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 3RD EDITION

Minor
Emergencies
Philip Buttaravoli, MD FACEP
Fellow of the American College of Emergency Physicians
Adjunct Assistant Professor in the Department of Emergency Medicine
Fletcher Allen Health Care
Burlington, Vermont

Stephen M. Leffler, MD FACEP

Fellow of the American College of Emergency Physicians
Professor of Emergency Medicine
University of Vermont College of Medicine
Fletcher Allen Health Care
Burlington, Vermont
 1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

MINOR EMERGENCIES ISBN: 978-0-323-07909-9

Copyright © 2012 by Saunders, an imprint of Elsevier Inc.
Copyright © 2007, 2000 by Mosby, Inc., an affiliate of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek permission,
further information about the Publisher’s permissions policies and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Buttaravoli, Philip M., 1945-
Minor emergencies / Philip Buttaravoli, Stephen M. Leffler. — 3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-323-07909-9 (pbk. : alk. paper)
I. Leffler, Stephen M. II. Title.
[DNLM: 1. Critical Care. 2. Emergencies. 3. Wounds and Injuries. WX 218]
616.02’5—dc23 2011049148

Senior Content Strategist: Kate Dimock

Content Development Strategist: Angela Rufino
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Claire Kramer
Designer: Louis Forgione
Cover Illustrator: Esao Andrews

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To Holly Lindsey

—Philip Buttaravoli

To my wife, Robyn, and my children, Zack and Emily, thank you for your love and support. To my
colleagues in the Fletcher Allen Emergency Department, thank you for your efforts and hard
work on this book and for the outstanding care you deliver to your patients on a daily basis.
To Phil Buttaravoli, thank you for the opportunity to participate in the third edition of Minor
Emergencies.

—Stephen M. Leffler
Contributors
Andrew Bushnell, MD
Associate Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Philip Buttaravoli, MD FACEP
Fellow of the American College of Emergency Physicians
Adjunct Assistant Professor in the Department of Emergency Medicine
Fletcher Allen Health Care
Burlington, Vermont
Maj Eisinger, MD
Associate Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Page Hudson, MD
Assistant Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Steve Hulsey, MD
Associate Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Wendy James, MD
Assistant Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Ray Keller, MD
Associate Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Stephen M. Leffler, MD FACEP
Fellow of the American College of Emergency Physicians
Professor of Emergency Medicine
University of Vermont College of Medicine
Fletcher Allen Health Care
Burlington, Vermont
vii
CONTRIBUTORS

Wayne Misselbeck, MD
Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Laurel Plante, MD
Assistant Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Alfred Sacchetti, MD FACEP
Chief Emergency Services
Our Lady of Lourdes Medical Center
Camden, New Jersey
Assistant Clinical Professor of Emergency Medicine
Thomas Jefferson University
Philadelphia, Pennsylvania
Michael Sheeser, MD
Assistant Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Mario Trabulsy, MD
Associate Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Katherine Walsh, MD
Assistant Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Daniel Wolfson, MD
Assistant Professor of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont
Kevin Wyne, PA-C
Clinical Instructor
Department of Surgery
Division of Emergency Services
University of Vermont College of Medicine
Burlington, Vermont

viii
Foreword

Patients do not experience emergencies that are “minor”; instead, acute care problems and
minor urgent problems are “major” to patients, who expect accurate and timely decision making.
Moreover, minor emergencies become a challenge to providers if they require an update on
management or they need additional information to give the patient the very best care. This
textbook details a full repertoire of minor emergencies and is an extremely effective resource in
the acute care setting.
Minor Emergencies is a straightforward resource that will aid clinicians on the front line of
medicine. The clinical problems are organized by system and are identifiable in the table
of contents. Readers will find that it is easy to review a problem, as well as pinpoint and
excerpt areas for further consideration. The highlighted discussions succinctly review the
pathophysiology or injury mechanism, in addition to the clinical prognosis.

Each section is carefully referenced and contains relevant illustrations, diagrams, and images.
Each chapter provides important cautions and highlights steps and strategies for the provider
to consider while offering the highest quality care. Each section reflects experience from clinical
practice and teaching sessions for learners of acute care medicine. The narrative contains up-to-
date scientific approaches that are interwoven with practical strategies. The appendixes contain
important protocols and references that will be useful in minor or major emergencies. Minor
Emergencies is an extraordinary acute care tool for medical students, as well as experienced
physicians.

My practice experience ranges from primary care offices in student health settings to athletic
fields and the backcountry wilderness and from urgent care settings to the emergency room. On
the basis of my experience, I fully recommend this book for the “go-to” shelf of your references.
The text is quick, accurate, comprehensive, and effective.
Thomas C. Peterson, MD
Professor and Chair of Family Medicine
University of Vermont College of Medicine
Burlington, Vermont

ix
Preface

Preface to the Second Edition

“Good judgment comes from experience, and a lot of that comes from bad judgment.”
—Will Rogers

As a medical student at the University of Vermont in the late 1960s interested in emergency
room care (this was considered peculiar at the time), I found myself disappointed that my
medical education (excellent in every other way) was lacking when it came to the treatment
of simple minor emergencies. I had this in mind when, in 1975, as the medical director of
the emergency service at George Washington University Medical Center (and the first
residency-trained emergency physician in the Washington, DC, area), I was given the
opportunity to present a 1-hour lecture to their medical students on emergency medical
care—“Common Simple Emergencies.” (At that time, 1 hour was considered very generous for
covering all of emergency medicine.)

I eventually expanded this slide show and lecture to a 6-hour series, which I presented regularly
at the Georgetown University Medical Center Emergency Department. Even though there were
still few published data on most of the topics covered in the lecture series, in 1985, with the
help of emergency medicine attending physician Dr. Thomas Stair, I turned “Common Simple
Emergencies” into a 300-page book. For the most part, the information contained within this
publication was based on common practice and personal experience.

Fifteen years later, with more published data available, the book was again published under
the present title and was expanded to 500 pages. The general format (“What To Do/What Not
To Do”) was maintained. Even with the greater volume of information, the book remained a
practical guide.

Today, in stark contrast to when the original edition was published in 1985, there is a plethora
of scientific data on most of the subject covered in Minor Emergencies. The book has now grown
to over 800 pages. In the face of the sometimes overwhelming volume of data now available,
I have endeavored to continue to present these topics on minor emergencies in a manner that
will still allow this larger text to be a useful and practical guide.

