oliver Wendell Holmes once said in delivering an address to the
graduating medical class of Harvard, "Young men, you have been taught
here at least twenty remedies for every disease; after you have
practiced medicine twenty years you will have one remedy for twenty
diseases."

The genial autocrat was nearly right. The longer one continues in the
practice of medicine, the fewer remedies he learns to depend upon. An
Irish medical friend of mine once put the thing in very apt form when
he said, "If I had to practice medicine on an island where I could have
only three remedies, I should choose castor oil, opium, and strychnia.
I'd physic them with the castor oil, constipate them with the opium,
and stimulate them with the strychnia."

These remarks are a little beside the subject, but I am constrained to
quote them to illustrate that but few medicines are needed, if these be
well understood, and the indications for their use can be mastered by
anyone in a short time.

For the past several years my emergency medical case has contained only
ten remedies, and with these I have not hesitated to make professional
trips of many miles. The case should be made of sole leather with a
pocket for a small note book and loops for a clinical thermometer. The
bottles should hold half an ounce and have screw caps. Have the glazier
etch with his diamond the numbers from 1 to 10 on the sides of the
bottles. The reason for this is that numbers pasted on are liable to
rub off, and as many tablets look much alike confusion may occur. Then
fill them in this manner:

No. 1: Calomel, gr. 1/4. Make this entry in the little note book that
is contained in the pocket. "No. 1, calomel gr. 1/4. Dose, one tablet
every thirty minutes for four hours. Indications, biliousness, headache
from disordered stomach, diarrhea, colds, and the beginning of all
fevers."

No. 2: Dosimetric trinity (Full strength). Dose, one granule every
half hour until skin becomes moist. Indications, all fevers, colds,
threatened pneumonia, and threatened typhoid.

No. 3: Chlorodyne. Dose, one tablet every hour to relief. Indications,
any gastric pain, cramps, diarrhea (after cleaning out the bowels),
colic, acute indigestion.

No. 4: Intestinal antiseptic. Dose, one tablet every hour for
four hours; then one every three hours. Indications, after bowels
have been cleaned out to correct any disorder of the tract, as a
routine treatment of typhoid; always valuable in diarrhea and other
inflammatory conditions of the bowels.

No. 5: Quinine sulphate, gr. 5. Dose, one tablet every four hours.
Indications, colds and catarrh, bilious fevers, specific in malaria.

No. 6: Elaterin, gr. 1/16. Dose, one tablet. Indications, to remove all
fermenting food matters in the stomach and bowels, produces excessive
watery evacuations. Valuable in dropsy; especially applicable where you
want to get rid of the entire contents of the bowels.

No. 7: Phenacetine, gr. 5. Dose, one tablet every three hours to
profuse perspiration. Indications, reduce fever where pulse is full and
bounding. Relieves headache; taken early cures severe cold.

No. 8: Sun Cholera. Dose, one every three hours. Indications, similar
to No. 3, only more powerful, valuable in severe summer complaint due
to eating fresh fruit, meat, drinking too much water. Relieves gastric
pain.

No. 9: Apomorphia hydrochlorate, gr. 1/10. Dose, two tablets followed
by swallow of hot water. Indications, as an emetic in poisoning. Use
cautiously.

No. 10: Digitalin, gr. 1/100. Dose, one tablet every hour to effect.
Indications, the most powerful heart tonic and reconstructive. Must be
used cautiously. Valuable in loss of blood, excessive heart action from
altitude, and all conditions where heart is not performing properly.

It will be noted that I did not mention morphine, strychnia, or
cocaine, as they were spoken of in connection with the hypodermic. In
the case I also place a one-minute clinical thermometer. All of these
instruments are now made self-registering and must be shaken down after
each using. This should be done, not by a jar, but with a long sweep of
the arm. Too sudden a jar will snap the instrument in two. Shake until
the mercury column stands below the △ mark. This △ mark indicates the
body heat at normal condition, that is, 98.4° F.

Every man should familiarize himself with certain physiological facts,
and with these as guideposts he ought to be able to follow a train of
indications to a reasonably fair diagnosis. The pulse rate, taken at
the wrist, is generally a fair index of the condition of the body. The
normal man has a pulse rate of about seventy-two beats per minute,
women somewhat more rapid; high elevations also produce a more rapid
pulse.

If there is an increase of heart beat above eighty per minute,
accompanied by other subjective symptoms, it is an indication that
something is wrong. In the absence of a clinical thermometer, one can
arrive at a pretty fair knowledge of the body heat by counting the
pulse. It is estimated that there will be an elevation of one degree F.
for every ten beats above the normal. This rule varies, but is a fair
average.

The appearance of the tongue is a valuable signpost, but one that
is difficult of mastery. A few prominent indications will be noted.
A thin, white, even furring of the tongue is indicative of gastric
disturbances and mild fever states. A flabby, swollen, indented tongue
covered with a uniform yellow, pasty fur is indicative of profound
gastric states and gastro-duodenitis; it may also be produced by a
continued moderate fever.

