- Email: [email protected]
ARTIFICIAL RESPIRATION
178
.
-
would also
particularly in arecommending appropriate placement. It is however churlish to remark unduly on the present centre
be invaluable,
deficiencies of a scheme which presents a notable advance in the coordination of industrial and medical services. The employment and health of the men investigated do not lend any colour to the belief that neurosis in soldiers is a medical euphemism for dodging military service, and that therefore the symptoms will disappear when the dodge has worked. These men are worse off in health and status than they It would be easy, but were before enlistment. to conclude that the change is due simply mistaken, to their military service. Their pre-enlistment record was to a large extent their prewar record : and, although the market for labour is now wide open, it is not always skilled labour that is most in demand, nor are the general conditions under which the civilian has to live so easy that one -can properly assume them to be negligible in assessing the causes of an ex-soldier’s present disabilities. The war has brought with it many stresses unknown in peacetime : some of the neurotically predisposed men are now less fit than before 1939, as much because of these extra burdens as because of the hardships of military service and the disruption of the routine of their lives-especially of their jobs and homeswhich entry- into service entailed. Some benefit men indeed by living under psychopathic are to and go to pieces when Army discipline apt thrown on their own resources as civilians ; but they are few compared with the number of those concerning whom summary arbiters mistakenly declare that " the Army will make a man of him." The interests of the individual can in some contexts be set against the interests of the community, but certainly not here. Health and working capacity will go together-will indeed be dependent on each other, reciprocal agents. If neurotic illness makes a man undertake unsuitable work, or makes his work unsuitable for him, his neurosis will thereby be fostered or aggravated ; but neurosis is due to, and can be remedied by, other influences than the purely occupational, just as the choice or allocation of a man’sjob is determined in these days by much else besides the ideal requirements for his talent and the nice balance of idiosyncrasy. It is in these factors that the skill of the doctor and the experience and judgment of social agencies can most happily be shown, conjoined in a good example of social medicine.
military
settling
ARTIFICIAL RESPIRATION SINCE the beginning of the war men and women who deem themselves competent to stay haemorrhage and revive the apparently drowned have multiplied exceedingly ; general practitioners whose connexion with formal teaching ended when they ceased to be students now find themselves in the local chair of traumatic surgery and emergency medicine, and their students, whether drawn from the ranks of the British Red Cross, the St. John Ambulance or the local Civil Defence bodies share a strong taste for dogma. In the field of artificial respiration the method of Schafer has steadily gained ground, -since it can be done single-handed and with no apparatus
or improvisation. Once the first-aider has learned the method all he requires, in order to practise it, is a suitably asphyxiated individual. GIBBENSi produces an old bone of contention in the shape of figures from various authorities purporting to show the superiority of either the Schafer or the Sylvester method. He concludes that the results, ’which are certainly discordant, depend on the of the observer, and points out the importance of having a method for use at sea which is above suspicion. Many men who ought to survive die after only a
nationality
’
short immersion. It has long been known2 that hyperventilation, which by removing carbon dioxide causes apnoea in the normal subject, also renders the chest resistant to ventilation by Schafer’s and possibly other methods. A similar involuntary rigidity might conceivably arise from other causes. In conjunction with variations in the build of the subject and the technique of the operator, this might account for widely difterent results on different occasions. While GiBBENs states that such a loss of elasticity is in fact apparent in drowned men, LOUGHEED, JANES and HALL 3 actually found in drowning dogs that, after a preliminary rise, the blood-C02 surprisingly fell. Occasional breathing, as might result from the struggles of a victim bringing him intermittently to the surface, enhanced the C02-deficiency whose cause was not definitely established. The condition was well known to YANDELL HENDERSON, who called it acarbia and regarded it as a potent factor in the onset of circulatory failure.4 The value of 5-7 % C02 in making artificial respiration easier, in preserving a normal CO2 level in the body, and in stimulating the respiratory centre is now recognised, and it should be supplied in oxygen as soon as
possible.