I have maintained the simple basic format used in the previous edition and have continued
to use bold font to bring the reader’s eye to the key information in each chapter. I have added
red font to help identify different topics within the text. The discussions are now highlighted
and compressed using small font and double columns. These changes have allowed me to
make the book more complete and comprehensive and yet still allow it to remain useful at
a glance.

xi
PREFACE

The clinical material has all been updated, new topics have been added, and I have used
evidence-based data whenever available. Many more photographs and drawings have been
added (in color) to benefit the reader. In addition, I have personally reviewed the index to help
ensure its usefulness and have attempted to include many identifying symptoms in the index to
help users find the topic they are searching for.

I have done all of this so that you as a clinician can have more fun with your patients. When
emergencies are minor, it gives you an opportunity to lighten up and enjoy the art of healing.
Patients appreciate a confident clinician with a good sense of humor who can stop the pain
and/or the worry, fix the problem in a compassionate way, and also make them laugh. This
book can provide you with the information that you need to perform competently and to relax
when presented with the minor emergencies that patients will always need your help with. (You
will have to supply the humor.) You will be greatly rewarded for your treatment by seeing their
smiling faces and hearing their expressions of gratitude after happily making them well.
Philip M. Buttaravoli, MD FACEP

Preface to the Third Edition

To incorporate an academic element to the latest edition of Minor Emergencies, I have returned
to my alma mater, the University of Vermont, thereby bringing the book full circle to its earliest
origins. I asked Emergency Department Medical Director Stephen M. Leffler, MD, whether he and
the rest of the emergency department medical staff would be interested in updating the clinical
material in Minor Emergencies and bringing the book into the digital age with an electronic
publication that would include video displays.

Steve, along with his department staff, accepted the challenge enthusiastically.

With their involvement, this latest edition of Minor Emergencies should prove to be more
accurate and convenient for the user. There will be periodic updates of the electronic version,
and this will maintain a continuous renewal of clinical information.

The book title of this third edition has been shortened with the elimination of the subtitle
Splinters to Fractures. This subtitle was thought to be more misleading than informative, and the
new abbreviated title better reflects the book’s true essence.

It is my hope that this new edition will continue to provide support for all of the clinicians out
there who are caring for the public’s minor emergencies on a daily basis.
Philip Buttaravoli, MD FACEP

A note from the authors:

We have no relationships with or financial interests in any commercial companies that pertain to
any of the products mentioned in this publication.
Any comments, suggestions, and/or questions can be directed to Drs. Buttaravoli and Leffler
at e-med@juno.com and Stephen.Leffler@vtmednet.org under the subject heading Minor
Emergencies.
Philip Buttaravoli, MD FACEP
(Butter ah’voli)
Stephen M. Leffler, MD FACEP

xii
Acknowledgments

I have enjoyed the special opportunity to work with Kate Dimock, who has always been a
delight to work with and has been most informative and supportive in the creation of this third
edition. In addition, it has been a pleasure working with the extremely competent, efficient, and
hardworking assistance of Kate Crowley, Angela Rufino Claire Kramer, and Michael Fioretti, as
well as all the other contributors to this project at Elsevier.

Also, special thanks to the emergency department staff at Fletcher Allen Health Care and the
University of Vermont.

xiii
Contents

PART 1
Neurologic Emergencies 1
• Philip Buttaravoli and MarioTrabulsy

1 Dystonic Drug Reaction 1

2 Heat Illness (Heat Edema, Heat Syncope, Heat Cramps, Heat Exhaustion) 4
3 Hyperventilation 8
4 Hysterical Coma or Pseudoseizure 11
5 Idiopathic Facial Paralysis (Bell's Palsy) 14
6 Migraine Headache 18
7 Seizures (Convulsions, Fits), Adult 23
8 Seizures (Convulsions, Fits), Febrile and Pediatric 29
9 Tension-Type (Muscle Contraction) Headache 33
10 Trivial, Minimal, and Minor Head Trauma (Concussion) 37
11 Vasovagal or Neurocardiogenic or Neurally Mediated Syncope (Faint, Swoon) 42
12 Vertigo (Dizziness, Lightheadedness) 48
13 Weakness 56

PART 2
Ophthalmologic Emergencies 59
• Philip Buttaravoli and Ray Keller
14 Conjunctivitis (Pink Eye) 59
15 Contact Lens Complications 65
16 Corneal Abrasion 68
17 Foreign Body, Conjunctival 72
18 Foreign Body, Corneal 75
19 Hordeolum (Stye) 79
20 Iritis (Acute Anterior Uveitis) 81
21 Periorbital and Conjunctival Edema 85
22 Periorbital Ecchymosis (Black Eye) 87
23 Removal of Dislocated Contact Lens 90
24 Subconjunctival Hemorrhage 92
25 Ultraviolet Keratoconjunaivitis (Welder's or Tanning Bed Burn) 94

XV
CONTENTS

PART 3
Ear, Nose, and Throat Emergencies 97
• Philip Buttaravoli and Steve Hulsey

26 Cerumen Impaction (Earwax Blockage) 97

27 Epistaxis (Nosebleed) 100
28 Foreign Body, Ear 108
29 Foreign Body, Nose 113
30 Foreign Body,Throat 118
31 Laryngotracheobronchitis (Croup) 122
32 Mononucleosis (Glandular Fever) 126
33 Nasal Fracture (Broken Nose) 129
34 Otitis Externa (Swimmer's Ear), Acute 132
35 Otitis Media, Acute 137
36 Otitis Media with Effusion; Serous (Secretory) Otitis Media (Glue Ear) 142
37 Perforated Tympanic Membrane (Ruptured Eardrum) 145
38 Pharyngitis (Sore Throat) 147
39 Rhinitis, Acute (Runny Nose) 152
40 Rhinosinusitis (Sinusitis) 157

PART 4
Oral and Dental Emergencies 161
• Philip Buttaravoli and Daniel Wolfson

41 Aphthous Ulcer (Canker Sore) 161

42 Avulsed Tooth, Dental Subluxation, Dental Luxation 166
43 Bleeding after Dental Surgery 172
44 Burning Mouth Syndrome, Burning Tongue (Glossodynia) 174
45 Dental Pain, Periapical Abscess (Tooth Abscess) 178
46 Dental Pain, Pericoronitis 181
47 Dental Pain, Postextraction Alveolar Osteitis (Dry Socket) 183
48 Dental Pain, Pulpitis 185
49 Dental Trauma (Fracture, Subluxation, and Displacement) 187
50 Gingivitis and Acute Necrotizing Ulcerative Gingivitis (Trench Mouth) 191
51 Lacerations of the Mouth 193
52 Mucocele (Mucous Cyst) 196
53 Oral Candidiasis (Thrust or Yeast Infection) 198
54 Oral Herpes Simplex (Cold Sore, Fever Blister) 200
55 Orthodontic Complications 203
56 Perleche (Angular Cheilitis) 205
57 Sialolithiasis (Salivary Duct Stones) 207
58 Temporomandibular Disorder (TMD.TMJ Syndrome) 210
59 Temporomandibular Joint Dislocation (Jaw Dislocation) 214
60 Uvular Edema, Acute 217

xvi
 CONTENTS

PART 5
Pulmonary and Thoracic Emergencies 221
• Philip Buttaravoli and Katherine Walsh