A narrow tongue, with deep median fissure on each side of which
is a thick rough fur, the tip and edges being red and denuded, is
characteristic of typhoid states whether arising from typhoid or
not. The same condition will be found in profound intoxication from
septic poisons. If the tongue becomes dry and brown, tremulous when
protruded, and the patient returns it slowly when requested to do so,
he has typhoid beyond question. A brown fur on the root of the tongue,
especially in the morning, indicates a sluggish condition of the liver.
In jaundice the tongue is yellow.

It is estimated that the normal man in a state of rest will breathe
sixteen times per minute. Any radical departure from the rate will
indicate disease. An increase of two respirations per minute is
supposed to indicate a rise of one degree F. in the body temperature,
though this rule is subject to variations. Inspection of the bare chest
tells the trained physician much regarding the condition of his patient
and even the layman can glean much knowledge from that source.

If the patient is breathing from twenty-five to thirty-five times per
minute, the respiration being confined to one lung as indicated by the
lack of expansion in the other, and if he lies so as to take the strain
off the lung that does not expand, it is almost sure that the patient
has pneumonia. In case the lung is fixed rigidly by the muscles and the
opposite lung forced to do all the work, then the patient has pleurisy.

In profound typhoid states the breathing is very much slowed and
irregular, at last presenting what is known as the Cheyne-Stokes
respiration, in which the patient will breathe several short shallow
respirations, pause for a time, heave a deep sigh and then repeat the
rapid breathing. This type of breathing is looked upon as a very grave
symptom in all conditions characterized by lack of physical strength.

It will be readily appreciated that only enough discussion of symptoms
has been given above to aid somewhat in arriving at a diagnosis. To go
deeply into physical indications of diseases would be manifestly out
of place in an article of this character. We will now proceed to the
consideration of the diseases that will be most frequently encountered
in the camp. Of these the intestinal troubles stand pre-eminent. Change
of water, food, methods of life, and personal habits account for the
fact that nearly every person who seeks the outdoors at some time
during his stay is afflicted with some one of the diarrheas. Without
attempting to go deeply into the various classifications of the enteric
complaints, a brief résumé of the guiding symptoms common to all will
be given.

It matters very little so far as the treatment is concerned whether it
be an ileo-colitis, an ileitis, or simply colitis. The same treatment
would obtain in each case, and the same general trend of symptoms
would be present. The patient feels a general indisposition, loss of
appetite, headache, and sleeplessness, which is followed by pain and
griping in the bowels; then comes the diarrhea, which may be profuse
and watery or scanty and accompanied by much pain. The evacuations
become exceedingly frequent, sometimes as many as fifty or sixty per
day.

The patient vomits frequently and is quite ill, his face becomes
pinched and dusky, with an anxious look in the eyes. There is some
fever and thirst, though the water drunk is generally vomited. In the
above has been pictured an extreme case of summer diarrhea. There will
be all gradations below this, from a mere soreness of the abdomen and
looseness of the bowels up to profound prostration from constant drain
on the system induced by the evacuations.

By a sort of strange medical paradox, in order to stop the evacuations
it becomes necessary to increase them. We must sweep out the nest of
troublesome bacteria that are causing the disturbance. An ordinary
cathartic will not accomplish this. It is necessary to administer
something that will produce a profuse watery discharge from the bowels.
Nothing accomplishes this better than a heaping tablespoonful of
Epsom salts in hot water, but as we have not provided for such bulky
medicines in our case we will give our patient one tablet of elaterin
which will accomplish the same purpose.

Then, too, the patient is not nearly so liable to vomit the
elaterin. If he does, however, the vomiting can be controlled by the
administration of cocaine by the mouth, though this latter drug must be
used very cautiously. A tablet of 1/4 gr. cocaine hydrochlorate given
in a swallow of hot water will stop vomiting until the other remedies
can produce their effect. Before giving any other medicines await the
free action of the cathartic.

The patient should have at least three very copious discharges; then
begin to combat the inflammatory condition that exists in the bowels.
The chlorodyne tablet will in all ordinary cases, do this best of
all your remedies. There will be some few instances where it will be
necessary to resort to more powerful remedies; in that case the Sun
Cholera tablet given according to directions is the best. As an after
treatment in these cases the intestinal antiseptic gives the best
results. A tablet every four hours for two days will annihilate every
vestige of bacterial invasion that may remain.

Bronchial and pulmonary diseases supply a large percentage of the camp
ailments in the fall and early winter during the deer hunting season.
An attack of pneumonia following a severe drenching from being out
all day in a rain, or accidentally tumbling into the creek, is not
a pleasant thing to contemplate. It usually comes in the night. The
patient wakes out of a sound sleep with a chill. There is a sharp
sticking pain as though a knife were being thrust between the ribs, at
some point on the chest wall. The breath comes in short gasps and the
patient instinctively turns toward the affected side in order to ease
the pain.

The chill may or may not be followed by vomiting, and the fever lights
up immediately, rising to 102–4° F. A distressing short cough comes
along to add to the discomfort as each act of coughing increases the
pain in the chest. In less than twenty-four hours the patient begins to
expectorate what we call "prune-juice" mucus, that is, mucus streaked
with blood until it resembles the juice of cooked prunes. When you see
this "prune-juice" you need have no doubt as to the diagnosis. You
should, however, have been busy long before this.

