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Intubating the Critically
Ill Patient
A Step-by-Step Guide for Success
in the ED and ICU
Rachel Garvin
Editor

123
Intubating the Critically Ill
Patient
Rachel Garvin
Editor

Intubating the Critically

Ill Patient
A Step-by-Step Guide
for Success in the ED and ICU
Editor
Rachel Garvin
Departments of Neurosurgery
Emergency Medicine and Neurology
UT Health San Antonio
San Antonio, TX
USA

ISBN 978-3-030-56812-2    ISBN 978-3-030-56813-9 (eBook)

https://doi.org/10.1007/978-3-030-56813-9

© Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are reserved by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of transla-
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lar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service
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statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and
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lication. Neither the publisher nor the authors or the editors give a warranty,
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For years my dad said “you should write
a book.” He never really said what about,
and I don’t think specific content mattered
so much. It was more along the lines of
what I could teach to others. When he
learned of the plans for this publication
he was so excited, in his own earnest,
pragmatic, and understated way. He would
have been so proud to have seen this
come to fruition but unfortunately died
during the writing process. Despite my
best efforts, I watched his dignity, mental
and physical strength get stripped during a
prolonged hospital stay. He remained stoic
throughout, a testament to his steadfast
nature. My love of attention to detail and
analytical thinking are gifts from him that
I hope elevate the level of information
presented in this book and enhance the
knowledge of those that care for the sickest
patients. Treat each patient in the same
manner that you would want your loved
one to be treated. One size does not fit all.
Thanks Dad.

Rachel Garvin
Preface

There are many books available on how to pass an ETT

through the cords. But what about the preparation needed
beforehand? During my years of practice, I have witnessed
intubations gone awry because of no preparation and no plan
B. No two airways are alike, and the tools that we use to help
us predict airway difficulty are not 100%.
Plan for Success but Prepare for Failure. This is the motto
that I go by for every single airway. It is what I have taught
my fellows, residents, advanced practice providers, and stu-
dents as well. There have been many times I have gone to
plan C, but in a controlled and calm manner with all team
members doing their part because they all knew the plan.
Without an airway, you have pretty much nothing. Why not
make sure we are doing right by our patients every time? This
book looks at the who, what, where, when, and how of airway
management. Everything up until placing the tube between
the cords. Everything up until that point is the most impor-
tant part of airway management. From the ED to the ICU, be
the master of airway preparation and execution. Remember,
patients are not protocols. Every situation is unique. Plan for
success, but prepare for failure.

San Antonio, TX, USA Rachel Garvin, MD, FNCS

vii
Acknowledgments

Thank you to all my colleagues that took the time to prepare

these chapters. Despite hectic schedules and busy lives, you
all are an incredible group of practitioners, dedicated to out-
standing patient care.
A huge thank you to my husband, Dan, my daughters, Zoe
and Emma, and my boys Milo LL Cool J and Sir Charles von
Biscuit who encouraged me every step of the way.
In memory of my father, Dr. Stanley G. Siegel, who always
knew I would publish a book one day.

ix
Contents

  1 Who Needs Intubation?�������������������������������������������������   1

Georgia J. McRoy
  2 When to Pull the Trigger�����������������������������������������������   9
Zachary Kendrick
  3 Preparing Yourself for Intubation������������������������������� 21
Denise M. Rios
  4 Preparing the Patient����������������������������������������������������� 27
Danielle R. Stevens
  5 Preparing Your Team����������������������������������������������������� 39
Adriana Povlow
  6 The RSI Potpourri��������������������������������������������������������� 45
Amanda L. Fowler
  7 Should You RSI? ����������������������������������������������������������� 53
Jessica Solis-McCarthy
  8 Now the Tube Is In: Post-­Intubation Sedation����������� 73
Colleen Barthol
  9 The Cardiac Patient������������������������������������������������������� 79
Kari Gorder and Jordan B. Bonomo
10 The Obese Patient ��������������������������������������������������������� 95
Bradley A. Dengler
11 Intubating the Neurologically Injured Patient����������� 107
Shaheryar Hafeez

xi
xii Contents

12 Intubating the Septic Patient: Avoiding

the Crash and Burn ������������������������������������������������������� 115
Rahul K. Shah

Index����������������������������������������������������������������������������������������� 129
Contributors

Colleen Barthol, PharmD Department of Pharmacotherapy

& Pharmacy Services, University Health System, San Antonio,
TX, USA
Jordan B. Bonomo, MD, FCCM, FNCS Department of
Emergency Medicine, University of Cincinnati College of
Medicine, Cincinnati, OH, USA
Bradley A. Dengler, MD Department of Neurosurgery,
Walter Reed National Military Medical Center, Bethesda,
MD, USA
Amanda L. Fowler, PharmD, BCPS Department of
Pharmacotherapy and Pharmacy Services, University Health
System, San Antonio, TX, USA
Shaheryar Hafeez, MD Department of Neurosurgery, UT
Health San Antonio, San Antonio, TX, USA
Zachary Kendrick, MD Department of Emergency Medicine,
UT Health San Antonio, San Antonio, TX, USA
Georgia J. McRoy, MD Department of Emergency
Medicine, UT Health San Antonio, San Antonio, TX, USA
Adriana Povlow, MD Department of Emergency Medicine,
UT Health San Antonio, San Antonio, TX, USA
Denise M. Rios, MSN, RN, ACNP-BC Department of
Neurosurgery, UT Health San Antonio, San Antonio,
TX, USA

xiii
xiv Contributors

Rahul K. Shah, MD Department of Neurology/Neuro

Critical Care, Bakersfield Memorial Hospital, Bakersfield,
CA, USA
Jessica Solis-McCarthy, MD Department of Emergency
Medicine, UT Health San Antonio, San Antonio, TX, USA
Danielle R. Stevens, MD Department of Emergency
Medicine, UT Health San Antonio, San Antonio, TX, USA
Chapter 1
Who Needs Intubation?
Georgia J. McRoy

Key Points
• Endotracheal intubation is an invasive procedure.
• Understanding the clinical scenarios requiring
advanced airway management is essential to critical
care management of patients.
• Common indications for intubation are the
following:
–– Failure to ventilate.
–– Failure to oxygenate.
–– Airway protection.
–– Expected clinical course.
–– Airway obstruction.
• Both hypoxemia and hypercapnia can lead to respi-
ratory arrest and cardiovascular collapse.

G. J. McRoy (*)
Department of Emergency Medicine, UT Health San Antonio,
San Antonio, TX, USA

© Springer Nature Switzerland AG 2021 1

R. Garvin (ed.), Intubating the Critically Ill Patient,
https://doi.org/10.1007/978-3-030-56813-9_1
2 G. J. McRoy

 ailure to Ventilate: Hypercapneic

F
Respiratory Failure
• Unlike oxygenation which is a passive process, ventilation
is an active process.
• Obstructive diseases such as asthma and COPD can result
in CO2 retention [1, 6, 7, 11].
• These patients also develop bronchoconstriction and air-
way inflammation.
• Other causes of hypercapnia include the following [9, 10]:
–– Metabolic (dehydration, malnutrition).
–– Muscular weakness (from neuromuscular diseases or
spinal cord injury).
–– Drug-induced hypopnea [6, 9, 11].
Alcohols, barbiturates, opiates, benzodiazepines,
antidepressants, sedatives-hypnotics, stimulants.
–– Over sedation.
• For an acute respiratory acidosis, PCO2 does not have to
be very high to cause altered mental status [10, 13].
• Patients with chronic obstructive lung diseases can have
acute on chronic respiratory acidosis. These patients can
have very high PCO2, but because of chronic retention can
tolerate better (look for a high bicarbonate on your chem-
istry or significant base excess on your blood gas).
• Patients with retention of CO2 and not responding to inter-
ventions such as CPAP, BIPAP may need intubation if
noninvasive methods fail [1, 5].
• Don’t let the numbers fool you! There can be a state of
respiratory acidosis in setting of uncompensated metabolic
acidosis even with a paCO2 that is within normal range.
• Acute primary respiratory acidemias have a direct inverse
relationship between pH and pCo2:
–– pH 7.30 ➔pCO2 50
–– pH 7.20➔ pCO2 60
–– pH 7.1 ➔ pCO2 70
• If the numbers do not directly inversely match, there is a
second process going on.
 1 Who Needs Intubation? 3