61 Bronchitis (Chest Cold), Acute 221

62 Costochondritis and Musculoskeletal Chest Pain 226
63 Inhalation Injury (Smoke Inhalation) 229
64 Irritant Incapacitant Exposure (Lacrimators, Riot Control Agents,Tear Gas) 233
65 Rib Fracture and Costochondral Separation (Broken Rib) 236

PART 6
Gastrointestinal Emergencies 241
• Philip Buttaravoli and Maj Eismger

66 Anal Fissure 241

67 Constipation, Irritable Bowel Syndrome, and Colic (Stomach Cramps) 245
68 Diarrhea (Acute Gastroenteritis) 253
69 Enterobiasis (Pinworm, Threadworm, Seatworm) 260
70 Esophageal Food Bolus Obstruction (Steakhouse or Cafe Coronary Syndrome) 263
71 Foreign Body, Rectal 267
72 Foreign Body, Swallowed 273
73 Hemorrhoids (Piles) 280
74 Innocuous Ingestions 285
75 Singultus (Hiccups) 287
76 Vomiting (Food Poisoning, Gastroenteritis) 290

PART 7
Urologic Emergencies 295
• Philip Buttaravoli and Andrew Bushnell

77 Blunt Scrotal Trauma 29S

78 Colorful Urine 298
79 Epididymitis 301
80 Genital Herpes Simplex 306
81 Phimosis and Paraphimosis 310
82 Prostatitis, Acute Bacterial 314
83 Urethritis (Drip, Clap) 316
84 Urinary Retention, Acute 320
85 Urinary Tract Infection, Lower (Cystitis), Uncomplicated 323
86 Urinary Tract Infection, Upper (Pyelonephritis) 328

xvii
CONTENTS

PART 8
Gynecologic Emergencies 331
• Philip Buttaravoli and Wendy James

87 Bartholin Abscess 331

88 Condylomata Acuminata (Genital Warts) 334
89 Contact Vulvovaginitis 340
90 Dysmenorrhea (Menstrual Cramps) 342
91 Foreign Body, Vaginal 345
92 "Morning After" Emergency Contraception 347
93 Pelvic Inflammatory Disease (PID) 350
94 Vaginal Bleeding 355
95 Vaginitis 360

PART 9
Musculoskeletal Emergencies 367
• Philip Buttaravoli, Laurel Plante, and Wayne Misselbeck

96 Acromioclavicular (Shoulder) Separation 367

97 Ankle Sprain (Twisted Ankle) 372
98 Annular Ligament Displacement, Radial Head Subluxation (Nursemaid's Elbow) 379
99 Boutonniere Finger 383
100 Boxer's Fifth Metacarpal Fracture 387
101 Bursitis 390
102 Carpal Tunnel Syndrome 394
103 Cervical Strain (Whiplash) 399
104 Cheiralgia Paresthetica (Handcuff Neuropathy) 404
105 Clavicle (Collarbone) Fracture 406
106 Coccyx Fracture (Tailbone Fracture) 410
107 De Quervain Paratenonitis (ThumbTenosynovitis) 412
108 Extensor Tendon Avulsion — Distal Phalanx (Baseball or Mallet Finger) 415
109 Finger Dislocation (PIP Joint) 419
110 Finger Sprain (PIP Joint) 423
111 Fingertip (Tuft) Fractures 425
112 Flexor Digitorum Profundus Tendon Avulsion—Distal Phalanx (Splay Finger) 427
113 Ganglion Cysts 429
114 Gouty Arthritis, Acute 431
115 Knee Sprain 436
116 Lateral Epicondylitis and Medial Epicondylitis (Tennis Elbow, Golfer's Elbow) 443
117 Ligament Sprains (Including Joint Capsule Injuries) 447
118 Locked Knee 449
119 Lumbar Strain, Acute ("Mechanical" Low Back Pain, Sacroiliac Dysfunction) 451
120 Monarticular Arthritis, Acute 458
121 Muscle Cramps (Charley Horse) 465
122 Muscle Strains and Tears 467

xviii
 CONTENTS

123 Myofascial Pain Syndrome, Fibromyalgia (Trigger Points) 471

124 Patellar Dislocation (Kneecap Dislocation) 481
125 Plantar Fasciitis ("Heel Spur") 485
126 "Plantaris Tendon" Rupture, Gastrocnemius Muscle Tear (Calf Muscle Tear) 489
127 Polymyalgia Rheumatica 493
128 Radial Head Fracture 496
129 Radial Neuropathy (Saturday Night Palsy) 499
130 Scaphoid Fracture 502
131 Shoulder Dislocation 507
132 TendinopathyrTendinosis, Paratenonitis (Tendinitis) 514
133 Toe Fracture (Broken Toe) 518
134 Torticollis (Wryneck) 521
135 Ulnar Collateral Ligament Tear of the Thumb (Ski Pole or Gamekeeper's Thumb) 524

PART 1 0
Soft Tissue Emergencies 527
• Philip Buttaravoli, Michael Sheeser, and Kevin Wyne

136 Bicycle Spoke Injury and Other Crush Injuries 527

137 Contusion (Bruise) 530
138 Fingernail or Toenail Avulsion 535
139 Fingertip Avulsion, Superficial 539
140 Fishhook Removal 543
141 Foreign Body Beneath Nail 547
142 Impalement Injuries, Minor 550
143 Laceration, Simple 553
144 Mammalian Bites 567
145 Marine Envenomations 574
146 Nail Bed Laceration 581
147 Nail Root Dislocation 584
148 Needle (Foreign Body) in Foot 587
149 Paronychia 591
150 Pencil Point Puncture 597
151 Puncture Wounds 599
152 Ring Removal 604
153 Sliver, Superficial (Splinter) 609
154 Subcutaneous Foreign Bodies (Metal, Dental Fragments,
Glass, Gravel, and Hard Plastic) 614
155 Subungual Ecchymosis (TennisToe) 621
156 Subungual Hematoma 623
157 Torn/Split Earlobe 627
158 Traumatic Tattoos and Abrasions 632
159 Zipper Entrapment (Penis or Chin) 635