But this does not solve the problem of how to begin. Drowning (or any other form of asphyxia) is as acuie an emergency as oar spurting artery : a- 6-minute delay produces an 80% increase in the death-rate. GIBBENS has Schafer artificial respiration started the minute the patient is out of the water and transfers him to Eve’s as soon as occasion permits. It is now some ten since EvE first described his years gravity method of actuating the inert diaphragm. He used the weight of the abdominal viscera to move the diaphragm by rocking the casualty on a stretcher through a total angle of 60° at the rate of 12 double rocks a minute, but 90° rock at first assists lung drainage. Schafer’s method, carried out by brawny mariners, in the grip of altruism, entails for the patient a risk of fractured ribs and ruptured liver. Eve’s method, GzBBErls believes, produces greater lung ventilation for less effort ; it can be applied even when the chest has been severely damaged. All the materials required are : a plane to which the patient can be fastened ; a fulcrum high enough to allow a 50° angle with the horizontal; a stop to prevent the plane skidding on the fulcrum. Such things are more readily availabla on- board ship than on bomb sites though they can readily be contrived with a stretcher and a suitable mass of debris. GrBBENS has done well to revive interest in Eve’s method ; and for once the 1. Gibbens, G. H. Brit. med. J. 1942, ii, 751. 2. Henderson, Y. J. Amer. med. Ass. 1914, 62, 1133. 3. Lougheed, D. W., Janes, J. M. and Hall, G. E. Canad. med. Ass. J. 1939, 40, 423. 4. Henderson, Y. J. Amer. med. Ass. 1934, 103, 750. 5. Eve, F. C. Lancet, 1932, ii, 995.
179
medical officer may slake the first-aider’s thirst for dogma.. Schafer’s is the method in an emergency, say for a patient asphyxiated by coal gas from a ruptured main ; it is literally first-aid, and may be continued in the ambulance if necessary. On arrival ,at hospital and on shipboard the method of Eve has a valuable place in treatment, which GIBBENS is not alone in insisting should continue after drowning until rigor mortis has set in, a difficult feat with the older methods.
Annotations PERIPHERAL NERVE TESTING SOME bad habits have wormed their way into the of peripheral nerves. general surgeon’s examination Selected muscle-movement " trick " tests have come to be extensively used for deciding on nerve integrity : thus if the extended fingers can firmly grasp a thin envelope the ulnar nerve is declared sound ; if the wrist or ankle can be actively extended that rules out radial or anterior tibial nerve damage ; and the characteristic 4C policeman’s tip " ppsition clinches the diagnosis of an Erb’s or upper trunk brachial plexus lesion. Attempts are rarely made to examine muscle after muscle in the order of their supply from the branches of the suspected damaged nerve. Where a more detailed muscle report is considered necessary, the patient is usually referred to the massage department for electrical muscle reactions, and the surgeon often does not realise how difficult it is to record these reliably. A valuable memo/ prepared for the Medical Research Council’s nerve injuries committee by the department of surgery, Edinburgh University, urges that as far as possible each muscle-should have its action separately tested, and not only must the weak and the paralysed muscles be charted but also those with full power. The memo suggests a simple system for recording the state of each muscle : 0 = no contraction ; 1 flicker 2 = active movement, with or trace of contraction ; gravity eliminated ; 3 = active movement against gravity ; 4 = active movement against gravity and resistance ; and 5 = normal power. It lays stress on the importance of both looking for and feeling the contraction of any accessible muscle that is being testeda thing that few examiners of peripheral nerves doand nearly sixty photographs demonstrate the most generally useful methods of testing individual muscles. A businesslike way of examining muscle function and recording the findings 1’s particularly valuable in gunshot ’injuries, which are commonly multiple, so that the exact site of the nerve lesion is difficult to determine. Nor is the examiner at a special peripheral nerve centre to be regarded as a sort of nerve-damage diviner. The assessment of the case and the decision where to explore will be based on the records of the previous examinations. Often the patient is transferred to the special centre only after many months ; adequate records may then tell that the muscle now working was formerly paralysed, and this will be an important bit of evidence in deciding on the need for exploration: The memo points out that a cold limb does not move freely, and that " numb with cold " is no layman’s exaggeration. Sensation is often poorly tested. It cannot be hurried, nor can pin prodding be continued for long without wearying the patient (not to mention the examiner) ; 20 minutes is about the maximum session that most can endure. The patient must be warm and if he be of the sons of Esau the hairs must be shaved ; the cotton-wool wisp should be used for light touch, and a fine needle to test pinprick. Sensation should be tested from the anaesthetic to the sensitive =
