THE APPLICATION OF THE PHYSIOLOGICAL FACTS ESTABLISHED IN THE PRECEDING CHAPTERS, TO THE GENERAL TREATMENT OF ASPHYXIA.
Although our researches into the causes and phenomena of asphyxia, or suspended animation, will afford, on many occasions, but very scanty encouragement with regard to the extent and value of the resources of art, yet we apprehend that to the intelligent practitioner they will not on that account be less acceptable; for to him it must be well known, that the detection of error is the first step in the discovery of truth, and although the tendency of the present investigation will be to reject, as useless, many of those plans of treatment which have long enjoyed the confidence of the public and the profession; yet it will suggest the application of some that have not hitherto been duly appreciated, and regulate that of others whose efficiency entirely depends upon the time and manner of their administration. But the fact is not to be concealed, that the medical profession, as well as the public, have long been too sanguine in their estimate of the probabilities of recovery by art, in cases where life is suddenly arrested by the operation of external causes; and upon this occasion, the establishment of the “Royal Humane Society for the recovery of persons apparently dead,” requires some notice, in relation to the possible extent of its successful exertions. Without some explanation it will be impossible to reconcile the reports of that philanthropic institution, with the physiological views which we have attempted to establish in the present work; it therefore becomes a part of our duty to explain the nature of the fallacies into which the witnesses and reporters of cases of suspended animation appear to us to have been unconsciously betrayed, and which have so frequently bestowed upon fable the colour of truth, and given to vague report, the apparent stability of credible testimony. In the first place we would observe, that in those cases in which a long interval is stated to have occurred between the suspension of breathing, from drowning, and the restoration of that function by art, it is probable that the anxiety of by-standers who witnessed the struggles, and the impossibility of justly appreciating the lapse of time in such moments of anxiety[[67]] and distress, have led to the erroneous statements with which the subject is embarrassed. There is, moreover, another fallacy into which the anxious observer is very likely to fall,—the sufferer may have breathed unobserved during the alleged interval of asphyxia; and if this fact be admitted, we at once reduce some of the most incredible of these reports to the rational standard of physiological probability. Nor shall we hesitate in the present chapter to offer our remarks upon the plan of recovery proposed by this society with as much freedom, and as little reserve, as we have ventured to question the literal accuracy of their reports. But while, thus fortified by physiological arguments, we profess to discredit many of the results stated by this society, let it not be supposed that we would prefer a charge of insincerity against their authors, or attempt to withhold any portion of that public patronage and consideration, to which their zeal and philanthropy so justly entitle them.
The agents which are employed in cases of suspended animation, are far too indiscriminately recommended; some of them, without doubt, offer valuable resources to the physician, and only require a judicious application to ensure their success; while others are entirely useless and frivolous, and ought to be dismissed from our service, since the retaining them only embarrasses the practitioner, and that too at a period which of all others requires the utmost decision in the selection of a plan of treatment, and the greatest promptness in its execution.
The following may be considered as the principal resources upon which the Humane Society rely for restoration of persons apparently dead from sudden accidents, viz.
1. Inflation of the lungs.
2. Application of heat.
3. Internal Exhibition of stimulants.
4. Friction.
5. Electricity.
6. Exposure of the surface of the body to cool air.
7. Blood-letting.
We shall offer a few observations upon the methods of applying these agents.
On the manner of producing artificial respiration.
We are indebted to Mr. Brodie for the valuable directions that are to guide the execution of this important operation. (Manuscript Notes.) A common pair of bellows will be found as manageable and efficient an apparatus for the inflation of the lungs, as any instrument that could be contrived; those manufactured for the service of the Humane Society are not of a size sufficient to inflate the lungs of even a large dog, much less those of man; nor is it necessary to employ double bellows on this occasion, for the air will escape from the lungs without being withdrawn by suction; besides which, it is stated that the forcible exhaustion of the lungs is liable to occasion pulmonic hemorrhage. It has been proposed to insert the tube of the bellows into the trachea, by means of a wound in that structure, but there are great objections to such a proceeding; the hemorrhage which is likely to occur,[[68]] may inundate the windpipe; besides which, the operation occasions delay, which, however trifling, will be important in cases where the action of the heart has become much enfeebled; and moreover the wound itself is an evil which ought to be avoided, if artificial respiration can be established without it; and were these objections even overruled, there still remains another; experience has shewn that the air thus introduced issues by the opening of the larynx, without having dilated the lungs.
A tube may be constructed for the purpose of being inserted through the mouth into the rima glottidis; if the patient be sensible, the introduction of such a tube might be difficult; but as the patient is in a state of insensibility, the introduction may usually be effected without much difficulty, but not altogether without trouble; for the mere circumstance of having to open the mouth, to pull forward the epiglottis, to direct the tube into the proper aperture, may occasion delay which will be of importance in cases where success depends upon the skill with which the time has been economised.