 ailure to Oxygenate: Hypoxemic Respiratory

F
Failure
• Oxygenation is a passive process and gets altered by
mechanisms that interrupt diffusion.
–– Causes of failure to oxygenate: Problem with V/Q
mismatch.
Pneumonia and other secretions [1].
• Alveoli gets full of material that impedes oxygen
diffusion.
Pulmonary edema/effusion [1, 6, 15].
• Interstitial fluid and fluid compressing lung tissue
prevents diffusion.
Pneumothorax or other collapse (atelectasis) [3, 4, 8].
• Collapsed lung cannot diffuse oxygen.
Pulmonary embolism [6, 8].
• No blood flow, no place for O2 to diffuse to.
Poisons (cyanide).
• Does not allow oxygen to be used.
–– Patients with progressively worsening hypoxia often
become distressed and agitated before becoming cya-
notic [1, 3, 9, 15].
–– Hypoxia can lead to deterioration of mental status to
the point of obtundation [1, 9, 13].
–– Hypoxia can lead to respiratory arrest and cardiovascu-
lar collapse [5].
–– Be wary of the sick agitated patient – this could be
hypoxia and sedating them could lead to devastating
consequences! [3]
–– If possible, a definitive airway should be placed before
the situation becomes emergent.
–– Some patients can become hypoxemic and develop
respiratory failure just from their work of breathing [5].
–– Asthmatics can have both a failure to oxygenate and a
failure to ventilate due to secretions and bronchocon-
striction [3, 6, 7].
4 G. J. McRoy

–– Sepsis causes an increased oxygen consumption cou-

pled with a decreased oxygen delivery which affects the
body’s ability to properly oxygenate and fulfill all of its
metabolic needs [6, 10, 11].
–– In these patients, airway management can become a
necessity to help the body deal with metabolic acidosis
but requires appropriate ventilator settings to achieve
compensation [6, 10].
–– Laboratory values that should give a high index of sus-
picion for the need to intubate are PaO2 < 60 mmHg
and oxygen saturation <90% despite noninvasive inter-
ventions [7].

Airway Protection
• Altered mental status
–– Depression of alertness can subsequently lead to inabil-
ity to protect the airway [1, 9, 13, 15].
–– The loss of protective airway reflexes, such as cough,
requires endotracheal intubation whether it is second-
ary to a neurological or traumatic injury [1, 3, 4, 6, 15].
–– Altered mental status can be caused by multiple etiolo-
gies [3, 9, 10, 15]:
Brain injury (stroke, trauma).
Infection (CNS, systemic).
Medications (prescribed, illegal, toxins).
Temperature control (heat stroke, hypothermia, and
serotonin syndrome) [10].
Status epilepticus unresponsive to other interven-
tions [3, 6, 9–11].
• Aspiration.
–– Mental status can be intact but large volumes in the
oropharynx can compromise airway protection [1, 10].
–– Aspiration risks include [2, 3]:
Ongoing hematemesis.
Refractory emesis.
Inability to manage oral secretions (peritonsillar
abscess, angioedema).
 1 Who Needs Intubation? 5

Expected Clinical Course

• Combativeness [3]
–– Patients who are intoxicated, acutely psychotic or under
the influence of substances who are a danger to them-
selves or others
–– May be needed to allow for a safe workup to rule out
life threatening injuries
• Need for transport:
–– Patients with a high risk of decompensation during
transport [1, 9, 10]
–– Critically ill patient with prolonged transport time [1]
• Trauma:
–– High likelihood of deterioration [10, 14]
–– Immobilized trauma patients (with cervical spine or
facial injuries) presenting with hypoxia, decreased GCS
(glascow coma scale), or blood in the oropharynx [3, 8,
10, 12, 15]
–– Patients with facial wounds who may be unable to
handle oral secretions [3, 12].
–– Patients with penetrating neck injury or with an expand-
ing hematoma leading to airway compression [3, 12]
–– Chest injuries such as hemo-/pneumothoraces which
cause hypoxia despite drainage or proper oxygen ther-
apy, bilateral flail segments or multiple rib fractures
resulting in fatigue due to painful respirations [3, 4]

Airway Obstruction
• Airway edema [4, 12]
–– Obstruction can occur from mouth to subglottic region
[4, 10].
–– Airway edema often presents with inspiratory stridor.
–– Diminished stridor should prompt a higher index of
suspicious for imminent airway collapse [4].
–– Causes of airway edema can include the following:
6 G. J. McRoy

Anaphylaxis not responding to medical manage-

ment: progression can lead to complete airway
obstruction.
Epiglottis can cause supraglottic obstruction [15].
Angioedema whether it is a genetic predisposition or
secondary to a medication.
Ludwig’s Angina can prevent orotracheal tube
access.
Smoke inhalation can lead to airway edema which
may go unnoticed since it is at the glottic level [1, 11].
–– These are situations where your approach will be criti-
cal and where considerations such as nasotracheal,
awake fiberoptic or surgical airway may need to be
considered [2].
• Foreign bodies (FB) [15]
–– Aspirated items can obstruct airway supraglottically, at
the glottis or infraglottic, including the trachea [3].
–– History is of the utmost importance, especially in the
pediatric population.
–– Maintaining calm and comfort of the patient is vital to
prevent further airway compromise.
–– If unable to remove the foreign body, placing a defini-
tive airway and sedating patient to maintain oxygen-
ation until appropriate resources obtained for FB
removal.
• Difficult anatomy
–– Anatomical conditions that can contribute to a more
difficult airway include the following [2, 3, 6, 8, 11, 12, 15]:
Poor dentition
Bull neck
Obesity
Orofacial masses
Macroglossia
Small mandible
Restricted mouth opening
Major burns
Anterior vocal cords
 1 Who Needs Intubation? 7

–– Other conditions that can affect the management of

airways include the following:
Tracheomalacia
Subglottic stenosis
Mediastinal mass

References
1. Brown C, Walls R, Grayzel J. UpToDate. 2008. In: Uptodate.com.
http://www.uptodate.com/contents/the-decision-to-intubate.
2. Bucher J, Cuthbert D. The difficult airway: common errors dur-
ing intubation – emDOCs.net – emergency medicine education.
In: emDOCs.net - Emergency Medicine Education. 2019. http://
www.emdocs.net/difficult-airway-common-errors-intubation/.
3. Carley S, Gwinnutt C, Butler J. Rapid sequence induction in
the emergency department: a strategy for failure. Emerg Med J.
2002;19:109–13.
4. Divatia J, Bhowmick K. Complications of endotracheal intu-
bation and other airway management procedures. Indian J
Anaesth. 2005;49:308–18.
5. Divatia J, Myatra S, Khan P. Tracheal intubation in the ICU: life
saving or life threatening? Indian J Anaesth. 2011;55:470.
6. Dufour D, Larose D, Clement S. Rapid sequence intubation in
the emergency department. J Emerg Med. 1995;13(5):705–10.
7. Guthrie K. Near fatal asthma. In: Life in the fast lane. 2019.
https://lifeinthefastlane.com/acute-severe-asthma/.
8. Ho A, Ho A, Mizubuti G. Tracheal intubation: the proof is in the
bevel. J Emerg Med. 2018;55(6):821–6.
9. Hua A, Haight S, Hoffman RS, Manini AF. Endotracheal intuba-
tion after acute drug overdoses: incidence, complications, and
risk factors. J Emerg Med. 2017;52(1):59–65.
10. Nickson C. Rapid Sequence Intubation (RSI) LITFL CCC
Airway. In: Life in the Fast Lane LITFL Medical Blog. 2015.
https://litfl.com/rapid-sequence-intubation-rsi/.
11. Reid C, Chan L, Tweeddale M. The who, where, and what of
rapid sequence intubation: prospective observational study of
emergency RSI outside the operating theatre. Emerg Med J.
2004;21:296–301.
8 G. J. McRoy

12. Sakles J, Mosier J, Patanwala A, Arcaris B, Dicken J. The utility

of the C-MAC as a direct laryngoscope for intubation in the
Emergency Department. J Emerg Med. 2016;51(4):349–57.
13. Smith C. Rapid-sequence intubation in adults: indications and
concerns. Clin Pulm Med. 2001;8:147–65.
14. Stevenson A, Graham C, Hall R, Korsah P, McGuffie A. Tracheal
intubation in the emergency department: the Scottish district
hospital perspective. Emerg Med J. 2007;24:394–7.
15. Wang HE, Kupas DF, Greenwood MJ, Pinchalk ME. An algo-
rithmic approach to prehospital airway management. Prehosp
Emerg Care. 2005;9(2):145–55.
Chapter 2
When to Pull the Trigger
Zachary Kendrick

Key Points
• The need for a definitive airway presents on a con-
tinuum, from elective to crash.
• There are factors to help predict how soon a patient
may require intubation.
• Reassessment of the patient is critically important to
know which path the patient may be on.
• Don’t rely on the numbers to tell you when to pull
the trigger: the clinical evaluation of your patient is
the most important; data points only supplement.