xix
CONTENTS

PART 1 1
Dermatologic Emergencies 639
• Philip Buttaravoli and Page Hudson

160 Allergic Contact Dermatitis 639

161 Arachnid Envenomation (Spider Bite) 645
162 Arthropod Bites (Bug Bites, Insect Bites) 650
163 Cutaneous Abscess or Pustule 655
164 Cutaneous Larva Migrans (Creeping Eruption) 661
165 Diaper Dermatitis (Diaper Rash) 663
166 Erysipelas, Cellulitis, Lymphangitis 666
167 Fire Ant Stings 671
168 Friction Blister 674
169 Frostnip, Frostbite, and Mild Hypothermia 676
170 Herpes Zoster (Shingles) 680
171 Hymenoptera (Bee, Wasp, Hornet) Envenomation (Bee Sting) 686
172 Impetigo 691
173 Partial-Thickness (Second-Degree) Burns and Tar Burns 694
174 Pediculosis (Lice, Crabs) 699
175 Pityriasis Rosea 705
176 Pyogenic Granuloma or Lobular Capillary Hemangioma (Proud Flesh) 709
177 Scabies (Human Itch Mite) 711
178 Sea Bather's Eruption (Sea Lice) 716
179 Sunburn 719
180 Tick Bite, Tick Removal 724
181 Tinea Pedis,Tinea Cruris, Tinea Corporis (Athlete's Foot, Jock Itch, Ringworm) 733
182 Toxicodendron (Rhus), Allergic Contact Dermatitis (Poison Ivy, Oak, or Sumac) 740
183 Urticaria, Acute (Hives) 746
184 Warts (Common Wart, Plantar Wart) 752

Appendixes
A Complete Eye Examination 757
B Digital Block 758
C Fingertip Dressing, Simple 761
D Oral Nerve Blocks 763
E Procedural Sedation and Analgesia 765
• Alfred Sacchetti 765
F Rabies Prophylaxis 769
G State and Regional Poison Control Centers 772
H Tetanus Prophylaxis 779

XX
Video Contents

CHAPTER 12 Video 1: Epley or (Canalith) Otolith Repositioning Maneuver

CHAPTER 17 Video 2: Eyelid Eversion with Cotton-tipped Applicator

CHAPTER 20 Video 3: Slit Lamp Examination: Normal Anterior Chamber

CHAPTER 22 Video 4: Symmetric Palpation of the Facial Bones

CHAPTER 26 Video 5: Ear Irrigation Technique

CHAPTER 27 Video 6: Initial Management of Epistaxis

CHAPTER 51 Video 7: Stitch for Laceration of Vermilion Border

CHAPTER 65 Video 8: Diagnosing a Rib Fracture Clinically with Indirect Stress

CHAPTER 75 Video 9: Granulated Sugar for Stopping Hiccups

CHAPTER 91 Video 10: Foreign Body Removal: Lost Vaginal Tampon

CHAPTER 119 Video 11: Sacroiliac Joint Injection

CHAPTER 123 Video 12:Trigger Point Injection

CHAPTER 124 Video 13: Reduction: Patellar Dislocation

CHAPTER 126 Video 14: Calf Squeeze Test

CHAPTER 131 Video 15: Reduction of Shoulder Dislocation: Modified Kocher

Maneuver or External Rotation Technique

CHAPTER 133 Video 16: Buddy Taping After Reduction of Dislocated Second Toe

CHAPTER 140 Video 17: Fishhook Removal: Needle Technique

Video 18: Fishhook Removal: Push Through or Advance and Cut
Method
Video 19: Fishhook Removal: Retrograde or Modified String
Technique
Video 20: Fishhook Removal: String Technique
Video 21: Fishhook Removal: Treble Fishhook

xxi
VIDEO CONTENTS

CHAPTER 142 Video 22: Removal of a Minor Impaled Object

CHAPTER 148 Video 23: Foreign Body Removal: Needle in Foot

CHAPTER 149 Video 24: Draining Acute Paronychia Without Invasion of Skin

CHAPTER 150 Video 25: Pencil Point Puncture Tattoo Removal

CHAPTER 152 Video 26: Ring Removal-Compression: Exsanguination Technique

Video 27: Ring Removal: Ring Cutter
Video 28: Ring Removal-Traction: Countertraction
Video 29: Ring Removal: Orthopedic Pin Cutter
Video 30: Ring Removal: Pin Cutter-Cast Spreader Technique

CHAPTER 153 Video 31: Foreign Body Removal: Superficial Wooden Sliver

CHAPTER 154 Video 32: Producing a Bloodless Field

Video 33: Subcutaneous Foreign Body Removal: Probe Technique

CHAPTER 158 Video 34: Removal of Traumatic Tattoos from Abrasions

CHAPTER 159 Video 35: Entrapped Zipper Removal: Attempting to Cut

the Slide Apart
Video 36: Zipper Entrapment Removal Techniques: Lubrication
and Opening Zipper from Rear

APPENDIX C Video 37: Fingertip Dressing

Video 38: Homemade Fingertip Dressing

See expertconsult.com

xxil
 PART 1
Neurologic Emergencies
n Philip Buttaravoli n Mario Trabulsy

CHAPTER

Dystonic Drug Reaction 1

Presentation
The patient arrives at the emergency department (ED) or clinic with peculiar posturing, facial
grimacing and distortions with a variety of involuntary muscle movements, and/or difficulty
speaking. The patient is usually quite upset and worried about having a stroke. Pain is minimal,
if at all. The jaw, tongue, lip, throat, and neck muscles are frequently involved. Hyperextension
and lateral deviation of the neck along with upward gaze are the classic presentations. Often no
history is offered. The patient may not be able to speak, may not be aware that he or she took
any phenothiazines or butyrophenones (e.g., Haldol that has been used to cut heroin), may
not admit that he or she takes illicit drugs or psychotropic medication, or may not make the
connection between the symptoms and drug use (e.g., one dose of Compazine given to treat
nausea or vomiting). The drugs that are most likely to produce a classic dystonic reaction are
prochlorperazine (Compazine), haloperidol (Haldol), chlorpromazine (Thorazine), promethazine
(Phenergan), and metoclopramide (Reglan). Acute dystonias usually present with one or more of
the following types of symptoms:

Buccolingual—protruding or pulling sensation of the tongue

Torticollic—twisted neck or facial muscle spasm
Oculogyric—roving or deviated gaze
Tortipelvic—abdominal rigidity and pain
Opisthotonic—spasm of the entire body

These acute dystonias can resemble partial seizures, the posturing of psychosis, or the spasms
of tetanus, strychnine poisoning, or electrolyte imbalances. More chronic neurologic side effects
of phenothiazines, including the restlessness of akathisia, tardive dyskinesias, and parkinsonism,
do not usually respond as dramatically to drug treatment as do the acute dystonias (Figure
1-1). Onset of oculogyric crisis and torticollis reactions usually occurs within a few minutes or
hours but may occur 12 to 24 hours after treatment with a high-potency neuroleptic, such as
haloperidol.

