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to pericardial adhesion and ossification, by which the right side of the heart was disabled.
On November 26th, 1850, a female child, 10 years old, came under my care for debility. She had suffered from a febrile attack; her friends thought from scarlet fever, as there had been a rash on the skin, and as scarlet fever had been present in a house near by. I ordered the child a saline, and afterwards a tonic; and continued to look in upon her daily until the 26th of August. On the morning of that day she seemed so well that I stated the visit to be the last: she was, when I called, actively at play, and had no complaint except of slight stiffness of the neck, which had been present from the first, but was so trifling that in my mind it passed as a little affectation on the part of the child, rather than as a fact. On the evening of the 26th, I was summoned hastily to this child. She had been well all day, but towards the close of the evening had once or twice coughed. At half-past ten she went to bed with her sister, and got into bed making great merriment. As she was sitting down, she gave a scream, and cried for breath. Her sister turning round, saw her face turn bloodlessly pale, her head being drawn back, and her chest heaving: she gave an alarm, and within six minutes I was by the bedside. The patient was reclining on two pillows, with her head drawn back, and the trunk of her body as rigid as marble. She was conscious; and, when I asked her whether she was in pain, she tried to make an affirmative movement with her head, and pointed to the sternum. I rushed home to fetch some sulphuric ether: when I returned, she was in the same position as I had left her, but dead. She remained rigid for some hours.
I opened the body next day. There was a little thin fluid in the pleural cavities, but no adhesions. The lungs were inflated with air, and were not in the least congested; there was a slight frothy mucus in the larger bronchi, but no obstruction in any part of the respiratory channels. The heart was so contracted, that it had the appearance of a walnut, and it felt to the grasp as hard as a walnut. When it was laid open, its rigid contraction was still evident, but on immersion in warm water it relaxed. Its endocardial surface, prior to the relaxation, was approximated, so that really no cavities existed, so firm was the contraction. There was not a trace of blood in the organ; but the large veins leading into the auricle were full to distension. All other parts of the patient's body were normal except the kidneys, which were slightly marbled in appearance. The whole of the soft tissues were pale, from absence of blood.
In this illustration, the cardiac apnoea was due to tonic spasm of the heart.
In the year 1847, a boy, 12 years of age, residing in Saffron Walden, Essex, was induced by his comrades to take a lesson in smoking tobacco. He smoked two or three pipes, and then, to crown the mischief, put a portion of the weed into his mouth and commenced to chew. He soon spat a portion of tobacco out, but probably swallowed the remainder. These events, taking place in a very short space of time, were quickly followed by terrible effects. After one or two unavailing attempts to vomit, the body of the boy became suddenly rigid as in tetanus, and the face deadly pale. Alarm being now given, my own assistance and that of Mr. Thos. Brown were sought. I arrived first. By the time of my arrival, the rigidity had relaxed, and in lieu of that the limbs were flaccid, as in profound narcotism from chloroform. The boy, nevertheless, was conscious, although he was unable to articulate. There was no pulse at the wrist ; but in the respiration the most striking phenomena were exhibited. Between each act, an interval of several seconds occurred, then a sharp, deep inspiration was made, which seemed to draw up the whole body, and produced the most painful contortions of the face, with tremor in the hands. Not apprised at first as to the cause, I ran my ear over the thorax, under the suspicion that a foreign substance had entered the larynx and was producing obstruction ; but the air entered freely, and fully inflated the lungs. After a little time, one of the lad's comrades, more candid than the rest, told me the cause of the attack. Mr. Brown coming in at this juncture, and hearing the history, joined with me in trying to produce vomiting by tickling the fauces. This failing, we quickly surrounded the patient with warm flannels and bottles, and, as soon as it could be got ready, introduced into the stomach, by the sophagus-tube, a full emetic
dose of sulphate of zinc dissolved in warm water. The stomach fortunately responded freely, and gradually the youth began to recover ; but for more than twenty-four hours later there were frequent recurrences of attacks of cardiac apnea. At first these attacks remitted for two or three minutes, then for five or six minutes, and so on, in gradually increased proportion. As they passed away and the boy became able to converse, his dread of the pain, as each paroxysm approached, was acutely expressed, and, as the spasm appeared, he announced it in a sharp scream. He defined the pain precisely as I have heard it defined by the other patients whose histories have been given—a cutting sensation through the chest, attended with utter inability to breathe until relaxation commenced, and then easily re-excited if the attempt to inspire were rapidly made. The attacks recurred even during sleep; but ultimately they subsided, and a good recovery was the result.
In this case, the cardiac apnoea was dependent on the presence, in the blood, of an alkaloidal poison.
I could multiply largely these illustrations ; but the typical cases supplied are all-sufficient for the present history. They present cardiac apnea as the accompaniment of five pathological states affecting the circulation, viz., obstruction on the right side of the heart; degeneration of the cardiac structure; mechanical embarrassment of the heart from external pressure; spasm of the heart itself; and the influence of a poison. These changes from the
normal life include, I believe, all the states in which cardiac apnea is induced. They may, however, be modified in detail in various ways. Instead of obstruction in the pulmonary artery from concretion, there may be disease of the vessel and narrowing of its diameter. Instead of external adhesion or ossification of the pericardium, there may be pericardial effusion : and, in addition to the poison of tobacco, a vast number of analogous poisons may be placed on the list, such as strychnia, hydrocyanic acid, ammonia, and chloroform. Further, we may add to the list various animal poisons produced in the body, such as the poison of tetanus, and of the fevers of the typhous class.
DIAGNOSIS OF CARDIAC APNEA, DIFFERENTIAL AND
ABSOLUTE. Differential Diagnosis. From the other forms of apnea--the laryngeal, the bronchial, and the pneumonic-cardiac apnea is differentiated by the following facts.
From laryngeal apnca, cardiac apnæa differs: (a) In that the stethoscope declares the absence of any obstruction in the larynx or tracheal tube, and the capability of free inspiration when the chest-wall itself can be raised to produce inspiration. (6) In that there is no deep congestion or blueness of the lips or cheeks; but, in place of these indications, a livid pallor. (c) In that the muscular contraction is not a rapidly convulsive act, but of the character of tonic spasm, as in tetanus. (d) In that the mind is not necessarily obscured, but on the contrary is, as a