Types of Intubation
• Elective
–– This is typically done to facilitate a procedure and can
be planned out hours to days in advance.

Z. Kendrick (*)
Department of Emergency Medicine,
UT Health San Antonio, San Antonio, TX, USA
e-mail: KendrickZ@uthscsa.edu

© Springer Nature Switzerland AG 2021 9

R. Garvin (ed.), Intubating the Critically Ill Patient,
https://doi.org/10.1007/978-3-030-56813-9_2
10 Z. Kendrick

–– Not typically done in the Emergency Department, but

sometimes in the ICU setting.
Preparation:
• Complete history and physical
• Airway evaluation (LEON) [1]
• Obtain collateral information
• Review of allergies
• Discussion of risks and benefits with patient,
guardian, or medical power of attorney
• Written consent
• Select delayed versus rapid sequence intubation
• Select and discuss different sedative and paralytic
medications
• Identify and plan for primary, secondary, and ter-
tiary methods of intubation (direct laryngoscopy,
video laryngoscopy, and gum elastic bougie, etc.)

L Look externally (facial trauma, loose teeth, beard, and

large tongue)
E Evaluate 3-3-2 rule (finger breadths)
 Incisor distance: 3 FB
 Hyoid-mental distance: 3 FB
 Thyroid-to-mouth distance: 2 FB
O Obstruction (epiglottis, abscess, and trauma)
N Neck mobility (spinal fusion, cervical spine precautions, and
arthritis)

Examples:
• Surgery
–– Nonemergent exam under anesthesia (rigid
sigmoidoscopy, esophagogastroduodenoscopy,
etc.)
• Urgent
–– The patient may have some time before
decompensation.
Preparation:
• Resuscitate the Patient
 2 When to Pull the Trigger 11

–– Intubation will be complicated and possibly a

terminal procedure unless hemodynamics are
carefully optimized, monitored, and protected
before, during, and after intubation [2–4].
• Complete history and physical.
• Airway evaluation (LEON) [1]
• Review of allergies.
• Discussion of risks and benefits with patient,
guardian, or medical power of attorney.
• Verbal consent if patient has capacity to do so,
otherwise consent is implied (unless DNI).
• Select delayed versus rapid sequence intubation.
• Select and discuss different sedative and paralytic
medications.
• Identify and plan for primary, secondary, and ter-
tiary methods of intubation (direct laryngoscopy,
video laryngoscopy, gum elastic bougie, nasotra-
cheal, and cricothyrotomy, etc.).
Examples include the following:
• Intracranial hemorrhage that is expanding
• Traumatic brain injury with altered level of
consciousness
• Pulmonary edema not improving with non-inva-
sive positive pressure ventilation and
medications
• Developing acute respiratory distress syndrome
(ARDS)
• Smoke inhalation
• Emergent
–– The patient is imminently going to lose their airway.
Preparation:
• Resuscitate the Patient
–– Resuscitation is still important in the emergent
intubation situation.
Consider rapid crystalloid bolus and/or pres-
sor administration if patient hypotensive [5].
Hyperoxygenate if possible (high flow nasal
cannula, BiPAP, etc.) while preparing for intu-
bation - higher PaO2 will give you more time.
12 Z. Kendrick

Anticipate initial ventilator setting

requirements.
• Adjusting minute ventilation (respiratory
rate × tidal volume in L/min) to compen-
sate for acidemic state.
• Adjust PEEP for obstructive processes [6].
• Consider pressure control for restrictive
lung pathologies [7–9].
• Consider airway pressure release ventila-
tion (APRV) for severe ARDS [10].
• May not have time for full history and physical.
–– Chief complaint
–– Airway evaluation (LEON) [1]
Measuring distances with finger breadths
may not be feasible in this situation.
• There may not be enough time.
• The patient may not be able to participate
in the exam.
• The patient may not tolerate removal of
BiPAP/CPAP long enough to allow for
evaluation.
The core concepts of the exam should still be
identifiable [11, 12].
• Abnormalities of neck mobility.
◦◦ Cervical collar in place.
◦◦ Severe arthritis/neck stiffness.
• Swollen or distorted anatomy.
◦◦ Tongue swelling.
◦◦ Neck hematoma.
◦◦ Neck trauma.
• Short thyromental distance.
◦◦ “Weak” chin.
• Abnormal dentition.
◦◦ Dentures.
◦◦ Overbite.
◦◦ Mouth trauma.
• Review of allergies (if known).
• Verbal consent if patient has capacity to do so,
otherwise consent is implied (unless DNR/DNI).
• Rapid sequence intubation.
 2 When to Pull the Trigger 13

• Choice of sedation/paralytic medications still

depends on available history if known.
–– Sedation: based on hemodynamics and indica-
tion for intubation.
–– Paralytic: Consider rocuronium if history not
known and suspicion high for contraindication
to succinylcholine (hyperkalemia, crush injury,
significant burn, end-stage renal disease, etc.).
• Identify and plan for primary, secondary, and ter-
tiary methods of intubation (direct laryngoscopy,
video laryngoscopy, gum elastic bougie, nasotra-
cheal, and cricothyrotomy, etc.).
Examples included are the following:
• Anaphylaxis with worsening oropharyngeal
edema
• Status epilepticus lasting longer than 30 minutes
and refractory to first and second line
antiepileptics
• Flash pulmonary edema
• Active, profuse hematemesis
• Crash
–– Patient has lost airway or has gone into cardiac arrest.
–– No time for questions but you can bag while you get a
plan together.
–– May still require RSI drugs to relax clenched jaw.

Tools to Decide How Much Time You Have

• Airway Protection [12]

–– Is the patient clearing their own secretions or are they
pooling in the oropharynx?
–– Can they cough (may need to stimulate with
suctioning)?
–– Do they have a gag reflex (alone not an indication as some
people lack a gag reflex at baseline, but in addition to other
factors should be considered higher risk for aspiration)?
–– Worsening mental status (TBI or stroke).
• Work of Breathing [12]
14 Z. Kendrick

–– Is respiratory fatigue setting in?

No longer tachypneic, but still with significant meta-
bolic acidosis (no longer compensating)
Increasing accessory muscle use
Patient becoming agitated or increasingly anxious
–– Is work of breathing not improving with initial
interventions?
Asthma exacerbation refractory to inhaled medica-
tions and noninvasive ventilation
• Rate of Clinical Deterioration [12]
Rapidly losing airway: anaphylaxis, epiglottitis, angio-
edema, trauma with expanding neck hematoma, etc.)
–– A condition that is going to take a long time to
resolve (toxic ingestion, angioedema, traumatic brain
injury, etc.)
–– Impending cardiac arrest
–– Venous/arterial blood gas: NOTE! This is a helpful
tool but can be deceiving [11].
Even if the blood gas looks OK, if the patient is clini-
cally worsening (mental status, work of breathing,
rate of deterioration), intubate. Don’t wait for the
numbers to tell you what to do!
For acidemic patients, make sure that they are appro-
priately compensated (if you only remember one
formula, remember Winter’s Formula)
• Bicarb + ½ Bicarb + 8 (+/− 2)
• Tells you what the Pco2 should be for compensa-
tion in metabolic acidosis
–– Hypoxic versus hypercapnic respiratory failure
Patient can tolerate hypercapnia longer than
hypoxia; there is no compensation for hypoxia!
Hypercapnia may suggest an urgent intubation
whereas hypoxia is usually more emergent.
–– Compensation
Is patient’s breathing pattern compensating for
blood gas abnormalities? [12]
Metabolic acidosis (DKA, sepsis)
–– RESUSCITATE FIRST
–– If patient able to compensate, let them
 2 When to Pull the Trigger 15