1
MINOR EMERGENCIES

Figure 1-1 Patient with dystonic drug reaction.

What To Do:
Administer 1 to 2 mg of benztropine (Cogentin) or 25 to 50 mg of diphenhydramine
(Benadryl) IV, and watch for improvement of the dystonia over the next 5 minutes. Usually, the
medication begins to work within 2 minutes of intravenous administration, and the symptoms
completely resolve within 15 minutes. This step is both therapeutic and diagnostic.
Benztropine produces fewer side effects (mostly drowsiness) and may be slightly more effective,
but diphenhydramine is more likely to be on hand in the ED or physician’s office. Benztropine
may be given to children older than 3 years of age at the dose of 0.01 to 0.02 mg/kg IV, IM, or PO.

Instruct the patient to discontinue use of the offending drug and arrange for follow-up
if medications must be adjusted. If the culprit is long acting, prescribe benztropine 2 mg or
diphenhydramine 25 mg PO q6h for 24 to 72 hours to prevent a relapse.

What Not To Do:

Do not do any diagnostic workup when findings are typical. Administer benztropine or
diphenhydramine first to see if symptoms completely resolve.

Do not confuse dystonia with tetanus, seizures, stroke, hysteria, psychosis, meningitis, or
dislocation of the mandible. None of these will resolve with IV benztropine or diphenhydramine.

Do not persist with treatment if the response is questionable or there is no response.

Continue with the workup to find another cause for the dystonia (e.g., tetanus, seizures,
hypomagnesemia, hypocalcemia, alkalosis, muscle disease).

Do not use IV diazepam first because it relaxes spasms resulting from other causes and thus
leaves the diagnosis unclear.

2
Another random document with
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 Lucrezia. Madonna Adriana brought me here;
She stays without: I go back to the convent.
Cesare—;tell me all that I should pray.

Cesare [turning his head back towards her from

the couch]. Amanda, that your scruples be removed.
That I be Cesar.

Lucrezia. Take a little rest.

Cesare. Shall you, from prayer?

To-night you look a sibyl.
Who did this deed?

Lucrezia. Let Juan play the lute;

You must have music through these restless nights.
How lost you look!

Cesare. You startled me. How lost!

[He closes his eyes.
Lucrezia. He is dreaming; he has quite forgotten me.
Come, Adriana, soft! As an astronomer
He must not be disturbed: he is quite lost.

One leaves Borgia reluctantly, having done so much less than justice to
it: nevertheless, it is refreshing to turn to Deirdre after an atmosphere so
charged and tropical. Not that Deirdre is set on any lower plane of emotion,
for it also deals with vast passions. But in this play we pass visibly to a
more northerly latitude, to an austerer race and a more primitive age; and it
is in an air swept clean by storm that the business of sowing the wind and
reaping the whirlwind goes forward.
Michael Field has made a noble rendering of this old Irish story which,
its subject dating from the first century, suggests a cause no less remote
than that for the ancient feud between Ulster and the rest of Ireland. The
story is well known: the birth of Deirdre and the prophecies of doom to
Ulster through her; the defiance of the doom by Conchobar the king, and
the fostering of Deirdre to be his wife; the carrying off of Deirdre on the
eve of her wedding by Naisi and their flight to Alba; the invitation to Naisi
and his brothers to return under Conchobar’s promise of forgiveness; and
the treacherous assassination of them upon their arrival. There are many
variants of the legend; and our poet has chosen the oldest of them all, that
preserved in the Book of Leinster, for the chief events of her drama. She
was compelled to alter the story at one point, for it would hardly have been
convenient to represent the Sons of Usnach slain, all three at one stroke, by
the magic sword. But in varying the manner of their death she was enabled
to adopt another form of the legend, in which Naisi and his two brothers
were overcome by a Druid’s enchantment, and, believing themselves to be
drowning, dropped their weapons and were immediately overpowered by
Conchobar’s men. There was, however, a difficulty here too; for whereas
three heads lopped off at one blow was a little too dynamic even for the
purposes of drama, an unseen spell of wizardry was altogether too static;
and the poet therefore contrived a scene in which Naisi’s comrades are
actually drowned, and he, left alone to protect Deirdre, is slain by Eogan.
Another modification, with less warrant from the documents, perhaps,
but of even greater interest, is that which introduces into this primitive
world the first gleam of Christianity. The fact might suggest that the Deirdre
play was written after the poets’ conversion, did one not know that they
were at work on the theme some time before. But it is extremely probable
that the passage in which the wise woman Lebarcham tries to turn
Conchobar from brooding on vengeance by the tale of a new god who
refused to avenge himself on his enemies was inserted after the first draft of
the play was made. It is written in prose, and, placed at the beginning of Act
III, hardly affects the subsequent action. From that point of view it might be
considered superfluous; but Michael, though not Henry, was capable of so
much over-zeal. She was, however, also capable of justifying her act
artistically. The interpolation is at least not an anachronism. It is possible,
there in Ireland, that even so early had penetrated “the story of how a god
met his death ... young, radiant ... bearing summer in his hands.” But it
might have been a menace to the unity of the drama: it might have
destroyed the satisfying wholeness which, in whatever form one finds it, the
pagan story possesses. Michael Field avoided that calamity. She threw her
glimmer of Christian light across the scene in such a way that it reveals
more strongly by contrast the dark elements of which the story is composed.
By it one instinctively measures the barbarity of the age out of which the
story came, and realizes its antiquity. The poet does not allow it to influence
action, for that would weaken the tragedy; but she uses the occasion to
humanize and make credible that which, in the Conchobar of the records,
seems almost monstrous. In those ancient tales Conchobar plans his
vengeance on Naisi and his brothers with a coldness that is diabolic and a
precision almost mechanical. He provides for his own safety, too, with
comical caution, carefully sounding one after another of his knights until he
finds one who does not immediately threaten to kill him for suggesting such
a dastardly deed as the murder of the Sons of Usnach. Yet, as our poet has
re-created Conchobar, he is a human soul driven this way and that in a
running fight with passion; pitiable in his hopeless love for Deirdre,
comprehensible in his wrath against Naisi, sinister and terrifying in his
revenge. And underneath the overt drama lies a profounder irony; for while
he is plotting in his heart the enormous treachery, Lebarcham tells of the
young god who was betrayed by his friends, and he says:
Hush, woman, for my heart is broken. Would I had been there, I who can
deal division between hosts. I would have set the Bound One free. If I could
avenge him!
The play is written in five acts and a prologue; but is not divided into
scenes. Its form is for the most part blank verse—;the iambic pentameter of
Michael Field which is so often neither iambic nor a pentameter. Her verse
is, indeed, a very variable line, changing its unit as frequently as will
consist with a regular form; and as flexible, sinewy, and nervous as will
consist with dignity, grace, and splendid colour. Prose passages occur in
Acts III and V; and a form of lyrical rhapsody is used to express the Druid
prophecies and Deirdre’s lament. The use of lyrics in her drama was not
new to Michael Field, who from the beginning could always relieve the
strain of intense emotion by a graceful song. But in this case she is
following, with her accustomed fidelity, lines laid down in older renderings
of the legend.
The most notable feature of this play is its ending. No author of the more
important modern versions of this theme has dared to take his conclusion
from the oldest one of all. Usually he has preferred the variant which tells
of Deirdre, broken-hearted at Naisi’s murder, falling dead into his grave.
This is, of course, in some respects a more ‘poetic’ passing: it lends itself to
romantic treatment, and its tragedy is more immediate and final. Moreover,
from the dramaturgic point of view the action is easier to handle and more
certain of its effect. Michael Field was not, however, attracted by mere
facility. Truth drew her with a stronger lure, and to her the more ancient
story would make a claim deeper than loyalty. For she would see Deirdre’s
survival not only as a more probable thing, but as something more
profoundly tragic; and the manner of her death, when it came, as more
clearly of a piece with the old saga and essentially of Deirdre’s wilful and
resolute character.
Deirdre is no Helen, though her legend has features so similar. The mere
outline of her which the old story gives indicates a creature who will
compel destiny rather than suffer it; and our poet has but completed,
imaginatively, what the original suggests—;a girl whose instinct of chastity
drives her away from marriage without love; whose ardour and courage
claim her proper mate; whose fidelity keeps her unalterably true; and whose
head is at least as sound as her heart is tender. For although she is a rather
tearful creature, she is also very astute; and Naisi need not have died quite
so young if he had only listened to her warning and condescended to take
her advice. Deirdre is, in short, of her race and of her time as surely as
Lucrezia Borgia is a daughter of Pope Alexander VI and a child of the
Italian Renaissance. Michael Field’s range in the creation of women
characters is very wide, and the verisimilitude with which she presents
natures so alien from herself as the courtesan and the voluptuary might be
astonishing if one thought of her simply as a Victorian lady, and not as a
great creative artist. Nevertheless, in the re-creation of Deirdre one feels
that she must have taken an especial joy, as witness the opening passage of
Act I, where Lebarcham and Medv the nurse are discussing their fosterling.
It is the morning of her sixteenth birthday, and King Conchobar is coming
to the little secluded house where Deirdre has been brought up to claim her
as his bride:

