major accidents

1278

sues that brings the antigens of the spermatozoa into con-tact with antibody-forming cells; and yet spermaggluti-nation seems to precede tissue penetration. But Rumkedraws attention to another highly significant fact-name-ly, that mumps virus has exceptional power of spermag-glutination : a property shown also, though to a lesserextent, by other members of the myxovirus group.

1. Rice, R, L. Amer. J. Med. 1950, 8, 691.2. Engel, G. L., Ferris, F. B., Logan, M. Ann. intern. Med. 1947,

27, 683.3. White, P. D., Hahn, R, G. Amer. J. med. Sci. 1929, 177, 179.4. Gliebe, P. A., Averback, A. J. nerv. ment. Dis. 1944, 99, 600.5. Aronson, P. R. Ann. intern, Med. 1959, 50, 554.6. Rapoport, S., Guest, G. M. J. clin, Invest. 1945, 24, 759.7. Winters, R, W., White, J. S., Hughes, C., Ordway, N. K. Pediatrics,

1959, 23, 260.

THE HYPERVENTILATION SYNDROME

VOLUNTARY forced overbreathing is one of the mostfamiliar exercises in the physiology classroom, and thesame chemical and haemodynamic consequences follow

hyperventilatory states in clinical practice. According toRice, the hyperventilation syndrome occurs in one out ofevery ten patients attending the office of specialists ininternal medicine, and it is by no means rare in this

country. The symptoms and signs are due to the exces-sive removal of carbon dioxide leading to hypocapniaand respiratory alkalosis. The symptoms vary, but, apartfrom the obvious overbreathing, they usually include

dizziness, faintness, or nausea, and numbness and tingl-ing around the lips and in the extremities; there are oftensensations of discomfort or constriction in the chest. Theskin may become cold and clammy, and cyanosis mayappear. After an initial rise the pulse-rate and blood-pressure fall, causing an almost shock-like appearance.These effects are explained by the changes in the mecha-nics of respiration, blood chemistry, and cardiovasculardynamics which accompany the hyperventilation .Attacks of overbreathing are commonest in anxious

persons with unstable cardiorespiratory neurogenic con-trol,3 and are usually precipitated by sudden emotionalstress. No doubt fear of disease or death plays a largepart in their exaggerated respiratory responses. It is

therefore important that their symptoms should not bemisinterpreted and organic disease wrongly diagnosed.’It is equally essential that the hyperventilation syndromeshould not too readily be dismissed as " panic

" or

11

anxiety " attacks; for in those liable to such attacks, andeven in those who have never previously experiencedthem, the attacks may be precipitated by organic lesions.

There is considerable danger that the symptoms and signsof the underlying organic disease may be submergedbeneath the flamboyant marks of the hyperventilatorystate or be confused with it. Aronson 5 describes eightpatients in whom conditions such as coronary thrombosis,hiatus hernia, spontaneous pneumothorax, and acute

cholecystitis precipitated hyperventilation. The ensuingcomplex clinical picture required very careful history-taking and examination for its elucidation.

Recognition of the hyperventilation syndrome mayavert the diagnosis of an organic lesion where none

exists, but hyperventilation must always prompt a searchfor the underlying cause. In most cases it will be psycho-genic, but fear and panic may be induced by sudden andfrightening symptoms of organic disease as well as byemotional upset. If the attack is inexplicable in these

ways, a precipitating organic lesion must be sought. Thisis most likely to be either intrathoracic or just below thediaphragm. Lastly, it must be remembered that the

respiratory centre can be directly stimulated by metabolicacidosis, as in diabetic ketosis, or by the action of

salicylates.6 7

MAJOR ACCIDENTS

1. Lancet, 1954, i, 1226,

NOT very seldom, an accident causes casualties too

numerous to be treated properly by any one hospital inthe locality. In a disaster of this kind the action takenis unlikely to be swift and effective unless it is thoughtout in advance. In the past few years much careful

planning has been undertaken so as to devise arrange-ments which will work at any hour of day and night. Theplan has to link the various services on which call mustbe made-the police, the hospitals, the ambulance andfirst-aid services, and the fire services, which deal notonly with fires but also with the highly skilled businessof moving heavy debris. Other factors that have to be

taken into account are communications (the telephoneservices have sometimes been swamped) and the helpthat may be given by local doctors and by unskilled butwilling members of the public.Experience during and since the war has shown that,

however carefully plans are made, there are alwayslessons to be learnt from their actual operation. Arrange-ments for the future have been helped, for example,by the experience gained in the Harrow railway disasterin 1952 and especially perhaps in the Lewisham crash inDecember, 1957, when conditions were unusual enoughto provide a severe test.

After the Lewisham accident, Dr. James Fairley,senior administrative medical officer of the South East

Metropolitan Regional Hospital Board, convened a

series of meetings; and the result is a revised plan settingout what should be done, how it should be done, and whoshould do it. This plan accepts the view 1 that the doctorin charge of a mobile team has enough to do without alsoundertaking the general medical supervision of servicesat the disaster. Accordingly the arrangement now is that" a senior medical officer from the staff of the alerted

hospital nearest to the disaster shall proceed with expe-dition to the scene-(a) to establish a medical services

report centre, (b) to coordinate the medical and first-aidresources, and (c) to formulate the casulty evacuation

plan in collaboration with the senior ambulance officerpresent."

"

Although the plan at first glance looks complex, theprinciples upon which it is based are clear. Any emer-gency or 999 call will be directed to the police, fire

brigade, and ambulance services, and the first to be

called on will alert the designated hospital nearest theaccident. The hospital will send a senior doctor to carryout the tasks listed above; and on request, or after

assessing the extent of the disaster from messages recei-ved, another senior doctor at the hospital will send amobile medical team. On arrival at the site, the policeand fire services will set up a control unit, and the seniormedical officer will set up his ’ medical services reportcentre" close to this. Ambulances already on their waywill remove the first casualties; and, after devising a

casualty evacuation plan with his colleagues, the seniormedical officer will call up more mobile teams, ambu-lances, and other equipment, as circumstances mayrequire. " All plans, both at the site for evacuation, andfor the hospitals receiving, must be flexible ", and boththe senior medical officer on the spot and the hospitalsto which patients are sent will have to be prepared toalter their arrangements as events turn out. The need toestablish, at an early stage, an inquiry office wheredistracted relatives can get information without floodingthe hospitals with inquiries has not been forgotten, northe equally important need for suitable mortuary accom-modation.