–– If patient begins to tire, consider noninvasive

ventilation
Set a time frame for re-evaluation; i.e., if pH does
not improve to >7.2 in 1 hour, move to your next
step.
–– If noninvasive ventilation fails, urgent intubation is
needed.
If setting ventilator rate, set rate high to help with
ventilation (20 bpm or higher).

pH CO2
Metabolic acidosis ↓ ↓
Metabolic alkalosis ↑ ↑
Respiratory acidosis ↓ ↑
Respiratory alkalosis ↑ ↓

All you need to remember for acid–base

disorders in an acute situation
Metabolic acidosis PCO2 = (HCO3−) + (½ HCO3) + 8 +/− 2
[Winter’s formula]
Acute respiratory Direct inverse relationship between pH
acidosis/alkalosis and pCO2
7.5/30 ➔ pure respiratory alkalosis
7.3/50 ➔ pure respiratory acidosis

Failure of NIV
• Noninvasive oxygenation/ventilation is an incredibly help-
ful tool, but knowing when it has failed is critically
important.
• Set a time for re-evaluation: NIV will either help to pre-
vent an intubation, or it won’t.
• Has the patient’s work of breathing increased (even if blood
gas/spO2/etCO2 same)?
–– The underlying etiology may be worsening.
–– Consider an urgent intubation.
16 Z. Kendrick

• Has the patient’s work of breathing decreased?

–– Recheck blood gas, it may be worsening and the patient
is going into respiratory failure.
–– If patient has reached the point of respiratory failure, an
emergent intubation should be strongly considered.
• Work of breathing is same but blood gas/spO2 /etCO2 is
worsening?
–– The patient may need different settings or may need
sedation to allow for better compliance.
If hypoxic but normocapnic, consider CPAP or high
flow over BIPAP.
If hypercapnic but oxygenating fine, consider BIPAP
over high flow NC or CPAP.
If patient is overly anxious or dyssynchronous with
the machine, consider respiratory drive sparing seda-
tion medications.
• Dexmedetomidine or ketamine are good options.
• DO NOT use respiratory drive impairing agents
such as opioids or repeated doses of
benzodiazepines.
–– While attempting these adjustments, begin preparing for
an urgent intubation.
• Aspiration risk (abdominal distension)
–– An inherent disadvantage of a noninvasive ventilation
system is that air will inevitably go down the esophagus
in addition to the trachea. This can lead to gaseous
abdominal distension, vomiting, and create an aspira-
tion risk.
–– Vomiting while wearing a positive pressure mask can be
very dangerous as the vomitus is immediately pushed
back into the oropharynx and down the trachea.
–– Distention alone should prompt the provider to con-
sider urgent intubation. Vomiting, however, should
prompt consideration for a more emergent intubation
scenario to prevent aspiration.
 2 When to Pull the Trigger 17

Anticipated Clinical Course [13]

• There are some conditions that despite maximum inter-
ventions, you can expect to worsen before they get better.
• Some examples:
–– Angioedema [14]
Epinephrine and antihistamines are of minimal help.
Patient needs time for airway swelling to reduce.
Consider urgent intubation if early in swelling, other-
wise will become emergent.
Anticipate difficult intubation.
• Glottic swelling will make normal anticipated
endotracheal tube size difficult.
• Be prepared to use gum elastic bougie and/or per-
form surgical airway.
–– Smoke inhalation [15]
Patient may appear to be breathing fine, but tracheal
burns can cause rapid swelling.
Securing the airway sooner in an urgent manner
rather than later in an emergent or crash manner.
If unsure, if patient has tracheal burns, consider naso-
pharyngeal fiberoptic evaluation to look for soot,
edema, or other evidence.
–– TBI/IPH [16]
Patient will likely get worse over next 48–72 hours
and may need days/weeks/months to improve before
they regain ability to protect their own airway.
Consider urgent intubation.
–– Epiglottitis [17]
–– Swelling is going to rapidly obstruct the patient’s airway
and will make intubation very difficult.
–– Consider emergent intubation to prevent the necessity
of a surgical airway situation.
–– Ludwig’s Angina [17]
Swelling of the submandibular space that progres-
sively worsens.
The tongue will be elevated and make intubation dif-
ficult and eventually occlude the patient’s airway.
Consider urgent intubation before airway is
compromised.
18 Z. Kendrick

References
1. Ji SM, Moon EJ, Kim TJ, Yi JW, Seo H, Lee BJ. Correlation
between modified LEMON score and intubation difficulty in
adult trauma patients undergoing emergency surgery. World
J Emerg Surg. 2018;13:33. Published 2018 Jul 24. https://doi.
org/10.1186/s13017-018-0195-0.
2. Jaber S, Jung B, Corne P, et al. An intervention to decrease com-
plications related to endotracheal intubation in the intensive care
unit: a prospective, multiple-center study. Intensive Care Med.
2010;36(2):248–55. https://doi.org/10.1007/s00134-009-1717-8.
3. Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and
factors associated with cardiac arrest complicating emergency
airway management. Resuscitation. 2013;84(11):1500–4. https://
doi.org/10.1016/j.resuscitation.2013.07.022.
4. Kim WY, Kwak MK, Ko BS, et al. Factors associated with the
occurrence of cardiac arrest after emergency tracheal intubation
in the emergency department. PLoS One. 2014;9(11):e112779.
Published 2014 Nov 17. https://doi.org/10.1371/journal.
pone.0112779.
5. Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier
J. Efficacy of bolus-dose phenylephrine for Peri-intubation
hypotension. J Emerg Med. 2015;49(4):488–94. https://doi.
org/10.1016/j.jemermed.2015.04.033.
6. Reddy RM, Guntupalli KK. Review of ventilatory techniques to
optimize mechanical ventilation in acute exacerbation of chronic
obstructive pulmonary disease. Int J Chron Obstruct Pulmon
Dis. 2007;2(4):441–52.
7. Fernández-Pérez ER, Yilmaz M, Jenad H, et al. Ventilator set-
tings and outcome of respiratory failure in chronic interstitial
lung disease. Chest. 2008;133(5):1113–9. https://doi.org/10.1378/
chest.07-1481.
8. Gaudry S, Vincent F, Rabbat A, et al. Invasive mechanical venti-
lation in patients with fibrosing interstitial pneumonia. J Thorac
Cardiovasc Surg. 2014;147(1):47–53. https://doi.org/10.1016/j.
jtcvs.2013.06.039.
9. Vincent F, Gonzalez F, Do C-H, Clec’h C, Cohen Y. Invasive
mechanical ventilation in patients with idiopathic pulmonary
fibrosis or idiopathic non-specific interstitial pneumonia. Intern
Med Tokyo Jpn. 2011;50:173–4. author reply 175
Another random document with
no related content on Scribd:
Fig. 35.—19 specimens of Purpura lapillus L., Great
Britain, illustrating variation.
(1) Felixstowe, sheltered coast; (2), (3) Newquay,
on veined and coloured rock; (4) Herm, rather
exposed; (5) Solent, very sheltered; (6) Land’s End,
exposed rocks, small food supply; (7) Scilly, exposed
rocks, fair food supply; (8) St. Leonards, flat mussel
beds at extreme low water; (9) Robin Hood’s Bay,
 sheltered under boulders, good food supply; (10)
Rhoscolyn, on oyster bed, 4–7 fath. (Macandrew);
(11) Guernsey, rather exposed rocks; (12) Estuary of
Conway, very sheltered, abundant food supply; (13),
(14) Robin Hood’s Bay, very exposed rocks, poor food
supply; (14) slightly monstrous; (15), (16), (17)
Morthoe, rather exposed rocks, but abundant food
supply; (18) St. Bride’s Bay; (19) L. Swilly, sheltered,
but small food supply. All from the author’s collection,
except (10).
The common dog-whelk (Purpura lapillus) of our own coasts is an
exceedingly variable species, and in many cases the variations may
be shown to bear a direct relation to the manner of life (Fig. 35).
Forms occurring in very exposed situations, e.g. Land’s End, outer
rocks of the Scilly Is., coasts of N. Devon and Yorkshire, are stunted,
with a short spire and relatively large mouth, the latter being
developed in order to increase the power of adherence to the rock
and consequently of resistance to wave force. On the other hand,
shells occurring in sheltered situations, estuaries, narrow straits, or
even on open coasts where there is plenty of shelter from the waves,
are comparatively of great size, with a well-developed, sometimes
produced spire, and a mouth small in proportion to the area of shell
surface. In the accompanying figure, the specimens from the
Conway estuary and the Solent (12, 5) well illustrate this latter form
of shell, while that from exposed rocks is illustrated by the
specimens from Robin Hood’s Bay (13, 14). Had these specimens
occurred alone, or had they been brought from some distant and
unexplored region, they must inevitably have been described as two
distinct species.
 Fig. 36.—Valves of Cardium edule from the four upper
terraces of Shumish Kul, a dry salt lake adjacent to the
Aral Sea. (After Bateson.)