There is no doubt now among educated physicians that pneumonia, taken
in time, can be aborted. When the pain first manifests itself set
somebody to baking hot cakes made from flour stirred with water. While
these are still as hot as can be borne lay them over the painful spot
on the lung, renewing as fast as they become cool. To accomplish much
good this treatment must be kept up until the period of expectoration
and even after, at least twenty-four hours. At the same time begin by
administering calomel in 1/4 gr. doses every thirty minutes until at
least three grains have been given.

Two hours after the last tablet of calomel has been given, give a
tablet of elaterin. When the latter has "worked," start in with the
dosimetric trinity tablets and push them until the skin becomes moist
and the fever falls below 100° F. Do not give any of the coal tar
products in pneumonia, that is, do not give phenacetine or acetanilide.
When the patient is recovering it is well to keep up the heart by
strychnia or digitalin.

There is such a thing as giving too much of these heart stimulants
though, and you should watch the pulse closely. Stimulating the heart
too greatly is liable to cause congestion of the small blood vessels in
the lungs and defeat the very purpose you set out to accomplish.

Taking "cold" is a very popular camp method of feeling bad. The man who
does not at least once, while in camp, stuff himself full of a good
old-fashioned "cold" feels that he has been cheated out of a part of
the enjoyment of his outing. For the benefit of those of his companions
who do not appreciate his "barking" in season and out, the following
rules are suggested: First, take a bath; it may be painful but
necessary. Second, assist overworked eliminants to remove the debris
that has accumulated by reason of the failure of the ordinary processes
of waste removal.

This can be done very nicely with a heroic dose of calomel; by heroic
about three grains is meant. Follow up the calomel with several
five-grain doses of phenacetine, or until the patient is in a profuse
perspiration, roll him in warm blankets, and await developments. A
careful observance of the foregoing will annihilate any able-bodied
"cold" on earth.

The man who contracts rheumatism in camp has my sincere sympathy.
It requires no special skill to tell when one has it, but it does
require special powers of divination to tell when he will get rid of
it. Medical science has discovered only one drug that will affect the
progress of the disease in the least, and that only after an extended
course. Salicylic acid in one or another of its various combinations
furnishes the sheet anchor in the treatment of rheumatism. I purposely
omitted it from our pocket case of drugs because of the fact that the
combination that would suit one man's stomach would not another.

In practice we have to take many things into consideration in the
administration of the salicylates. The man with rheumatism in camp can
seek only to relieve the pain and assist Nature to eliminate the waste.
A thorough flushing of the bowels should be the first thing, followed
by aconitine, gr. 1/134, one tablet every hour for four hours; then one
every three hours. At the same time keep dry. If it be a limb that is
affected wrap it in blankets and "cook" it in front of the fire.

Cases of poisoning arising in camp will usually be confined to two
causes—the eating of poisoned foods and eating poisonous mushrooms. In
these days of tinned meats and vegetables it is not unusual to hear of
persons becoming seriously and even fatally poisoned by eating certain
canned goods. Canned fish and beef are the worst offenders in this
regard.

The symptoms of ptomaine poisoning are characteristic and generally
easily traced to the material producing them. There is a dryness and
metallic taste in the mouth shortly after eating suspected food. This
is followed by severe cramps, vomiting, violent purging, rapid loss of
strength, great depression and coldness of the surface of the body.
The hands and face break out in clammy sweat and the temperature falls
below normal. The picture is very characteristic and when once seen is
readily recognized.

The treatment consists in getting rid of the offending substance as
quickly as possible. Nothing accomplishes this more readily than a
quick emetic. Apomorphia hydrochlorate furnishes us with the most
convenient emetic, though mustard water or hot salt water will do.
Take a tablet of 1/10 gr. apomorphia hypodermically, or two tablets
of the same size by the mouth, followed by a swallow of hot water.
Hypodermically the emetic acts in a very short time; by the mouth
it requires somewhat longer, say ten minutes. Purge the bowels with
elaterin, one tablet, then keep up the vital forces by administering
strychnia, 1/60 gr. every hour or two, watching the circulation
meanwhile.

In severe cases, in addition to the strychnia, it may become necessary
to resort to external heat, hot water bottles, hot stones, etc. The
patient is much debilitated for several days and requires careful diet.

Mushrooms should never be eaten unless the person gathering them is
known to be thoroughly conversant with the different varieties. Certain
poisonous varieties resemble the edible so closely that only an expert
can tell the difference. The knowledge, however, is one that every
hunter and camper should familiarize himself with as mushrooms are
usually plenty in the hills and furnish an agreeable addition to the
menu.

Phalline, the toxic principle of the _phalloidæ_ group of mushrooms,
is a toxalbumin of extreme violence and resembles very much the toxic
albuminose of rattlesnake virus; in fact, it seems to act upon the
digestion very much as crotalin does upon the circulation. There is
another toxic principle present in certain other varieties of fungi
called muscarine; both these poisons act very similarly.

