ASPHYXIA

1130

the prisons zealously endeavour to reform the adultcriminal. But the future is with the prevention ofdelinquency rather than with the treatment of crime,the causes of which are often to be found at a veryearly stage in the life of the individual. The mentalhealth of all children, therefore, should become theintelligent care of each community; all characterdeviations and mental abnormalities should be earlydetected and early corrected to avoid the waste ofgood citizens and the tremendous expense of criminal,repair that is our present portion. In that prophy.’laxis lies the hope-indeed, the purpose-of themental hygiene and child guidance movements.

ASPHYXIA.THERE are three principal causes of acute asphyxia :

drowning, electric shock, and the inhalation of

poisonous gas or vapour. The increasing ease withwhich town populations can reach bathing-placesmakes the tale of drowning accidents longer everysummer; the second risk is increasing with the

growing industrial and domestic use of electricity,and the third has become much greater since motorvehicles came into popular use. It is, therefore,becoming more and more necessary for the ’prac-titioner to be certain in his mind of the methodshe will employ when confronted with asphyxia.Artificial respiration immediately occurs to the mindof doctor and first-aid worker alike, and the Schaferprone-pressure method 1 has proved so successfulof recent years that it has almost superseded allothers. The patient’s air-passages are cleared as

well as possible, and he is laid prone on the floor withone arm bent and the other extended, and the faceturned to the side. The operator kneels astride thethighs and places his hands on the lower ribs. He

compresses the thorax by leaning forward on his

straight arms, and releases the pressure by swingingback. Inspiration and expiration should last abouttwo seconds each. So much every first-aid workerknows, but while artificial respiration is undoubtedlythe corner-stone of treatment for asphyxia the doctoris properly expected to offer more skilled help thanthe layman, and there are other very importantfacts to be remembered. !

Drowning, to quote a recent and able summaryof the position by Dr. C. K. DRINKER,2 is, as far as isknown, a relatively simple form of asphyxia, andwhen the mouth and nose have been cleared ofobstruction the Schafer method is all that remainsto be done. Nerve cells die at different rates whendeprived of a regular supply of oxygenated blood.The small pyramidal cells of the cerebrum die, hesays, in eight minutes, while the spinal cord andsympathetic ganglia may last for an hour. Completeimmersion in a healthy person does not cut off theoxygen supply completely, and the chances of recoverydepend on the great viability of the medullarycentres. It is necessary, of course, to lose no timebefore starting rescue measures, but a healthyindividual has a good chance if artificial respirationis commenced, even after 15 minutes. Dr. DRINKERdoes not recommend drugs for drowning, or indeedfor any form of asphyxia. Alpha-lobelin he stigma-tises as inefficacious and dangerous. Caffeinesodiobenzoate may have some effect if given intra-venously, and can do no harm, but the doctor maysafely leave his hypodermic case at home. Whenelectric shock is the cause of the asphyxia, perseverance

1 Harvey Lectures, 1907-1908. J. B. Lippincott Company.2 Jour. Amer. Med. Assoc., 1928, xc., 1263.

t is the keynote of treatment. It cannot be too widelyf known that death from electricity is usually no more-, than apparent death. Artificial respiration should7be begun immediately and continued for several1 hours, for no form of asphyxia yields such a good

recovery-rate. Lay workers are instructed to con-. tinue their efforts for four hours ; recovery is common, after three hours and has even occurred after eight. Electricity may act primarily on the circulation, so1, that respiration continues for a few minutes after

the shock and then ceases ; in such patients the heartis probably in fibrillation and the prognosis is bad.Generally, however, the current paralyses the-respiratory centre while leaving the circulationnormal, and the patient may recover his breath afterhours of apncea. All the evidence warns us againstdeclaring patients dead unless heart sounds and

pulse are entirely absent after a long period of pronepressure respiration ; they turn cyanotic and regaincolour as treatment proceeds. To combat the riseof intrathecal pressure which sometimes occurs,Prof. S. JELLINEK recommends lumbar puncture.3Asphyxia caused by carbon monoxide poisoning

introduces an entirely different factor, as Prof.HAMILTON HARTRIDGE pointed out in a lecture

reported on p. 1137 of our present issue. Theasphyxia resulting from inhalation of coal-gas,motor-car fumes, or the effluent from badly ventilatedgas and anthracite stoves, is chiefly due to the affinityof the monoxide for haemoglobin, so that oxygenis excluded from the blood. This chemical effectcalls for oxygen inhalation to assist the starvedtissues. As the respiration is depressed in the latestages, 5 per cent. of carbon dioxide should be addedto stimulate the respiratory centre. Prof. HARTRIDGE,also suggested the exhibition of sodium cyanidefor this purpose. Artificial respiration should, if

possible, be performed with the oxygen-carbondioxide mask in place,o1 and it is important that theoxygen be administered as early as possible, for thedamage done by oxygen-want is, as we have said,

directly proportional to time, and it is possible thata patient may recover from the asphyxia and yet bepermanently crippled in cerebral function. It should,however, be remembered that high concentrationsof oxygen are dangerous to the lungs if given con-tinuously for long periods, and the oxygen should bereplaced by air and carbon dioxide as soon as thereal urgency has passed. All carbon monoxideshould have left the blood after an hour and a half.Another useful way of supplying oxygen to thetissues is by transfusion, but this must be done

early. Finally, a valuable hint, that does not always.occur either to doctor or layman, is that the nearestgas-works will probably provide trained help andsuitable inhalation apparatus more efficiently andpromptly than any hospital.

THE EVOLUTION OF A HERESY.THE heresy of one generation becomes the orthodoxy

of the next. Prof. ERNST KRETSCHMER, known inthis country by the translation of his work on

" Physique and Character," contributes an importantarticle to the Deutsche Medizinische Wochenschrift ofApril 13th on Further Developments of Psycho-therapeutic Technique, especially of Psycho-analysis.He begins by noting that whoever, as a bystander,might seek to form a judgment from the theoretical

3 Wien. Klin. Woch, 1928, May 3rd, p. 622.4 Booklet of American Gas Association, Lexington-avenue,New York.