Mr. W. Bateson has made[195] some observations on the shells of

Cardium edule taken from a series of terraces on the border of
certain salt lakes which once formed a portion of the Sea of Aral. As
these lakes gradually became dry, the water they contained became
salter, and thus the successive layers of dead shells deposited on
their borders form an interesting record of the progressive variation
of this species under conditions which, in one respect at least, can
be clearly appreciated. At the same time the diminishing volume of
water, and the increasing average temperature, would not be without
their effect. It was found that the principal changes were as follows:
the thickness, and consequently the weight, of the shells became
diminished, the size of the beaks was reduced, the shell became
highly coloured, and diminished considerably in size, and the
breadth of the shells increased in proportion to their length (Fig. 36).
Shells of the same species of Cardium, occurring in Lake Mareotis,
were found to exhibit very similar variations as regards colour, size,
shape, and thickness.
Unio pictorum var. compressa occurs near Norwich at two similar
localities six or seven miles distant from one another, under
circumstances which tend to show that similar conditions have
produced similar results. The form occurs where the river, by
bending sharply in horse-shoe shape, causes the current to rush
across to the opposite side and form an eddy near the bank on the
outside of the bend. Just at the edge of the sharp current next the
eddy the shells are found, the peculiar form being probably due to
the current continually washing away the soft particles of mud and
compelling the shell to elongate itself in order to keep partly buried at
the bottom.[196]
The rivers Ouse and Foss, which unite just below York, are rivers
of strikingly different character, the Ouse being deep, rapid, with a
bare, stony bottom, and little vegetable growth, and receiving a good
deal of drainage, while the Foss is shallow, slow, muddy, full of
weeds and with very little drainage. In the Foss, fine specimens of
Anodonta anatina occur, lustrous, with beautifully rayed shells. A few
yards off, in the Ouse, the same species of Anodonta is dull brown in
colour, its interior clouded, the beaks and epidermis often deeply
eroded. Precisely the same contrast is shown in specimens of Unio
tumidus, taken from the same rivers, Ouse specimens being also
slightly curved in form. Just above Yearsley Lock in the Foss, Unio
tumidus occurs, but always dwarfed and malformed, a result
probably due to the effect of rapidly running water upon a species
accustomed to live in still water.[197] Simroth records the occurrence
of remarkably distorted varieties in two species of Aetheria which
lived in swift falls of the River Congo.[198]
A variety of Limnaea peregra with a short spire and rather strong,
stoutly built shell occurs in Lakes Windermere, Derwentwater, and
Llyn-y-van-fach. It lives adhering to stones in places where there are
very few weeds, its shape enabling it to withstand the surf of these
large lakes, to which the ordinary form would probably succumb.[199]
Scalariform specimens of Planorbis are said to occur most
commonly in waters which are choked by vegetation, and it has been
shown that this form of shell is able to make its way through masses
of dense weed much more readily than specimens of normal shape.
Continental authorities have long considered Limnaea peregra
and L. ovata as two distinct species. Hazay, however, has
succeeded in rearing specimens of so-called peregra from the ova of
ovata, and so-called ovata from the ova of peregra, simply by placing
one species in running water, and the other in still water.
According to Mr. J. S. Gibbons[200] certain species of Littorina, in
tropical and sub-tropical regions, are confined to water more or less
brackish, being incapable of living in pure salt water. “I have met,”
says Mr. Gibbons, “with three of these species, and in each case
they have been distinguished from the truly marine species by the
extreme (comparative) thinness of their shells, and by their colouring
being richer and more varied; they are also usually more elaborately
marked. They are to be met with under three different conditions—
(1) in harbours and bays where the water is salt with but a slight
admixture of fresh water; (2) in mangrove swamps where salt and
fresh water mix in pretty equal volume; (3) on dry land, but near a
marsh or the dry bed of one.
“L. intermedia Reeve, a widely diffused E. African shell, attaches
itself by a thin pellicle of dried mucus to grass growing by the margin
of slightly brackish marshes near the coast, resembling in its mode
of suspension the Old World Cyclostoma. I have found it in vast
numbers in situations where, during the greater part of the year, it is
exposed to the full glare of an almost vertical sun, its only source of
moisture being a slight dew at night-time. The W. Indian L. angulifera
Lam., and a beautifully coloured E. African species (? L. carinifera),
are found in mangrove swamps; they are, however, less independent
of salt water than the last.”
Mr. Gibbons goes on to note that brackish water species
(although not so solid as truly marine species) tend to become more
solid as the water they inhabit becomes less salt. This is a curious
fact, and the reverse of what one would expect. Specimens of L.
intermedia on stakes at the mouth of the Lorenço Marques River,
Delagoa Bay, are much smaller, darker, and more fragile, than those
living on grass a few hundred yards away. L. angulifera is unusually
solid and heavy at Puerto Plata (S. Domingo) among mangroves,
where the water is in a great measure fresh; at Havana and at
Colon, where it lives on stakes in water but slightly brackish, it is
thinner and smaller and also darker coloured.
(c) Changes in the Volume of Water.—It has long been known that
the largest specimens, e.g. of Limnaea stagnalis and Anodonta
anatina, only occurred in pieces of water of considerable size.
Recent observation, however, has shown conclusively that the
volume of water in which certain species live has a very close
relation to the actual size of their shells, besides producing other
effects. Lymnaea megasoma, when kept in an aquarium of limited
size, deposited eggs which hatched out; this process was continued
in the same aquarium for four generations in all, the form of the shell
of the last generation having become such that an experienced
conchologist gave it as his opinion that the first and last terms of the
series could have no possible specific relation to one another. The
size of the shell became greatly diminished, and in particular the
spire became very slender.[201]
The same species being again kept in an aquarium under similar
conditions, it was found that the third generation had a shell only
four-sevenths the length of their great grandparents. It was noticed
also that the sexual capacities of the animals changed as well. The
liver was greatly reduced, and the male organs were entirely lost.
[202]

K. Semper conducted some well-known experiments bearing on

this point. He separated[203] specimens of Limnaea stagnalis from
the same mass of eggs as soon as they were hatched, and placed
them simultaneously in bodies of water varying in volume from 100
to 2000 cubic centimetres. All the other conditions of life, and
especially the food supply, were kept at the known optimum. He
found, in the result, that the size of the shell varied directly in
proportion to the volume of the water in which it lived, and that this
was the case, whether an individual specimen was kept alone in a
given quantity of water, or shared it with several others. At the close
of 65 days the specimens raised in 100 cubic cm. of water were only
6 mm. long, those in 250 cubic cm. were 9 mm. long, those in 600
cubic cm. were 12 mm. long, while those kept in 2000 cubic cm.
attained a length of 18 mm. (Fig. 37).
An interesting effect of a sudden fall of temperature was noticed
by Semper in connection with the above experiments. Vessels of
unequal size, containing specimens of the Limnaea, happened to
stand before a window at a time when the temperature suddenly fell
to about 55° F. The sun, which shone through the window, warmed
the water in the smaller vessels, but had no effect upon the
temperature of the larger. The result was, that the Limnaea in 2000
cubic cm., which ought to have been 10 mm. long when 25 days old,
were scarcely longer, at the end of that period, than those which had
lived in the smaller vessels, but whose water had been sufficiently
warm.