Medv. But look at her!

Lebarcham. Ay, Medv, it is not for our eyes to look.

The beauty!

Medv. She is dreaming.

Lebarcham. She sees true;

 Lebarcham. She sees true;
Therefore she is no poet. Gentle Medv,
My sister with the mother-eyes that rest
But when they rest on her, she is not ours,
Nor fate’s, nor any man’s; for she will choose,
Close prisoner as she is, her destiny,
Choose for herself the havoc she will make,
The tears that she will draw from other eyes,
The tears that will burn through her, the delights
That she will ravish from the world. She knows
So definitely all she wants: such souls
Attain. She is not dreaming; look at her!

Medv. She does not sigh as other maids kept close;

She is soft as a wood-pigeon, but no crooning—;
And when I speak of love—;King Conchobar
To be her lord—;she laughs.

Lebarcham. A wanton laugh!

Medv. No, no! Dear heart, she has no wantonness;

And yet I am afraid to hear her laughter,
It is so low and sure. My maid, my maid!
What shall I do that bitter day the King
Tears her away from me?

Lebarcham. Be comforted.
She loves you, she will bless you all her years:
But if she hate—;I would not be the creature
To cross her path, not if I were the chieftain
Of Ulla, or of Alba, or the world.

Medv. She has no malice. Would you slander her?

Lebarcham. I praise her! She can hate as only those

Of highest race, without remorse, for ever.

Again, in the same first act, when Deirdre has prevailed on Lebarcham
to bring Naisi to the hut, and the two have spoken of their love, it is she
who at once perceives where that confession must lead. Naisi would rather
kiss and part than rob the mighty Conchobar of his bride. But for Deirdre,
having kissed, there shall be no parting:

Deirdre. But we shall never part again, O Naisi,

Bear me away with you. I cannot speak,
Not much, not anything to listen to,
Yet I shall lie awake at night to ease
The pain it is to think of you by thinking
More constantly each moment. Bear me with you
To Alba, to the loveable, soft land.
[Naisi pauses stupefied: then turns away.
Naisi. But he has waited
For sixteen years; I am his chosen knight:
At dance, at feasting never has he turned
His eyes on woman, or if idly turned
An instant, he was back with Lebarcham
Asking of thee, thy years.
Where are you stepping?
Your feet are towards the waves.

Deirdre. For I shall travel

Either across this narrow sea with you,
Or else alone with the currents and the creatures
That travel fleet and silent underneath.

Naisi. O vehement, mad girl, it is for freedom

That you would draw this ruin on us all,
On the great King my Overlord, on Erin.
It is not well.
Women are ever captive
In their spirits and their bodies: so the gods
Have fashioned it and there is no escape.

Deirdre. You will not give me love?

Naisi. Your liberty

I shall not give you, if I give you love.
 Love is the hardest bondage in the world.
I would not put such chains on any woman
To love me....

Deirdre. Let me be with you, the name

Of being with you call it what you will—;
Bondage or freedom, I should still be happy,
Yea, for a year, yea, for a brood of years.