The symptoms are a feeling of giddiness coming on from one hour to
fifteen hours after eating the fungus. This is followed by profuse
salivation, the water running out of the patient's mouth in a stream.
Blindness ensues, and vomiting and diarrhea come in their train. The
heart is weakened and the patient breathes with difficulty. At the last
he lies in a stupor.

The treatment is similar to that of ptomaine poisoning. Remove the
offending material at once by the same process. For a purgative
oleaginous agents are the best if available, castor oil being
preferable; failing in that any active cathartic will do. The heart
then must be stimulated by the digitalin; strychnia also plays a
prominent role here.

It had not been my intention to mention typhoid, but upon reflection I
have decided to include it. Typhoid fever is little liable to attack
people living under such conditions as exist in the mountains where the
air is pure, the water comes from eternal springs, and flies are few.
Summer camps along lake shores and the larger, slow-moving streams are
liable to it, and it is just as well to recognize it when it arrives.

The person about to come down with typhoid generally feels extremely
tired for several days, the head and back ache, the nose frequently
bleeds slightly, a rumbling is present in the right side just below
the ribs, and the ears rings as though one had taken an overdose of
quinine. The tongue is characteristic of the disease, so much so, in
fact, that we speak of a particular condition as the "typhoid tongue."

After a few days the patient begins to feel feverish. All the symptoms
increase until he is quite ill and takes to his bed. About this time
tiny red spots called "rose spots" appear on the abdomen, perhaps only
a few, again they are quite frequent. The mind becomes dull and the
hearing imperfect.

Typhoid is said to be a self-limiting disease, that is, it cannot be
cut short or aborted in any way. That, however, is hardly the case. By
vigorous treatment, at the outset, it is now thought by a great many
that the disease can be limited to a few days. If the treatment is not
begun early and carried out, the disease will run a course of some
twenty-one days.

The treatment consists in eradicating the nest of typhoid bacillus
that is setting up the disturbance. Here, again, we resort to calomel.
Four grains given in quarter-grain doses every half hour will usually
produce sufficiently free passages. After this administer the
intestinal antiseptic religiously, with aconitine for the fever. Give
plenty of water to drink and restrict the diet. If the disease gets
beyond control, the routine treatment is the intestinal antiseptic.

Cold packs for the fever, in the later stages of the disease, will
be found preferable to any medicines. All the time the diet should
be watched. No solid foods should be allowed. Milk, light broths,
fruit juices, and rice water supply sufficient nourishment and do not
irritate the tender glands of Peyer and Brunner that are the seat of
the disease. These glands become very friable in typhoid, and any
violent action of the walls of the intestines, as in digesting food,
will cause them to break through and permit the bowel contents to
enter the general peritoneal cavity, when the patient will die from
inflammation of the bowels.




  SERPENT WOUNDS AND THEIR
  TREATMENT




CHAPTER IV

SERPENT WOUNDS AND THEIR TREATMENT


Every summer outdoor America leaves the heat and dust and turmoil of
the city for the peace and quiet of the wild. Doubtless many persons
penetrate, in their outing, regions where venomous serpents abound.
These will carry as a part of their equipment remedies intended for the
relief of wounds inflicted by these. Many of these remedies will be
absolutely valueless for the purpose intended, and many more will fail
from lack of intelligent application. A brief discussion of serpents
and the approved methods of treating their wounds may prove of interest
at this time.

Permit me to state at the outset that such information as may be
contained in this chapter is not the result of conjecture and
guesswork, but is derived from over twenty-five years study of
reptilian zoölogy, many years investigation in the laboratory, during
which time an extended series of experiments were carried out, and
twelve years' actual practice, in which all of the methods that have
suggested from time to time have been thoroughly tested.

There are, roughly speaking, something like twenty-eight varieties
of venomous reptiles in the United States. These figures include the
one lizard that is known to be poisonous and the several scorpions.
Of this number the rattlesnakes comprise at least eighteen. In fact,
so important are they that all others may be included in a discussion
of the crotalidæ; more particularly so as all serpent venoms act
chemically in the same manner.

Man is unreasoningly afraid of snakes. It is rare, indeed, that a
person concerns himself with the classification of the serpent that
chances to cross his path. He immediately possesses himself of a stout
club and proceeds to maul the unoffending reptile into the earth
without troubling his mind to find out if the snake is harmless or
otherwise. This is wrong, for when one comes to know them serpents
are quite interesting. It is wrong, too, for with a little study the
ordinary man can familiarize himself with the characteristic markings
of the venomous serpents and differentiate them from those that are
non-venomous.

All the deadly snakes, with the exception of the little harlequin snake
of the extreme South, are similarly marked and all belong to the class
of "pit" vipers, characterized by a depression or "pit" back of the
nostril. The head is triangular, with massive muscular development of
the jaw; the neck slender in proportion to the size of the head and
body. The body itself is quite thick, the skin rough. The pupil of the
eye is elliptical instead of being round as in the non-venomous snakes.

The harmless varieties, on the other hand, are long and slender, the
skin smooth and shining, the head oval or round. If in doubt after the
above, the investigator can pin his subject to the ground with a forked
stick placed just back of the head and examine the teeth. If he finds,
hanging from the upper jaw, or inclined forward from it, two fangs,
long and sharp as needles, he can be pretty safe in assuming that his
subject is poisonous. The non-venomous snakes have a dentition very
much the same as some of the smaller rodents, the mice for instance.