Fig. 37.—Four equally old shells

of Limnaea stagnalis,
hatched from the same mass
of ova, but reared in different
volumes of water: A in 100, B
in 250, C in 600, and D in
2000 cubic centimetres.
(After K. Semper.)
 CHAPTER IV
USES OF SHELLS FOR MONEY, ORNAMENT, AND FOOD—CULTIVATION OF
THE OYSTER, MUSSEL, AND SNAIL—SNAILS AS MEDICINE—PRICES GIVEN
FOR SHELLS

The employment of shells as a medium of exchange was

exceedingly common amongst uncivilised tribes in all parts of the
world, and has by no means yet become obsolete. One of the
commonest species thus employed is the ‘money cowry’ (Cypraea
moneta, L.), which stands almost alone in being used entire, while
nearly all the other forms of shell money are made out of portions of
shells, thus requiring a certain amount of labour in the process of
formation.
One of the earliest mentions of the cowry as money occurs in an
ancient Hindoo treatise on mathematics, written in the seventh
century a.d. A question is propounded thus: ‘the ¼ of 1/16 of ⅕ of ¾
of ⅔ of ½ a dramma was given to a beggar by one from whom he
asked an alms; tell me how many cowry shells the miser gave.’ In
British India about 4000 are said to have passed for a shilling, but
the value appears to differ according to their condition, poor
specimens being comparatively worthless. According to Reeve[204] a
gentleman residing at Cuttack is said to have paid for the erection of
his bungalow entirely in cowries. The building cost him 4000 Rs.
sicca (about £400), and as 64 cowries = 1 pice, and 64 pice = 1
rupee sicca, he paid over 16,000,000 cowries in all.
Cowries are imported to England from India and other places for
the purposes of exportation to West Africa, to be exchanged for
native products. The trade, however, appears to be greatly on the
decrease. At the port of Lagos, in 1870, 50,000 cwts. of cowries
were imported.[205]
A banded form of Nerita polita was used as money in certain parts
of the South Pacific. The sandal-wood imported into the China
market is largely obtained from the New Hebrides, being purchased
of the natives in exchange for Ovulum angulosum, which they
especially esteem as an ornament. Sometimes, as in the Duke of
York group, the use of shell money is specially restricted to certain
kinds of purchase, being employed there only in the buying of swine.
Among the tribes of the North-West coasts of America the
common Dentalium indianorum used to form the standard of value,
until it was superseded, under the auspices of the Hudson’s Bay
Company, by blankets. A slave was valued at a fathom of from 25 to
40 of these shells, strung lengthwise. Inferior or broken specimens
were strung together in a similar way, but were less highly esteemed;
they corresponded more to our silver and copper coins, while the
strings of the best shells represented gold.
The wampum of the eastern coast of North America differed from
all these forms of shell money, in that it required a laborious process
for its manufacture. Wampum consisted of strings of cylindrical
beads, each about a quarter of an inch in length and half that
breadth. The beads were of two colours, white and purple, the latter
being the more valuable. Both were formed from the common clam,
Venus mercenaria, the valves of which are often stained with purple
at the lower margins, while the rest of the shell is white. Cut small,
ground down, and pierced, these shells were converted into money,
which appears to have been current along the whole sea-board of
North America from Maine to Florida, and on the Gulf Coast as far as
Central America, as well as among the inland tribes east of the
Mississippi. Another kind of wampum was made from the shells of
Busycon carica and B. perversum. By staining the wampum with
various colours, and disposing these colours in belts in various forms
of arrangement, the Indians were able to preserve records, send
messages, and keep account of any kind of event, treaty, or
transaction.
Another common form of money in California was Olivella
biplicata, strung together by rubbing down the apex. Button-shaped
disks cut from Saxidomus arata and Pachydesma crassatelloides, as
well as oblong pieces of Haliotis, were employed for the same
purpose, when strung together in lengths of several yards.
 “There is a curious old custom,” writes Mr. W. Anderson Smith,
[206] “that used formerly to be in use in this locality [the western coast
of Scotland], and no doubt was generally employed along the sea-
board, as the most simple and ready means of arrangement of
bargains by a non-writing population. That was, when a bargain was
made, each party to the transaction got one half of a bivalve shell—
such as mussel, cockle, or oyster—and when the bargain was
implemented, the half that fitted exactly was delivered up as a
receipt! Thus a man who had a box full of unfitted shells might be
either a creditor or a debtor; but the box filled with fitted shells
represented receipted accounts. Those who know the difficulty of
fitting the valves of some classes of bivalves will readily
acknowledge the value of this arrangement.”
Shells are employed for use and for ornament by savage—and
even by civilised—tribes in all parts of the world. The natives of Fiji
thread the large Turbo argyrostoma and crenulatus as weights at the
edge of their nets, and also employ them as sinkers. A Cypraea tigris
cut into two halves and placed round a stone, with two or three
showy Oliva at the sides, is used as a bait for cuttles. Avicula
margaritifera is cut into scrapers and knives by this and several other
tribes. Breast ornaments of Chama, grouped with Solarium
perspectivum and Terebra duplicata are common among the Fijians,
who also mount the Avicula on a backing of whales’ teeth sawn in
two, for the same purpose. The great Orange Cowry (Cypraea
aurantiaca) is used as a badge of high rank among the chieftains.
One of the most remarkable Fijian industries is the working of
whales’ teeth to represent this cowry, as well as the commoner C.
talpa, which is more easily imitated.
Among the Solomon islanders, cowries are used to ornament their
shields on great field days, and split cowries are worn as a necklace,
to represent human teeth. Small bunches of Terebellum subulatum
are worn as earrings, and a large valve of Avicula is employed as a
head ornament in the centre of a fillet. The same islanders ornament
the raised prows of their canoes, as well as the inside of the stern-
post, with a long row of single Natica.
 The native Papuans employ shells for an immense variety of
purposes. Circlets for the head are formed of rows of Nassa
gibbosula, rubbed down till little but the mouth remains. Necklaces
are worn which consist of strings of Oliva, young Avicula, Natica
melanostoma, opercula of Turbo, and valves of a rich brown species
of Cardium, pendent at the end of strings of the seeds known as
Job’s tears. Struthiolaria is rubbed down until nothing but the mouth
is left, and worn in strings round the neck. This is remarkable, since
Struthiolaria is not a native Papuan shell, and indeed occurs no
nearer than New Zealand. Sections of Melo are also worn as a
breast ornament, dependent from a necklace of cornelian stones.
Cypraea erosa is used to ornament drinking bowls, and Ovulum
ovum is attached to the native drums, at the base of a bunch of
cassowary feathers, as well as being fastened to the handle of a
sago-beater.
In the same island, the great Turbo and Conus millepunctatus are
ground down to form bracelets, which are worn on the biceps. The
crimson lip of Strombus luhuanus is cut into beads and perforated for
necklaces. Village elders are distinguished by a single Ovulum
verrucosum, worn in the centre of the forehead. The thick lip of
Cassis cornuta is ground down to form nose pieces, 4½ inches long.
Fragments of a shell called Kaïma (probably valves of a large
Spondylus) are worn suspended from the ears, with little wisps of
hair twisted up and thrust through a hole in the centre. For trumpets,
Cassis cornuta, Triton tritonis, and Ranella lampas are used, with a
hole drilled as a mouthpiece in one of the upper whorls. Valves of
Batissa, Unio, and Mytilus are used as knives for peeling yams.
Spoons for scooping the white from the cocoa-nut are made from
Avicula margaritifera. Melo diadema is used as a baler in the
canoes.[207]
In the Sandwich Islands Melampus luteus is worn as a necklace,
as well as in the Navigator Islands. A very striking necklace, in the
latter group, is formed of the apices of a Nautilus, rubbed down to
show the nacre. The New Zealanders use the green opercula of a
Turbo, a small species of Venus, and Cypraea asellus to form the
eyes of their idols. Fish-hooks are made throughout the Pacific of the
shells of Avicula and Haliotis, and are sometimes strengthened by a
backing made of the columella of Cypraea arabica. Small axe-heads
are made from Terebra crenulata ground down (Woodlark I.), and
larger forms are fashioned from the giant Tridacna (Fiji).
Shells are used to ornament the elaborate cloaks worn by the
women of rank in the Indian tribes of South America. Specimens of
Ampullaria, Orthalicus, Labyrinthus, and Bulimulus depend from the
bottom and back of these garments, while great Bulimi, 6 inches
long, are worn as a breast ornament, and at the end of a string of
beads and teeth.[208]