It is for such reasons more expedient to inflate the lungs by means of a tube inserted into one nostril, keeping the other and the mouth carefully closed: the bellows having been thus disposed, the air should be driven into the lungs with a certain degree of force; the lungs will thus become fully inflated, and in the intervals between the different inflations, the air from the lungs will escape by the mouth and by the other nostril, and when the lungs are thus emptied, the process may be repeated. There is but one objection to this method of exciting artificial respiration, viz. that at each inflation, a portion of air will sometimes find its way into the stomach, through the œsophagus: it is very desirable to prevent such an occurrence, for when the stomach is much distended with air, the descent of the diaphragm is prevented, and, consequently, a perfect inspiration cannot be accomplished. The passage of air into the stomach may be prevented by pressing on the thyroid cartilage, so as to close the communication between the pharynx and œsophagus. All that is necessary for the operator is, to produce the inspiration; we are recommended indeed to press the margin of the ribs gently upwards, so as to expel the air, and produce expiration; but this is altogether unnecessary, for the elasticity of the ribs, and the pressure of the abdominal muscles and viscera, and the elasticity of the lungs themselves, are quite sufficient to occasion the expiration without any assistance from external pressure. We must not omit to state that the inhalation of oxygen gas, instead of common air, has been strongly recommended, not only as being in itself a more powerful stimulus, but as being more efficient in the removal of the accumulation of that carbonized matter which, under ordinary circumstances of respiration, is regularly thrown off; the practical eligibility however, of such a plan is very questionable, and to say nothing of the difficulty of obtaining oxygen upon an occasion where the least delay is fatal, it is very doubtful whether the effects of this gas are really such as our theory would at once lead us to believe. We have deemed it necessary to enter into these details, in order to afford some practical instruction upon a subject of manipulation but little understood, but which is undoubtedly the most valuable of all the resources which art can furnish for the preservation of human beings that are in danger of perishing from accidental causes. The principal circumstances to be remembered are comprised in the following precepts.
1. The lungs are to be sufficiently, but not too much inflated.
2. The inspiration must be made of sufficient frequency.
3. The air is to be allowed a free exit from the lungs, so that the same air shall not be transmitted more than once.
4. The method of inflating the lungs must be simple, and easy of adoption; for as the interval of time, during which the artificial respiration can possibly be of any service, is very limited, it is important to avoid whatever may occasion the least delay.
Application of Heat.
There is perhaps no medium through which we can more successfully apply heat to the human body than that of the bath, because we can manage its application with precision; we know the exact degree of heat, and can avoid applying it in extremes; we, at the same time, can communicate it more rapidly, and more equally, than by any other means, and we are enabled to increase or diminish the temperature, by the addition of fresh portions of water, as circumstances may render it expedient.
Internal Exhibition of Stimulants.
The introduction of fluids into the stomach is not an easy process in many cases of suspended animation, as trismus is by no means an uncommon occurrence; where, however, the spasm of the jaw has subsided, the practitioner with a little address may by means of a flexible tube easily accomplish his object. Glysters will likewise furnish an easy mode of applying stimulants.
Electricity.
No sooner was the discovery made that galvanism is capable of exciting muscular contraction in animals apparently dead, than the physiological enthusiast seized it with avidity, and at once hailed it as the long desired influence that was to restore vigour to the enfeebled, and resuscitation to those that were in a state of suspended animation. It had been long known that muscles could be made to contract, by irritating the nerves belonging to them with the point of the scalpel, but not in a degree that remotely approached the vigorous contractions occasioned by the galvanic influence, whose stimulus seemed almost equivalent to that of volition. The sanguine expectations, however, which were thus very naturally excited, have ended in the most complete disappointment; and we are bound to confess that although galvanism is capable of exciting extraordinary contractions in the VOLUNTARY muscles, and of astonishing the multitude, yet its influence does not extend to those that are INVOLUNTARY. Bichat states distinctly that the involuntary muscles are beyond the reach of galvanism.[[69]] Mr. Brodie has frequently attempted to restore the heart’s action by the galvanic stimulus, in an animal dead from syncope, but never with success. The author of the present work may add, that he has attempted the same object by modifying the experiment in several different ways, but with no better success. But it may be said that, as galvanism will excite the contractions of the diaphragm, and other muscles of respiration, it may be made subservient to the purpose of producing artificial respiration: granted,—but it never can be made to act with the certainty, regularity, promptness, or convenience, which attend the operation of a common pair of bellows, nor even if it could, would any advantage be obtained which might not be equally insured by the use of this latter simple instrument. It is, moreover, questionable whether so powerful a stimulus may not produce a subsequent exhaustion of the muscular energy; such effect indeed would appear to have happened in the case related by Dr. Babington, where the asphyxia had been occasioned by the fumes of burning charcoal; “having passed,” says he, “a galvanic shock through the chest, the patient instantly, to our surprise, drew his breath deep; the muscles of the abdomen were seen to react, though feebly, while those of the face were slightly convulsed, and the eyelids were raised; at each successive application of this powerful agent, the respirations were more forcibly performed, and the stroke of the artery at the wrist rose in the same proportion. Having procured a bladder filled with oxygen gas, we caused it to be inspired, and we thought that it was followed by an increased activity of the powers of respiration and circulation; as the heat of the body was not deficient, we now sprinkled the face and chest with cold water, which also had the effect of rousing the dormant powers of sensation, as the respiratory muscles were uniformly thrown by it into action, though in a more feeble and interrupted manner than when we employed the galvanic influence. Having received a large supply of oxygen gas, we repeated the inhalation and the galvanic succussions alternately, through the chest and head, every half-hour, for three hours, when the galvanic influence was discontinued, as the heart, though uniformly excited by it, seemed in the intervals to act more feebly, and we were apprehensive that by exalting the action of one power continually, we might destroy that equilibrium of forces which is necessary to the maintenance of life.”[[70]]