1. Aids to the Investigation of Peripheral Nerve Injuries. MRC War Mem No. 7. 1942. Pp. 48. HM Stationery Office. 2s.
and the stimuli should not follow each other too An accurate guide to the extent of anaesthesia. can often be obtained by giving the patient a pin and asking him to mark it outon himself. The loss of sensation to be expected in the different major nerve lesions is illustrated in the memo by twenty charts. area
closely.
INTERPRETATION OF THE SCHICK TEST Schick1 himself regarded the presence in the circulating blood of at least 1/30 unit of antitoxin (AT) per c.cm. as necessary to afford protection against an attack of clinical diphtheria, and adjusted the amount of toxin (1/50 mld) in his test accordingly. But Parish and Wrightshowed that a negative reaction-that is, Schick-immunity-was consistent with as little as 0-002 unit AT per c.cm.; and, as Phairhas pointed out, it is now established that the theoretical threshold between positive and negative Schick reactions is about 0-01 unit AT per c.cm. or less. Negative reactors contract clinical diphtheria only very occasionally and Phair shows that this may happen to individuals possessing more than 0-01 unit AT per c.cm. Such occasional discrepancies may be found in any large series of observations and give rise to doubts about the value of the test. Phair has therefore investigated the sources, extent and commonness of error. He reminds us that, whereas the blood sample is usually taken when the test is done, the reading of the test is not made until several days later. Many years ago Glenny and Siidmersen4 showed that the amount of AT produced by a primary stimulus is small compared with that resulting from a secondary stimulus ;. and it is well recognised that the antitoxin produced by a primary stimulus tends in time to be lost wholly or in part, but (as O’Brien 5 demonstrated in 1926) may be restored by tlie tiny secondary antigenic stimulus provided by a Schick test. Thus, a negative test, says Phair, may reflect not only the presence of appreciable amounts of circulating AT but also in some degree the ability to mobilise this antibody ; the test thus measures a dynamic rather than a static situation. Phair h4,s,cla,rified this point by the analysis of three series of observations. comprised 165 adults and children chosen and tested by Van Volkenburgh and Frobisher without reference to previous antigenic experience ; the control dilutions consisted of heated toxin only and blood specimens were obtained at the time of the tests. Accepting 0-01 unit AT as the threshold and correlating titrations with tests, the tests were found to be correct in 152 out of 165 (92.1%). Series B (1939) comprised 3 groups: 45 white adult male students ; 106 coloured children (aged 6 months to 20 years) in an orphanage ; and 65 white children in another orphanage-a total of 216 adults and children. All received 4 intranasal instillations of concentrated formol-toxoid (FT) and a month later Schick tests were done and controlled with both heated toxin and diluted toxoid, blood samples being taken at the same time as the tests. The FT provided a recent specific antigenic stimulus and augmented the AT titre before the tests and titrations were done. Adopting the same AT threshold, the test proved correct in 207 out of 216 (95-8%). Consideration of the results in series A and B showed that the test can differentiate with fair accuracy those without demonstrable AT at the time of the test, since 85-2% and 89-2% of those with less than 0-0025 (1/400) unit and 74-3% and 84-6% of those with less than 0-01 unit gave a positive or pseudo-positive reaction. The more complete correlation between test and titre in series B suggested the possible importance of antigenic history or immunity status and therefore series C (1940)
particular Series A(1934)
1. Schick, B. Münch. med. Wschr. 1908, 55, 504 ; Ibid, 1913, 60, 2608. 2. Parish, H. J. and Wright, J. Lancet, 1938, i, 882. 3. Phair, J. J. Amer. J. Hyg. 1942, 36, 283. 4. Glenny, A. T. and Südmersen, H. J. J. Hyg., Camb. 1921, 20, 176. 5. O’Brien, R. A. J. Path. Bact. 1926, 29, 320.