The habitat frequently furnishes a key to the character of the snake.
The venomous varieties choose by preference the rocky uplands, either
open or sparsely wooded. The harmless snakes live almost exclusively
in low swampy lands or along water courses. Venomous snakes are purely
terrestrial. One was never known to ascend a tree. In fact it is
impossible for one to do so.

While rattlesnakes are dangerous, their bite is not nearly so fatal as
is popularly supposed. This fact has at least two important reasons,
viz., season and the habits of life of the snake. In the extreme South
and in midsummer the venom attains its highest state of virulence.
Then the person fairly struck by a large rattler is in extreme danger,
provided the second factor in the equation does not intrude, that is,
the habits of life.

All venomous snakes, and more especially rattlesnakes, are sluggish.
They do not move rapidly or over great distances. Their lethal power
is given them as a means of procuring food and when once the snake
strikes he expends practically all the ammunition in his arsenal. It
requires hours and perhaps days to renew the supply, during which time
the serpent is defenseless. Should the human victim happen along at
such time and be bitten it is quite probable that he would not receive
a fatal dose of the poison.

The manner in which the rattlesnake inflicts his wound is worthy of
some study. In the first place, it may be assumed as axiomatic that the
snake cannot strike farther than his own length and seldom even that.
Stories of rattlesnakes lifting themselves from the ground bodily and
hurling themselves through the air are purely imaginative. Nor can
the snake strike unless coiled. It does not follow that he must be
in complete coil, but he must have at least a few kinks in his spine
before he can deliver a blow; then he can only strike the length of the
kinks.

If permitted he will assume full coil before striking and when
undisturbed he lies in that position. The maneuver of assuming full
coil takes longer than is generally thought. Writers who assert that
the snake can throw himself into full coil instantly are far from the
truth. In fact it takes, on an average, something like five seconds
for him to get his length in position to deliver his most powerful
blow. My experiments have developed another interesting fact, that the
snake cannot strike an object held directly over his head. It must be
held at an angle.

How deep will the needle-sharp fangs penetrate. That depends, too, upon
conditions. A large snake, striking from full coil, will naturally
drive his fangs much deeper than another smaller, striking from a less
advantageous position. Upon the bare flesh the snake will sink his
fangs to their full extent. His blow, however, is often delivered with
a raking motion and the wound inflicted resembles the scratch of a
briar.

Certain articles of dress are less permeable than others. Rubber, even
thin rubber, is wellnigh impenetrable. Soft, closely woven cloth is
also resistent. In experiments I have placed blotting paper behind two
thicknesses of heavy flannel and only in rare instances have I found
the virus staining the paper. This fact will serve to inform the reader
that the ordinary protection of the lower limbs will be adequate to
shield the wearer in a rattlesnake country.

The chances of being bitten, even in a country abounding in snakes,
are really quite insignificant. The rattler is the most inoffensive
gentleman of my serpentine acquaintance. He is perfectly willing,
if you will permit him, to lie all day basking in the sun upon some
convenient rock and never molest the passer in the least. If he has
sufficient warning he will slip quietly out of your path and give you
the right of way. He only strikes when in his reptilian mind he deems
himself insulted or in danger.

An extended discussion of the chemistry of serpent venoms would be
manifestly out of place at this time. We owe practically all our
knowledge upon the subject to the painstaking efforts of two men, S.
Weir Mitchell and Prof. Reichert. These gentlemen gave to the world
almost simultaneously the result of their labors. The lethal principle
of all serpent venoms consists of two elements, a venom peptone and a
venom globulin.

These elements are albuminoid in character, and it is interesting
to note that they act no differently from the pure albuminoses of
digestion. One element has the power to destroy the fibrin ferment in
the blood, the other acts as a paralyzant upon motor and sensory nerve
trunks.

Time has no effect apparently upon the poisonous quality of these
venoms. After twenty years' preservation in glycerine Dr. Mitchell
found the virus as active as ever, and it is known that arrows steeped
in rattlesnake venom retain their power for many years. Heat in varying
degrees, or a sudden violent application of it, will destroy the
poisonous property, as will also absolute alcohol.

The action of the virus on the animal economy is interesting and
worthy of study. When taken into the circulation the symptoms are
quite characteristic and not easily mistaken, even by the man of no
scientific training. This is well, as the wound itself is insignificant
and might be overlooked. In fact, I have known many persons to be
bitten and not know it until the symptoms apprised them of the fact.

A stinging, burning pain radiates from the wound and the wound itself
becomes inflamed and angry. Swelling comes on, the heart action is
immediately accelerated, and the respiration hurried. In a short time,
as the virus penetrates deeper into the systemic circulation, the heat
and respiratory symptoms change, the heart slows down, the respiration
decreases, the face becomes dusky and anxious, covered with profuse
perspiration, and the mind grows dull. Blindness, due to the effect
upon the optic nerve, takes place.