It is, however, in the last act that Michael Field again triumphantly
proves her mettle as poet and dramatist. She had stubborn material here,
harsh and crude stuff which kept the poets long at bay. For Deirdre’s end as
related by the old bard is a bit of primitive savagery matched in terms of the
plainest realism. Conchobar, after Naisi is enticed back to Ulster and
murdered, takes possession of Deirdre; and she remains in his house for a
year. But her constant reproaches and lamentation weary him; and at last, in
order to subdue her, he threatens to lend her for a year to the man she hates
most, Eogan, the slayer of Naisi. She is thereupon driven off in Eogan’s
chariot, apparently subdued, seated in shame between him and Conchobar.
At a gross taunt from Conchobar, however, she springs up, and flings
herself out upon the ground. “There was a large rock near: she hurled her
head at the stone so that she broke her skull, and killed herself.”
Our poet does not try to make this pretty or pleasing: and at one point at
least she uses the exact terminology of the translation from which she
worked. Its brutal elements are not disguised: Deirdre’s humiliation and the
animal rage of Conchobar and Eogan remain hideous even after the poet,
accepting all the material, has wrought it into a tragedy of consummate
beauty. Its beauty has, indeed, more terror than pity in it—;it is brimmed
with life’s actual bitterness—;but the depth and power of this Deirdre are
not equalled by any other.
In quoting the closing passage of the play one does not afflict the reader
by a comment on it; but there is a technical point which should be noticed.
It is the device of the Messenger by which the poet avoids the
representation of Deirdre’s death. The manner of that death was not only
too awkward to present, but its horror as a spectacle was too great for
artistic control. In causing it to be related by the charioteer Fergna, the poet
has, in classic fashion, removed it from actual vision, but has enabled the
mind to contemplate what the eyes could not have borne to look upon.
The chariot has driven off with Deirdre, Eogan, and Conchobar; and
Lebarcham watches it till it passes out of sight beyond the mound that
marks Naisi’s grave. Then she turns away, lamenting; and suddenly Fergna,
the charioteer, re-enters, scared and breathless:

Lebarcham. Speak, Fergna! Are they dead?

Fergna. I scarce may say.

The woman’s shoulders panted on the rocks,
And over her a struggle fiercely raged
Of Conchobar with Eogan.

Lebarcham. Fosterling,
My Deirdre! Had they cast her from the car,
That thus she lay on the sharp rocks of stone?

Fergna. None touched her. She had gazed on yonder mound,

Setting her eyes on it, while car and horses
Moved on, until the little crests at last
Rose over it; then she awoke and swept
One fierce glance over Eogan, set before,
And slid one glance as fierce toward Conchobar,
Behind her and more close! It was one hatred,
The hatred of each glance. A shudder ran
All through my body: and through all the air
Ran laughter.

Lebarcham. Hers?—;her laughter?

Fergna. No, the king’s.

And then his words, the words of jest that followed!
“Deirdre, the glance a ewe
Would cast between two rams you cast on us,
Eogan and me.”
She started, and the horses
Started beneath my hand. I tightened rein,
And the whole chariot shivered as she leapt
Upon the rocks before her. Then those two
Sprung to the place where she was dashed, their breath
Whistled like winds: their crossing swords, with gnash
Of hungry teeth, affrighted me. I fled,
Leaving behind the chariot stopped by trees,
Rock-rooted....
He returns—;
The king! He leads the horses of his car
Slowly along. They come, but yet as night
Comes by long twilight.

Lebarcham. Lonely Conchobar!

[Re-enter Conchobar solemnly leading
the chariot.
O king....

Conchobar. Your horses, Fergna! Take the reins;

Lead them....

Fergna. My lord, forgive me. I will lead them

Back to their stable.

Lebarcham. Deirdre? Where is Eogan?

And Deirdre—;where?

Conchobar [with a hoarse laugh]. Ho, they have passed the borders,
Passed from my realm.
Nay, Fergna,
Lead the great car, checking the horses’ heads
Beside yon barrow of a hero: there
Unyoke them. Dig a neighbour sepulchre.
And let the bases of each monument
Touch where they spring.

Fergna. My lord ... and shall I seek

Among the rocks?

Conchobar You shall but lift its burthen

 Conchobar. You shall but lift its burthen
Forth of the chariot to the hollowed grave.

Lebarcham. O Deirdre! She is hidden by that cloak.

O shattered loveliness of Erin, hidden
From the ages, evermore! Thy Lebarcham,
Who saw thee come from hiding to our light,
Will go with thee along
To thy last screening cover, to thy tomb.
[Exit, following the chariot led by Fergna.
Conchobar. The land!... I wended hither: car and horses
Are wending from me. Did I move like that,
So solitary, dark above the grass?—;But
to no goal. In one of those near graves
She will be with him, one of them will open;
There can but be one tomb. The chariot lingers
Its way in happy sloth: so wheat is carried
Till night-fall to the barn....
[He remains watching in the silence.
The car
Has turned the cromlech....
So wheat is carried.

* * *
In concluding this very brief survey of Michael Field’s life and poetry,
one turns back with a sense of illumination to her sonnet called The Poet,
which has been already quoted. For therein Michael Field has indicated the
nature of her own genius and the conditions of its activity. She was not
thinking of herself, of course, but of the poetic nature in the abstract, when
she declared in the first two lines of the sestet that the poet is

a work of some strange passion

Life has conceived apart from Time’s harsh drill.