.
-
would also
particularly in arecommending appropriate placement. It is however churlish to remark unduly on the present centre
be invaluable,
deficiencies of a scheme which presents a notable advance in the coordination of industrial and medical services. The employment and health of the men investigated do not lend any colour to the belief that neurosis in soldiers is a medical euphemism for dodging military service, and that therefore the symptoms will disappear when the dodge has worked. These men are worse off in health and status than they It would be easy, but were before enlistment. to conclude that the change is due simply mistaken, to their military service. Their pre-enlistment record was to a large extent their prewar record : and, although the market for labour is now wide open, it is not always skilled labour that is most in demand, nor are the general conditions under which the civilian has to live so easy that one -can properly assume them to be negligible in assessing the causes of an ex-soldier’s present disabilities. The war has brought with it many stresses unknown in peacetime : some of the neurotically predisposed men are now less fit than before 1939, as much because of these extra burdens as because of the hardships of military service and the disruption of the routine of their lives-especially of their jobs and homeswhich entry- into service entailed. Some benefit men indeed by living under psychopathic are to and go to pieces when Army discipline apt thrown on their own resources as civilians ; but they are few compared with the number of those concerning whom summary arbiters mistakenly declare that " the Army will make a man of him." The interests of the individual can in some contexts be set against the interests of the community, but certainly not here. Health and working capacity will go together-will indeed be dependent on each other, reciprocal agents. If neurotic illness makes a man undertake unsuitable work, or makes his work unsuitable for him, his neurosis will thereby be fostered or aggravated ; but neurosis is due to, and can be remedied by, other influences than the purely occupational, just as the choice or allocation of a man’sjob is determined in these days by much else besides the ideal requirements for his talent and the nice balance of idiosyncrasy. It is in these factors that the skill of the doctor and the experience and judgment of social agencies can most happily be shown, conjoined in a good example of social medicine.
military
settling
ARTIFICIAL RESPIRATION SINCE the beginning of the war men and women who deem themselves competent to stay haemorrhage and revive the apparently drowned have multiplied exceedingly ; general practitioners whose connexion with formal teaching ended when they ceased to be students now find themselves in the local chair of traumatic surgery and emergency medicine, and their students, whether drawn from the ranks of the British Red Cross, the St. John Ambulance or the local Civil Defence bodies share a strong taste for dogma. In the field of artificial respiration the method of Schafer has steadily gained ground, -since it can be done single-handed and with no apparatus
or improvisation. Once the first-aider has learned the method all he requires, in order to practise it, is a suitably asphyxiated individual. GIBBENSi produces an old bone of contention in the shape of figures from various authorities purporting to show the superiority of either the Schafer or the Sylvester method. He concludes that the results, ’which are certainly discordant, depend on the of the observer, and points out the importance of having a method for use at sea which is above suspicion. Many men who ought to survive die after only a
nationality
’
short immersion. It has long been known2 that hyperventilation, which by removing carbon dioxide causes apnoea in the normal subject, also renders the chest resistant to ventilation by Schafer’s and possibly other methods. A similar involuntary rigidity might conceivably arise from other causes. In conjunction with variations in the build of the subject and the technique of the operator, this might account for widely difterent results on different occasions. While GiBBENs states that such a loss of elasticity is in fact apparent in drowned men, LOUGHEED, JANES and HALL 3 actually found in drowning dogs that, after a preliminary rise, the blood-C02 surprisingly fell. Occasional breathing, as might result from the struggles of a victim bringing him intermittently to the surface, enhanced the C02-deficiency whose cause was not definitely established. The condition was well known to YANDELL HENDERSON, who called it acarbia and regarded it as a potent factor in the onset of circulatory failure.4 The value of 5-7 % C02 in making artificial respiration easier, in preserving a normal CO2 level in the body, and in stimulating the respiratory centre is now recognised, and it should be supplied in oxygen as soon as
possible.