The patient staggers as he walks, and soon, unless relief comes, he
will become totally paralyzed. Spots of blood appear just beneath
the skin and especially upon the limb bitten. If the amount of the
virus is sufficient to produce death, all the above symptoms are soon
followed by tetanic convulsions and lockjaw. If, however, the dose is
not sufficient to produce death, they gradually subside, leaving the
patient much debilitated and subject to poisoned blood states that
manifest themselves in the form of skin eruptions and ulcers.

The reader will appreciate that in the above has been pictured an
extreme case. Nothing like nearly all cases bitten present even half
the symptoms described. Statistics reveal that only something like 12
per cent. of all persons bitten by the New World venomous serpents die
from their wounds.

Before passing to a consideration of the means for combating a poison
let us pause for a time and glance at the probabilities of being struck
even in a country where venomous serpents abound. The "rim rock" of
the Columbia River in Washington and Oregon is an ideal place for
rattlesnakes and they abound there in profusion.

Children run barefoot all summer among the basaltic rocks, and but
few of them are bitten. Haymakers fork them up with the haycocks,
harvesters find them beneath the bundles of bound grain, still it is
rare to hear of an accident. Among the "brakes" of the Clearwater in
Idaho the great "timber" rattler dwells. The Indians never molest him,
yet during my nine years' sojourn among them only seven cases appeared,
and two of these were very young children.

Still, people are bitten, and the location of the wound has much to do
with the chances of recovery. About 60 per cent. of all persons wounded
are struck on the lower limbs, thirty-five on the hand or arm, and
five on the trunk and face. Of these, wounds on the lower limbs are
the least dangerous and those on the trunk or face, being near large
nerve and arterial vessels, most so. The more remote from the general
circulation, the less danger from the wound.

The treatment of a rattlesnake wound resolves itself into the
application of a few very simple rules. In the first place a person
wounded by a snake usually does the very thing he should not do—that
is, goes tearing off at top speed for the nearest human habitation,
thereby increasing the circulation and disseminating the virus through
the system more rapidly. The man should sit calmly down and bind his
handkerchief around the limb (if it is a limb), break off a stout twig
and insert beneath the handkerchief, producing a rude tourniquet, and
twist until the circulation is effectually shut off.

With a sharp knife make an X incision over the wound, taking care to
penetrate deeper than the fangs have done. If he has good teeth and no
canker in his mouth, he may now suck vigorously upon the wound. It does
no good to suck the original wound. It is quite difficult to get any
virus back through an opening not greater in caliber than a fine needle.

If all this is done without delay, the chances are that the patient
will suffer no great inconvenience from his experience. If he chances
to have handy a stick of silver nitrate he can cauterize the wound
thoroughly. Failing that, a brand from the fire will serve. After a
time he may release his tourniquet somewhat and permit a portion of
the retained blood to enter the circulation; the system is capable of
taking care of a great deal of poison if it is allowed to flow into the
blood gradually.

If, however, the virus has been permitted to enter the circulation at
once the case is one calling for radical measures. In this connection
it is well to state that alcoholics defeat the end required. The
time-honored belief in the efficacy of whiskey in the treatment of
rattlesnake bites is pernicious in the extreme. Alcohol, like serpent
venom, has two effects, the later or depressant effect being exactly
the same as the depressant effect of the venom itself. Therefore the
man who recovers from a rattlesnake wound after drinking a large
quantity of whiskey does so in spite of his remedy, not with its aid.

The one sovereign remedy in these cases is strychnia, and no man should
penetrate a snake country without having this valuable adjunct with
him. The administration of strychnia is not so difficult but that any
man of ordinary intelligence can inform himself about it in a short
time. It is a powerful alkaloid, of course, and must be applied with
intelligence to accomplish the end desired. How much to administer will
depend upon the person and the character of the wound.

It must be taken into consideration that the system already poisoned
by the venom will tolerate a larger quantity than one in a normal
condition. The average dose of strychnia hypodermically applied is 1/30
of a grain. This may be increased to say 1/15 grain without any serious
danger. A person suffering from rattlesnake venom will bear without
danger perhaps 1/2 grain or even more.

It will be understood that this amount is not to be thrown into the
blood all at one dose, but spread out over an interval of thirty
minutes. Strychnia has its most important field in the treatment of
these cases after the depressant effect of the venom has taken place.
The rule then should be to administer until the heart approximates
the normal. The patient can take too much, then again he can take too
little.

Chemical antidotes directed against the venom of serpents are
extremely problematical. It is questionable if there is at present
any chemical that will exert more than an antiseptic effect upon the
virus. Permanganate of potassium may possess the property of setting
up a chemical reaction, but if so it is so prone to deteriorate when
in solution and requires so much time to place in solution that it is
nearly valueless.

Ammonia applied to certain of the less dangerous venoms is efficacious.
Applied to crotalus poison it is of no use. In fact, when the matter
is reduced to its lowest terms, the whole process of combating the
effect of serpent venoms is comprised in what has been stated above.
Restrict the circulation, destroy the virus by heat either chemically
or by fire, and keep up the vital forces. Very few Indian tribes have
any suggestion of a remedy for rattlesnake poison. The Moquis probably
have, though if so no white man has ever been able to extract the
secret from them. It is known that during the Moqui Snake Dance many
Indians are bitten and none of them die. It might be inferred then that
they do possess an effective antidote.