The chank-shell (Turbinella rapa) is of especial interest from its
connexion with the religion of the Hindoos. The god Vishnu is
represented as holding this shell in his hand, and the sinistral form of
it, which is excessively rare, is regarded with extraordinary
veneration. The chank appears as a symbol on the coins of some of
the ancient Indian Empires, and is still retained on the coinage of the
Rajah of Travancore.
The chief fishery of the chank-shell is at Tuticorin, on the Gulf of
Manaar, and is conducted during the N. E. monsoon, October-May.
In 1885–86 as many as 332,000 specimens were obtained, the net
amount realised being nearly Rs.24,000. In former days the trade
was much more lucrative, 4 or 5 millions of specimens being
frequently shipped. The government of Ceylon used to receive
£4000 a year for licenses to fish, but now the trade is free. The shells
are brought up by divers from 2 or 3 fathoms of water. In 1887 a
sinistral specimen was found at Jaffna, which sold for Rs.700.[209]
Nearly all the shells are sent to Dacca, where they are sliced into
bangles and anklets to be worn by the Hindoo women.
Perhaps the most important industry which deals only with the
shells of Mollusca is that connected with the ‘pearl-oyster.’ The
history of the trade forms a small literature in itself. It must be
sufficient here to note that the species in question is not an ‘oyster,’
properly so called, but an Avicula (margaritifera Lam.). The ‘mother-
of-pearl,’ which is extensively employed for the manufacture of
buttons, studs, knife-handles, fans, card-cases, brooches, boxes,
and every kind of inlaid work, is the internal nacreous laminae of the
shell of this species. The most important fisheries are those of the
Am Islands, the Soo-loo Archipelago, the Persian Gulf, the Red Sea,
Queensland, and the Pearl Islands in the Bay of Panama. The shell
also occurs in several of the groups of the South Pacific—the
Paumotu, Gambier and Navigator Islands, Tahiti being the centre of
the trade—and also on the coasts of Lower California.[210]
Pearls are the result of a disease in the animal of this species of
Avicula and probably in all other species within which they occur.
When the Avicula is large, well formed, and with ample space for
individual development, pearls scarcely occur at all, but when the
shells are crowded together, and become humped and distorted, as
well as affording cover for all kinds of marine worms and parasitic
creatures, then pearls are sure to be found. Pearls of inferior value
and size are also produced by Placuna placenta, many species of
Pinna, the great Tridacna, the common Ostrea edulis, and several
other marine bivalves. They are not uncommon in Unio and
Anodonta, and the common Margaritana margaritifera of our rapid
streams is still said to be collected, in some parts of Wales, for the
purpose of extracting its small ‘seed-pearls.’ Pink pearls are obtained
from the giant conch-shell of the West Indies (Strombus gigas), as
well as from certain Turbinella.
In Canton, many houses are illuminated almost entirely by
skylights and windows made of shells, probably the semitransparent
valves of Placuna placenta. In China lime is commonly made of
ground cockle-shells, and, when mixed with oil, forms an excellent
putty, used for cementing coffins, and in forming a surface for the
frescoes with which the gables of temples and private houses are
adorned. Those who suffer from cutaneous diseases, and
convalescents from small-pox, are washed in Canton with the water
in which cockles have been boiled.[211]
A recent issue of the Peking Gazette contains a report from the
outgoing Viceroy of Fukhien, stating that he had handed over the
insignia of office to his successor, including inter alia the conch-shell
bestowed by the Throne. A conch-shell with a whorl turning to the
right, i.e. a sinistral specimen, is supposed when blown to have the
effect of stilling the waves, and hence is bestowed by the Emperor
upon high officers whose duties oblige them to take voyages by sea.
The Viceroy of Fukhien probably possesses one of these shells in
virtue of his jurisdiction over Formosa, to which island periodical
visits are supposed to be made.[212]
Shells appear to be used occasionally by other species besides
man. Oyster-catchers at breeding time prepare a number of imitation
nests in the gravel on the spit of land where they build, putting bits of
white shell in them to represent eggs.[213] This looks like a trick in
order to conceal the position of the true nest. According to
Nordenskjöld, when the eider duck of Spitzbergen has only one or
two eggs in its nest, it places a shell of Buccinum glaciale beside
them. The appropriation of old shells by hermit-crabs is a familiar
sight all over the world. Perhaps it is most striking in the tropics,
where it is really startling, at first experience, to meet—as I have
done—a large Cassis or Turbo, walking about in a wood or on a hill
side at considerable distances from the sea. A Gephyrean
(Phascolion strombi) habitually establishes itself in the discarded
shells of marine Mollusca. Certain Hymenoptera make use of dead
shells of Helix hortensis in which they build their cells.[214] Magnus
believes that in times when heavy rains prevail, and the usual
insects do not venture out, certain flowers are fertilised by snails and
slugs crawling over them, e.g. Leucanthemum vulgare by Limax
laevis.[215]
Mollusca as Food for Man.—Probably there are few countries in
the world in which less use is made of the Mollusca as a form of food
than in our own. There are scarcely ten native species which can be
said to be at all commonly employed for this purpose. Neighbouring
countries show us an example in this respect. The French, Italians,
and Spanish eat Natica, Turbo, Triton, and Murex, and, among
bivalves, Donax, Venus, Lithodomus, Pholas, Tapes, and Cardita, as
well as the smaller Cephalopoda. Under the general designation of
clam the Americans eat Venus mercenaria, Mya arenaria, and
Mactra solidissima. In the Suez markets are exposed for sale
Strombus and Melongena, Avicula and Cytherea. At Panama Donax
and Solen are delicacies, while the natives also eat the great Murex
and Pyrula, and even the huge Arca grandis, which lives embedded
in the liquid river mud.
The common littoral bivalves seem to be eaten in nearly all
countries except our own, and it is therefore needless to enumerate
them. The Gasteropoda, whose habits are scarcely so cleanly, seem
to require a bolder spirit and less delicate palate to venture on their
consumption.
The Malays of the East Indian islands eat Telescopium fuscum
and Pyrazus palustris, which abound in the mangrove swamps. They
throw them on their wood fires, and when they are sufficiently
cooked, break off the top of the spire and suck the animal out
through the opening. Haliotis they take out of the shell, string
together, and dry in the sun. The lower classes in the Philippines eat
Arca inaequivalvis, boiling them as we do mussels.[216] In the
Corean islands a species of Monodonta and another of Mytilus are
quite peppery, and bite the tongue; our own Helix revelata, as I can
vouch from personal experience, has a similar flavour. Fusus
colosseus, Rapana bezoar, and Purpura luteostoma are eaten on
the southern coasts of China; Strombus luhuanus, Turbo
chrysostomus, Trochus niloticus, and Patella testudinaria, by the
natives of New Caledonia; Strombus gigas and Livona pica in the
West Indies; Turbo niger and Concholepas peruvianus on the Chilian
coasts; four species of Strombus and Nerita, one each of Purpura
and Turbo, besides two Tridacna and one Hippopus, by the natives
of British New Guinea. West Indian negroes eat the large Chitons
which are abundant on their rocky coasts, cutting off and swallowing
raw the fleshy foot, which they call ‘beef,’ and rejecting the viscera.
Dried cephalopods are a favourite Chinese dish, and are regularly
exported to San Francisco, where the Chinamen make them into
soup. The ‘Challenger’ obtained two species of Sepia and two of
Loligo from the market at Yokohama.
The insipidity of fresh-water Mollusca renders them much less
desirable as a form of food. Some species of Unionidae, however,
are said to be eaten in France. Anodonta edulis is specially
cultivated for food in certain districts of China, and the African
Aetheriae are eaten by negroes. Navicella and Neritina are eaten in
Mauritius, Ampullaria and Neritina in Guadeloupe, and Paludina in
Cambodia.
The vast heaps of empty shells known as ‘kitchen-middens,’ occur
in almost every part of the world. They are found in Scotland,
Denmark, the east and west coasts of North America, Brazil, Tierra
del Fuego, Australia and New Zealand, and are sometimes several
hundred yards in length. They are invariably composed of the edible
shells of the adjacent coast, mixed with bones of Mammals, birds,
and fish. From their great size, it is believed that many of them must
have taken centuries to form.
Pre-eminent among existing shell-fish industries stands the
cultivation of the oyster and the mussel, a more detailed account of
which may prove interesting.
The cultivation of the oyster[217] as a luxury of food dates at least
from the gastronomic age of Rome. Every one has heard of the
epicure whose taste was so educated that