But this does not solve the problem of how to begin. Drowning (or any other form of asphyxia) is as acuie an emergency as oar spurting artery : a- 6-minute delay produces an 80% increase in the death-rate. GIBBENS has Schafer artificial respiration started the minute the patient is out of the water and transfers him to Eve’s as soon as occasion permits. It is now some ten since EvE first described his years gravity method of actuating the inert diaphragm. He used the weight of the abdominal viscera to move the diaphragm by rocking the casualty on a stretcher through a total angle of 60° at the rate of 12 double rocks a minute, but 90° rock at first assists lung drainage. Schafer’s method, carried out by brawny mariners, in the grip of altruism, entails for the patient a risk of fractured ribs and ruptured liver. Eve’s method, GzBBErls believes, produces greater lung ventilation for less effort ; it can be applied even when the chest has been severely damaged. All the materials required are : a plane to which the patient can be fastened ; a fulcrum high enough to allow a 50° angle with the horizontal; a stop to prevent the plane skidding on the fulcrum. Such things are more readily availabla on- board ship than on bomb sites though they can readily be contrived with a stretcher and a suitable mass of debris. GrBBENS has done well to revive interest in Eve’s method ; and for once the 1. Gibbens, G. H. Brit. med. J. 1942, ii, 751. 2. Henderson, Y. J. Amer. med. Ass. 1914, 62, 1133. 3. Lougheed, D. W., Janes, J. M. and Hall, G. E. Canad. med. Ass. J. 1939, 40, 423. 4. Henderson, Y. J. Amer. med. Ass. 1934, 103, 750. 5. Eve, F. C. Lancet, 1932, ii, 995.
179
medical officer may slake the first-aider’s thirst for dogma.. Schafer’s is the method in an emergency, say for a patient asphyxiated by coal gas from a ruptured main ; it is literally first-aid, and may be continued in the ambulance if necessary. On arrival ,at hospital and on shipboard the method of Eve has a valuable place in treatment, which GIBBENS is not alone in insisting should continue after drowning until rigor mortis has set in, a difficult feat with the older methods.
Annotations PERIPHERAL NERVE TESTING SOME bad habits have wormed their way into the of peripheral nerves. general surgeon’s examination Selected muscle-movement " trick " tests have come to be extensively used for deciding on nerve integrity : thus if the extended fingers can firmly grasp a thin envelope the ulnar nerve is declared sound ; if the wrist or ankle can be actively extended that rules out radial or anterior tibial nerve damage ; and the characteristic 4C policeman’s tip " ppsition clinches the diagnosis of an Erb’s or upper trunk brachial plexus lesion. Attempts are rarely made to examine muscle after muscle in the order of their supply from the branches of the suspected damaged nerve. Where a more detailed muscle report is considered necessary, the patient is usually referred to the massage department for electrical muscle reactions, and the surgeon often does not realise how difficult it is to record these reliably. A valuable memo/ prepared for the Medical Research Council’s nerve injuries committee by the department of surgery, Edinburgh University, urges that as far as possible each muscle-should have its action separately tested, and not only must the weak and the paralysed muscles be charted but also those with full power. The memo suggests a simple system for recording the state of each muscle : 0 = no contraction ; 1 flicker 2 = active movement, with or trace of contraction ; gravity eliminated ; 3 = active movement against gravity ; 4 = active movement against gravity and resistance ; and 5 = normal power. It lays stress on the importance of both looking for and feeling the contraction of any accessible muscle that is being testeda thing that few examiners of peripheral nerves doand nearly sixty photographs demonstrate the most generally useful methods of testing individual muscles. A businesslike way of examining muscle function and recording the findings 1’s particularly valuable in gunshot ’injuries, which are commonly multiple, so that the exact site of the nerve lesion is difficult to determine. Nor is the examiner at a special peripheral nerve centre to be regarded as a sort of nerve-damage diviner. The assessment of the case and the decision where to explore will be based on the records of the previous examinations. Often the patient is transferred to the special centre only after many months ; adequate records may then tell that the muscle now working was formerly paralysed, and this will be an important bit of evidence in deciding on the need for exploration: The memo points out that a cold limb does not move freely, and that " numb with cold " is no layman’s exaggeration. Sensation is often poorly tested. It cannot be hurried, nor can pin prodding be continued for long without wearying the patient (not to mention the examiner) ; 20 minutes is about the maximum session that most can endure. The patient must be warm and if he be of the sons of Esau the hairs must be shaved ; the cotton-wool wisp should be used for light touch, and a fine needle to test pinprick. Sensation should be tested from the anaesthetic to the sensitive =