In conclusion permit me to suggest an equipment for the treatment
of rattlesnake wounds and briefly outline its uses. Procure a
rubber ribbon about four feet long, technically known as an Esmarch
tourniquet—this ribbon can be rolled into a compact form and is very
elastic—; a sharp surgeon's knife known as a bistoury which should
be securely wrapped in absorbent cotton; a blue bottle, or one about
which several thicknesses of blue paper have been wrapped, containing a
stick of silver nitrate; another bottle containing one hundred tablets
of strychnia sulphate gr. 1/30; an all-metal hypodermic syringe for
administering the same.

All these should be placed in an oiled silk bag and kept in a
convenient pocket. The bag should be changed when the clothing is
changed just the same as the watch or compass.

Now for their use: Let us suppose that you have encountered a rattler
and are not too scared to know what you are doing. You quietly sit
down, expose the limb, locate the wound, get out your Esmarch and
beginning at one end wrap it securely about the limb _above_ the wound,
gradually increasing the tension until the rubber sinks into the skin.

This done, take your knife and make a deep X over the wound, using
the cotton in which the knife was wrapped to sponge away the blood.
Encourage free bleeding. If you are near a stream bathe the wound
freely, either squeezing or sucking it. You need not fear to swallow
the poison. It will do no harm in the stomach. After the wound has bled
freely, take the stick of silver nitrate and burn it out quite to the
bottom. All of this will hurt, of course, but it is necessary.

The administration of the strychnia will follow next in order only if
the depressant symptoms of the venom indicate its need. Should the
patient feel the approach of the dizziness that is the beginning of the
stage of paralysis, he should then think about his strychnia. Dissolve
one of the tablets in warm water and fill the barrel of the syringe;
screw on the needle, first removing the fine wire that runs through it.
Plunge the needle into the fleshy part of the arm at an angle of about
ten degrees from the horizontal and push home the plunger. Repeat this
every fifteen minutes until the heart Has returned to the normal.

These directions closely followed will save every case of rattlesnake
bite, and in many instances the patient will not require the strychnia
at all. The wound made by the knife will require the same general
treatment as any other simple wound.




  THE CAMPER'S MEDICINE CHEST




THE CAMPER'S MEDICINE CHEST

_Surgical Supplies_


One instrument roll, 80 cents.

One paper medium size safety pins, 10 cents.

One paper medium size common pins, 5 cents.

One-half dozen assorted gauze bandage, size one-to three-inch; 10 cents
each.

Two yards sterilized plain gauze in carton, 20 cents yard.

Four ounces sterilized absorbent cotton in carton, 20 cents.

One roll three-inch adhesive plaster, $1.

One-fourth dozen silk ligature braided, in glass tube fitted with half
curved needles, 30 cents a tube.

One card braided silk ligature, assorted on one card (white), about 30
cents.

One-half dozen assorted egg-eyed surgeon's needles, half to full curve,
50 cents.

One ounce Squibb's surgical powder, 50 cents oz.; or a like amount of
camphophenique powder, $1.

One hundred Bernay's antiseptic tablets (blue), 25 cents.

Two five-inch hemostatic forceps (Kelly's), about $1 each.

One pair straight, sharp-pointed surgeon's shears, about $1.25.

One needle holder (Emmet's), $2.50.

One splinter forcep, may be used also for dressing forcep. This forcep
should neither have mouse tooth jaws nor serrated jaws, and should run
to a fine point; 50 cents.

One hypodermic syringe, all metal, in metal case, $1.50.

One one-minute clinical thermometer in metal case; will cost about
$1.25, according to reliability. The best registered instrument is
cheapest.

One number 9 soft rubber catheter, 25 cents.

One cake surgical soap, in metal box, 75 cents.

The above will comprise practically everything that may be found
absolutely necessary. With them the ingenious man can perform
practically every minor surgical operation that he would care to
undertake. If he cares for a more elaborate outfit he may add the
following:

One yard oiled silk, in tube, 75 cents.

One pure rubber fountain syringe, $1.75.

Four ounces creolin, in metal screw-cap bottle, 25 cents oz.

One or more first aid packages at 50 cents per package.

One emergency tourniquet, $1.25.

Eight ounces carron oil for burns, 25 cents oz.

The size of the surgical outfit will depend, of course, upon the size
of the party. The dressings and things that will be destroyed will
necessarily have to be increased in proportion to the number of the
party.


_Medical Stores_

The suggestions here will be based upon a party of four staying one
month.