“he could tell

At the first mouthful, if his oysters fed
On the Rutupian or the Lucrine bed
Or at Circeii.”[218]

The first artificial oyster-cultivator on a large scale appears to

have been a certain Roman named Sergius Orata, who lived about a
century b.c. His object, according to Pliny the elder,[219] was not to
please his own appetite so much as to make money by ministering to
the appetites of others. His vivaria were situated on the Lucrine
Lake, near Baiae, and the Lucrine oysters obtained under his
cultivation a notoriety which they never entirely lost, although British
oysters eventually came to be more highly esteemed. He must have
been a great enthusiast in his trade, for on one occasion when he
became involved in a law-suit with one of the riparian proprietors, his
counsel declared that Orata’s opponent made a great mistake if he
expected to damp his ardour by expelling him from the lake, for,
sooner than not grow oysters at all, he would grow them upon the
roof of his house.[220] Orata’s successors in the business seem to
have understood the secret of planting young oysters in new beds,
for we are told that specimens brought from Brundisium and even
from Britain were placed for a while in the Lucrine Lake, to fatten
after their long journey, and also to acquire the esteemed “Lucrine
flavour.”
Oysters are ‘in season’ whenever there is an ‘r’ in the month, in
other words, from September to April. ‘Mensibus erratis,’ as the poet
has it, ‘vos ostrea manducatis!’ It has been computed that the
quantity annually produced in Great Britain amounts to no less than
sixteen hundred million, while in America the number is estimated at
five thousand five hundred million, the value being over thirteen
million dollars, and the number of persons employed fifty thousand.
Arcachon, one of the principal French oyster-parks, has nearly
10,000 acres of oyster beds, the annual value being from eight to ten
million francs; in 1884–85, 178,359,000 oysters were exported from
this place alone. In the season 1889–90, 50,000 tons of oysters were
consumed in London.
Few will now be found to echo the poet Gay’s opinion:

“That man had sure a palate covered o’er

With brass or steel, that on the rocky shore
First broke the oozy oyster’s pearly coat,
And risq’d the living morsel down his throat.”

There were halcyon days in England once, when oysters were to

be procured at 8d. the bushel. Now it costs exactly that amount
before a bushel, brought up the Thames, can even be exposed for
sale at Billingsgate (4d. porterage, 4d. market toll), and prime
Whitstable natives average from 3½d. to 4d. each. The principal
causes of this rise in prices, apart from the increased demand, are
(1) over-dredging; (2) ignorant cultivation, and to these may be
added (3) the effect of bad seasons in destroying young oysters, or
preventing the spat from maturing. Our own principal beds are those
at Whitstable, Rochester, Colchester, Milton (famous for its ‘melting’
natives), Faversham, Queenborough, Burnham, Poole, and
Carlingford in Co. Down, and Newhaven, near Edinburgh.
The oyster-farms at Whitstable, public and private, extend over an
area of more than 27 square miles. The principal of these is a kind of
joint-stock company, with no other privilege of entrance except birth
as a free dredgeman of the town. When a holder dies, his interest
dies with him. Twelve directors, known as “the Jury,” manage the
affairs of the company, which finds employment for several thousand
people, and sometimes turns over as much as £200,000 a year. The
term ‘Natives,’ as applied to these Whitstable or to other English
oysters, requires a word of explanation. A ‘Native’ oyster is simply an
oyster which has been bred on or near the Thames estuary, but very
probably it may be developed from a brood which came from
Scotland or some other place at a distance. For some unexplained
reason, oysters bred on the London clay acquire a greater delicacy
of flavour than elsewhere. The company pay large sums for brood to
stock their own grounds, since there can be no certainty that the spat
from their own oysters will fall favourably, or even within their own
domains at all. Besides purchases from other beds, the parks are
largely stocked with small oysters picked up along the coast or
dredged from grounds public to all, sometimes as much as 50s. a
bushel being paid for the best brood. It is probably this system of
transplanting, combined with systematic working of the beds, which
has made the Whitstable oyster so excellent both as to quality and
quantity of flesh. The whole surface of the ‘layings’ is explored every
year by the dredge, successive portions of the ground being gone
over in regular rotation, and every provision being made for the well-
being of the crop, and the destruction of their enemies. For three
days of every week the men dredge for ‘planting,’ i.e. for the
transference of suitable specimens from one place to another, the
separation of adhering shells, the removal of odd valves and of every
kind of refuse, and the killing off of dangerous foes. On the other
three days they dredge for the market, taking care only to lift such a
number as will match the demand.
 The Colne beds are natural beds, as opposed to the majority of
the great working beds, which are artificial. They are the property of
the town of Colchester, which appoints a water-bailiff to manage the
concern. Under his direction is a jury of twelve, who regulate the
times of dredging, the price at which sales are to be made, and are
generally responsible for the practical working of the trade. Here,
and at Faversham, Queenborough, Rochester, and other places,
‘natives’ are grown which rival those of Whitstable.
There can be no question, however, that the cultivation of oysters
by the French is far more complete and efficient than our own, and
has reached a higher degree of scientific perfection combined with
economy and solid profits. And yet, between 40 and 50 years ago,
the French beds were utterly exhausted and unproductive, and
showed every sign of failure and decay. It was in 1858 that the
celebrated beds on the Ile de Ré, near Rochelle, were first started.
Their originator was a certain shrewd stone-mason, by name Boeuf.
He determined to try, entirely on his own account, whether oysters
could not be made to grow on the long muddy fore-shore which is
left by the ebb of the tide. Accordingly, he constructed with his own
hands a small basin enclosed by a low wall, and placed at the
bottom a number of stones picked out of the surrounding mud,
stocking his ‘parc’ with a few bushels of healthy young brood. The
experiment was entirely successful, in spite of the jeers of his
neighbours, and Boeuf’s profits, which soon began to mount up at an
astonishing rate, induced others to start similar or more extensive
farms for themselves. The movement spread rapidly, and in a few
years a stretch of miles of unproductive mud banks was converted
into the seat of a most prosperous industry. The general interests of
the trade appear to be regulated in a similar manner to that at
Whitstable; delegates are appointed by the various communities to
watch over the business as a whole, while questions affecting the
well-being of oyster-culture are discussed in a sort of representative
assembly.
At the same time as Boeuf was planting his first oysters on the
shores of the Ile de Ré, M. Coste had been reporting to the French
government in favour of such a system of ostreiculture as was then
practised by the Italians in the old classic Lakes Avernus and
Lucrinus. The principle there adopted was to prevent, as far as
possible, the escape of the spat from the ground at the time when it
is first emitted by the breeding oyster. Stakes and fascines of wood
were placed in such a position as to catch the spat and give it a
chance of obtaining a hold before it perished or was carried away
into the open sea. The old oyster beds in the Bay of St. Brieuc were
renewed on this principle, banks being constructed and overlaid with
bundles of wood to prevent the escape of the new spat. The attempt
was entirely successful, and led to the establishment or re-
establishment of those numerous parcs, with which the French coast
is studded from Brest to the Gironde. The principal centres of the
industry are Arcachon, Auray, Cancale, and la Teste.
It is at Marennes, in Normandy, that the production of the
celebrated ‘green oyster’ is carried out, that especial luxury of the
French epicure. Green oysters are a peculiarly French taste, and,
though they sometimes occur on the Essex marshes, there is no
market for them in England. The preference for them, on the
continent, may be traced back as early as 1713, when we find a
record of their having been served up at a supper given by an
ambassador at the Hague. Green oysters are not always green, it is
only after they are placed in the ‘claires,’ or fattening ponds, that they
acquire the hue; they never occur in the open sea. The green colour
does not extend over the whole animal, but is found only in the
branchiae and labial tentacles, which are of a deep blue-green.
Various theories have been started to explain the ‘greening’ of the
mollusc; the presence of copper in the tanks, the chlorophyll of
marine algae, an overgrowth of some parasite, a disease akin to liver
complaint, have all found their advocates. Prof. Lankester seems to
have established[221] the fact,—which indeed had been observed 70
years before by a M. Gaillon,—that the greening is due to the growth
of a certain diatom (Navicula ostrearia) in the water of the tanks. This
diatom, which is of a deep blue-green colour, appears from April to
June, and in September. The oyster swallows quantities of the
Navicula; the pigment enters the blood in a condition of chemical
modification, which makes it colourless in all the other parts of the