Those verses apply in some degree to the whole race of poets, which is,
indeed, the test of their truth. Yet it is significant that in choosing precisely
that form of expression for the truth, Michael Field has inadvertently stated
the essential meaning of her own life, of her long service to literature, and
of the peculiar greatness and possible limitation of her poetry.
“A work of some strange passion.” Strange, indeed, and in many ways.
For, first, it is no common thing to find, in a world preoccupied with traffic
and ambition, two souls completely innocent of both. Not small souls, nor
stupid nor ignorant ones—;as clever people might aver in order to account
for the phenomenon—;but of full stature, intelligent, level-headed, and with
their sober measure of English common sense. They knew themselves, too
—;were aware that they possessed genius, that they had first-rate minds and
were artists of great accomplishment. Moreover, for the larger part of their
life they were on terms with ‘the world’; they welcomed experience as few
Victorian women dared, gathered knowledge eagerly wherever it was to be
found, and had business ability sufficient to direct prudently their own
affairs.
They would have denied that there was anything of the fanatic or the
visionary in the dedication of themselves to their art, believing fanaticism to
be incongruous with the undiluted English strain of which they boasted.
And, indeed, there is something typical of the race in this deliberate setting
of a course and dogged persistence in it. Yet there is hardly an English
precedent for their career; and it is to France one must look—;to the
Goncourts or to Erckmann-Chatrian—;to match the long collaboration, or
to find similar examples of their artistic method. And not even there, so far
as I know, will be found another such case of disinterested service.
But the lines we have noted have an application to the work as well as to
the life of Michael Field. They may be used almost literally, to summarize
in a convenient definition the nature of her poetry. For in this body of work
one sees passion as an almost over-powering element, and it is of surprising
strangeness. However fully one may recognize the truth that there is no sex
in genius, I suppose that we shall always be startled at the appearance of an
Emily Brontë or a Michael Field. They seem such slight instruments for the
primeval music that the earth-mother plays upon them. And their
vehemence mingles so oddly with tenderer and more delicate strains that it
will always be possible for a reviewer to sneer at what is “to the Greeks
foolishness”—;he having no perception of the fact that in gentleness added
to strength a larger humanity is expressed. Such an eye as Meredith’s could
perceive that, and, catching sight of some reviewing stupidity about it,
would flash lightnings of wrath in that direction, and send indignant
sympathy to the poets.
There is strangeness, too, of another kind in the passion which was the
impulse of this poetry. Under the restraint that art has put upon it, it is, as
we have seen, an elemental thing. It is a creative force akin to that of Emily
Brontë or of Byron, and is tamer than their wild genius only in appearance.
Its more ordered manner grew from two causes: that one of the
collaborators blessedly possessed a sense of form, and that both of them
lived withdrawn from the brawl of life. They were placed, perhaps, a little
too far from “Time’s harsh drill.” Their lives were, on the whole, easier and
happier ones than are given to most people. That is why the loss of their
Chow dog caused them a grief which seems exaggerated to minds not so
sensitively tuned as theirs. Until the agony of the last three years overtook
them, their share of the common lot of sorrow had been the barest
minimum: adversity did not so much as look their way: poverty laid no
finger on them, and was but vaguely apprehended, in the distance, as
something pitiful for its ugliness. Therefore, secure and leisured, they
envisaged life, in the main, through art, through philosophy, through
literature, and hardly ever through the raw stuff of life itself. And thence
comes the peculiar character which the passion of their poetry acquired, as
of some fierce creature caught and bound in golden chains.
It may be that this seclusion from life will be felt in Michael Field’s
poetry as a limitation; that the final conviction imposed upon the mind by
the authority of experience is wanting; and that the work lacks a certain dry
wisdom of which difficult living is a necessary condition. It may be so; but
I do not think the stricture a valid charge against their work, first because of
our poets’ great gift of imagination, and second because they chose so
rightly their artistic medium. Comedy may require the discipline of
experience, the observing eye constantly fixed upon the object, and a rich
knowledge of the world; but surely tragedy requires before everything else
creative imagination, sympathy, and a certain greatness of heart and mind.
Those gifts Michael Field possessed in very large degree; so large that one
often stands in amazement before the protagonists of her drama,
demanding, in the name of all things wonderful, how two Victorian women
“ever came to think of that.” A Renaissance pope, a Saxon peasant, or a
priest of Dionysos—;decadent emperors, austere Roman patriots, or a
Frankish king turned monk—;those are only a few of the surprising
creatures of her imagination, conceived not as historical figures merely, but
as living souls. And by the range of her women characters—;from the
dignity of a Julia Domna to the wild-rose sweetness of a Rosamund; from
the Scottish Mary, with her rich capacity for loving, to the fierce chastity of
an Irish Deirdre, or the soul of goodness in a courtesan; from the subtlety of
a Lucrezia Borgia to the proud singleness of a Mariamne; from the virago-
venom of an Elinor to the sensitive simplicity of a country-girl, or the
wrong-headedness of a little princess whose instincts have been perverted
by frustration—;Michael Field has greatly enriched the world’s knowledge
of womanhood.
She did not set out to do that, of course. Her sanity is evident once more
in the moderation with which she held her feminist sympathies, despite the
clamour of the time and the provocation she received from masculine
mishandling of her work. Herein too she had removed herself from “Time’s
harsh drill,” having too great a reverence for her art to use it for the
purposes of propaganda. That fact leads us again to her sonnet and the light
it throws upon herself. For in studying her work one sees that she fulfilled
completely her own conception of the poet—;as an artist withdrawn from
the common struggle to wrestle with a fiercer power, and subdue it to a
shape of recognizable beauty.
 BIBLIOGRAPHY

Of the works of Michael Field, published to 1919

The New Minnesinger. (Arran Leigh.) Longmans, Green and Co.

1875.
Bellerophôn. (Arran and Isla Leigh.) C. Kegan Paul. 1881.
Callirrhoë, and Fair Rosamund. J. Baker and Son. First edition
in spring of 1884; second edition in autumn of 1884.
The Father’s Tragedy, William Rufus, and Loyalty or Love. J.
Baker and Son. 1885.
Brutus Ultor. J. Baker and Son. 1886.
Canute the Great and The Cup of Water. J. Baker and Son. 1887.
Long Ago. G. Bell and Sons, Ltd. 1889.
The Tragic Mary. G. Bell and Sons, Ltd. 1890.
Stephania. Elkin Mathews and John Lane. 1892.
Sight and Song. Elkin Mathews and John Lane. 1892.
A Question of Memory. Elkin Mathews and John Lane. 1893.
Underneath the Bough. G. Bell and Sons, Ltd. First edition in
spring of 1893; second edition in autumn of 1893; third edition,
published by T. B. Mosher, Portland, Maine, 1898.
Attila, my Attila! Elkin Mathews. 1896.
Fair Rosamund. Reissued from the Vale Press. Decorated by
Charles Ricketts. 1897.
The World at Auction. The Vale Press. Decorated by Charles
Ricketts. 1898.
Anna Ruina. David Nutt. 1899.
Noontide Branches. The Daniel Press. 1899.
The Race of Leaves. The Vale Press. Decorated by Charles
Ricketts. 1901.
Julia Domna. The Vale Press. Decorated by Charles Ricketts.
1903
Borgia. (Anonymous.) A. H. Bullen. 1905.
Queen Mariamne. (Anonymous.) Sidgwick and Jackson, Ltd.
1908.
Wild Honey. T. Fisher Unwin, Ltd. 1908.
The Tragedy of Pardon, and Diane. (Anonymous.) Sidgwick and
Jackson, Ltd. 1911.
The Accuser, Tristan de Leonois, and A Messiah. (Anonymous.)
Sidgwick and Jackson, Ltd. 1911.
Poems of Adoration. Sands and Co. 1912.
Mystic Trees. Eveleigh Nash. 1913.
Whym Chow. Privately printed at the Eragny Press. 1914.
Dedicated. G. Bell and Sons, Ltd. 1914.
Deirdre, A Question of Memory, and Ras Byzance. The Poetry
Bookshop. 1918.
In the Name of Time. The Poetry Bookshop. 1919.
Note.—;The volumes containing Borgia, Queen Mariamne, The
Tragedy of Pardon, and The Accuser are now controlled by the
Poetry Bookshop.
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