1. Aids to the Investigation of Peripheral Nerve Injuries. MRC War Mem No. 7. 1942. Pp. 48. HM Stationery Office. 2s.
and the stimuli should not follow each other too An accurate guide to the extent of anaesthesia. can often be obtained by giving the patient a pin and asking him to mark it outon himself. The loss of sensation to be expected in the different major nerve lesions is illustrated in the memo by twenty charts. area
closely.
INTERPRETATION OF THE SCHICK TEST Schick1 himself regarded the presence in the circulating blood of at least 1/30 unit of antitoxin (AT) per c.cm. as necessary to afford protection against an attack of clinical diphtheria, and adjusted the amount of toxin (1/50 mld) in his test accordingly. But Parish and Wrightshowed that a negative reaction-that is, Schick-immunity-was consistent with as little as 0-002 unit AT per c.cm.; and, as Phairhas pointed out, it is now established that the theoretical threshold between positive and negative Schick reactions is about 0-01 unit AT per c.cm. or less. Negative reactors contract clinical diphtheria only very occasionally and Phair shows that this may happen to individuals possessing more than 0-01 unit AT per c.cm. Such occasional discrepancies may be found in any large series of observations and give rise to doubts about the value of the test. Phair has therefore investigated the sources, extent and commonness of error. He reminds us that, whereas the blood sample is usually taken when the test is done, the reading of the test is not made until several days later. Many years ago Glenny and Siidmersen4 showed that the amount of AT produced by a primary stimulus is small compared with that resulting from a secondary stimulus ;. and it is well recognised that the antitoxin produced by a primary stimulus tends in time to be lost wholly or in part, but (as O’Brien 5 demonstrated in 1926) may be restored by tlie tiny secondary antigenic stimulus provided by a Schick test. Thus, a negative test, says Phair, may reflect not only the presence of appreciable amounts of circulating AT but also in some degree the ability to mobilise this antibody ; the test thus measures a dynamic rather than a static situation. Phair h4,s,cla,rified this point by the analysis of three series of observations. comprised 165 adults and children chosen and tested by Van Volkenburgh and Frobisher without reference to previous antigenic experience ; the control dilutions consisted of heated toxin only and blood specimens were obtained at the time of the tests. Accepting 0-01 unit AT as the threshold and correlating titrations with tests, the tests were found to be correct in 152 out of 165 (92.1%). Series B (1939) comprised 3 groups: 45 white adult male students ; 106 coloured children (aged 6 months to 20 years) in an orphanage ; and 65 white children in another orphanage-a total of 216 adults and children. All received 4 intranasal instillations of concentrated formol-toxoid (FT) and a month later Schick tests were done and controlled with both heated toxin and diluted toxoid, blood samples being taken at the same time as the tests. The FT provided a recent specific antigenic stimulus and augmented the AT titre before the tests and titrations were done. Adopting the same AT threshold, the test proved correct in 207 out of 216 (95-8%). Consideration of the results in series A and B showed that the test can differentiate with fair accuracy those without demonstrable AT at the time of the test, since 85-2% and 89-2% of those with less than 0-0025 (1/400) unit and 74-3% and 84-6% of those with less than 0-01 unit gave a positive or pseudo-positive reaction. The more complete correlation between test and titre in series B suggested the possible importance of antigenic history or immunity status and therefore series C (1940)
particular Series A(1934)
1. Schick, B. Münch. med. Wschr. 1908, 55, 504 ; Ibid, 1913, 60, 2608. 2. Parish, H. J. and Wright, J. Lancet, 1938, i, 882. 3. Phair, J. J. Amer. J. Hyg. 1942, 36, 283. 4. Glenny, A. T. and Südmersen, H. J. J. Hyg., Camb. 1921, 20, 176. 5. O’Brien, R. A. J. Path. Bact. 1926, 29, 320.