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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 oesophagus-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 apnoea. 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 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.

scream.

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 apnoea 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 apnoea 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 apnoea-the laryngeal, the bronchial, and the pneumonic-cardiac apnoea is differentiated by the following facts.

From laryngeal apnoea, cardiac apnoea 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. (b) 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

general rule, clear, and acutely alive to all impressions. (e) In that the patient is conscious of a terrible oppression of the chest, accompanied usually by a sharp lancinating pain extending from the sternum towards the vertebral column.

From bronchial apnoea, cardiac apnoea is differentiated: (a) In that it offers no indication by the stethoscope of bronchial obstruction, no cooing sounds, no râle. (b) In that there is no convulsive cough, nor expectoration. (c) In that there is pallor of the countenance, in lieu of turgescence and dark discoloration. (d) In that the inspirations are distant, and as it were withheld, instead of being hurried and short. (e) In that the mind is conscious, and vividly alive to pain and anxiety. (ƒ) In that the spasm of the general muscular system is tetanic rather than convulsive.

From pneumonic apnoea, cardiac apnœa is distinguished: (a) In that there is no pneumonic crepitation, no râle, and no dulness of the chest on percussion. (b) In that there is no expectoration. (c) In that the countenance is of a pallid, instead of being of a bronzed tint, and turgescent. (d) In that the mind is conscious, instead of being confused and excited. (e) In that the muscular system is tetanic, in lieu of being tremulous or rapidly convulsed.

Lastly, there are two particular symptoms which afford distinguishing marks between all the above named varied forms of apnoea, and cardiac apnœa. 1. The pulse, in other varieties of apnoea, may be slow, or slow and feeble; in cardiac apnoea it is

feeble and intermittent, being often for a long interval absent altogether, and on its return irregular and wiry. 2. In the three more ordinary forms of apnca, the pulse, if reduced or absent, returns when the difficulty to respiration, whatever it may be, is removed; in other words, the pulse waits for the respiration. In cardiac apnoea, the reverse obtains; the respiration is never relieved until there is returning pulse; in other words, the respiration waits for the heart.

From tetanus, which cardiac apnoea, in its severest forms, closely resembles, it may usually be distinguished by the circumstance that the attacks of apnoea have come on gradually, and with some preceding general derangement of the health, distinct from anything like a traumatic cause. The spasm, moreover, commences in the chest, and does not progress slowly, and as it were muscle by muscle, but is instantaneous, so as immediately to constrict and embarrass the respiration. Further, the spasm does not affect the limbs and muscles of the neck and back so manifestly as in tetanus, while such spasm as is excited is more prolonged in character during a single paroxysm. Lastly, in cardiac apnoea, the symptoms of one attack are usually completed in one paroxysm; this paroxysm may be very prolonged, but, once subsiding, will not recur; while in tetanus there will be alternation of spasm and relaxation.

From strychnine tetanus cardiac apnoea is differentiated with more difficulty than from trau

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