In the case with the hypodermic place one tube strychnia sulphate, gr.
1/30, price 20 cents. Use as a powerful stimulant hypodermically one
tablet every four hours, if needed, watching the action of the heart
carefully. One tube cocaine muriate, gr. 1/4, price 50 cents. Use as a
local anesthetic as suggested in chapter on surgery and for toothache.
Can be used to control vomiting—one tablet followed by swallow of hot
water every four hours, if needed. Solution of one tablet in spoonful
of hot water dropped in eye to deaden so as to remove foreign bodies.
One tube morphine sulphate, gr. 1/4, and atropine sulphate, gr. 1/100,
combined, price 25 cents. Use as a sedative for pain, one tablet
hypodermically repeated every two hours to effect; digitalin, gr.
1/100, price 25 cents. Use as heart stimulant where action of heart is
deranged, one tablet not oftener than thrice daily. One tube apomorphia
hydrochlorate, gr. 1/10, price 50 cents. Use to induce vomiting in
cases of poisoning, one tablet hypodermically only. One tube glonoin,
gr. 1/100, price 15 cents. Use as heart stimulant in shock and great
depression due to cerebral anemia; not in loss of blood, however.

One sole leather medicine case with screw-cap glass bottles, numbers
etched on bottles, price from $1 to $3, according to style and finish.

Book to slip in pocket for keeping list of remedies and their
therapeutic application, cost 25 cents.

The bottles filled as follows: The numbering need not adhere strictly
to that here given:

No. 1. Aconitine gr. 1/134. 200 at 25 cents per C. Use in cases of high
fever where heart is full and bounding and there is great congestion
as shown by headache, backache, etc. Use in beginning of all colds.
Take in all cases one tablet every fifteen minutes for an hour then
one tablet every two hours, or better still take every half hour until
pulse becomes soft and surface of skin is moist.

No. 2. Dosimetric Trinity No. 1. 200 at 50 cents per C. One tablet
every half hour to effect. The effect will be to reduce all fevers
much the same as above except that it may be continued over a longer
time and becomes a routine treatment in typhoid, pneumonia, grippe,
bronchitis, rheumatic fever, and in all cases of fever where the heart
seems to need a slight stimulation.

No. 3. Intestinal antiseptic. 500 at 50 cents per C. One tablet
every three hours as routine treatment in typhoid, diarrhea, colic,
dysentery, and all disordered fermentative conditions of the intestinal
tract.

No. 4. Quinine sulphate, gr. 5, either in tablet or capsule form, cost
about 10 cents a dozen; take 100. Use in malaria, one tablet every
four hours during attack and not less than fifteen grains daily as a
preventative. In decidedly malarial countries this amount will have to
be taken daily, consequently the amount carried should be materially
increased. Is somewhat valuable in colds, bronchitis, etc.

No. 5. Sun Cholera. 100 at 50 cents per C. One tablet every four hours
in cases of watery diarrhea, after bowels have been cleaned out by
purgative. Of use also in colic, flatulence, intestinal pain.

No. 6. Chlorodyne. 100 at $1.00 per C. Take one tablet every two or
three hours in extreme pain, vomiting from fermentative processes,
summer diarrhea, etc.

No. 7. Calomel, gr. 1/4. 200 at 10 cents per C. Use one tablet every
thirty minutes or every hour for eight doses, in all cases where bowels
need thorough cleaning out. As beginning treatment in all cases of
fever, vomiting, diarrhea, in fact about everything that happens.

No. 8. Phenacetine, gr. 5. 100 at 50 cents per C. One tablet every
four hours to reduce fever as in colds, some forms of dysentery, and
in severe headache. To be discarded when case bids fair to become
prolonged.

No. 9. Elaterin, gr. 1/16. 25 at one cent each. Use one tablet only
where it is necessary to secure an immediate watery passage from the
bowels in order to sweep out offending masses.

No. 10. Dover's powder, gr. 5. 100 at 50 cents per C. Use one tablet
every four hours in sudden acute colds. Its most valuable field is
in the colds and bronchitis of children. Continue until perspiration
ensues.

In case the medicine case holds more than ten bottles the additional
bottles may be filled with brown mixture, 100 at 25 cents per C.
One tablet every four hours to one three times a day in cases of
indigestion, flatulence, "sour stomach," etc.

Headache tablet consisting of acetanilid, sodium salicylate, ammonium
bromide. A choice tablet to be given every four hours where persons are
subject to congestive headaches. The least objectionable of all the
"coal tar" tablets. These may be had at about 25 cents per dozen, and
the case should contain at least 100 of them.

Tonsilitis tablet consisting of menthol, thymol, phenol, potash,
chlorate, and sodium chloride. Take 200 at about 25 cents per 100.
Use as a gargle in tonsilitis, sore throat, and pharyngitis. Dissolve
tablet in half pint hot water and gargle several times a day.

  It will be noted that in the above unnumbered list aconitine and
  Dover's powder have been substituted for apomorphia hydrochlorate
  and digitalin recommended in Chapter III. Either list is good, and
  will be found comprehensive for all ordinary emergencies.




THE END




       *       *       *       *       *




Transcriber's note:

Italics is represented with _underscores_ and small caps with ALL CAPS.
Ambiguous hyphens at the ends of lines were retained. The following
corrections have been made:

p. 15 it is unnecsary -> unnecsary changed to unnecessary

p. 46 cavity as it probably has) -> added opening bracket (as it
probably has)

p. 99 sodium salycilate -> salycilate changed to salicylate

Everything else (including inconsistent hyphenation and archaic
spelling) has been retained as printed.





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