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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 apnea, cardiac apnea is differentiated: (a) In that it offers no indication by the stethoscope of bronchial obstruction, no cooing sounds. no râle. (6) 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. (f) In that the spasm of the general muscular system is tetanic rather than convulsive.

From pneumonic apnæa, cardiac apnea 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 apnea, and cardiac apnea. 1. The pulse, in other varieties of apnea, may be slow, or slow and feeble ; in cardiac apnea 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 apnea, 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 apnea, 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 apnea, in its severest forms, closely resembles, it may usually be distinguished by the circumstance that the attacks of apnea 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 apnea, 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 apnea is differentiated with more difficulty than from trau

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matic tetanus; or I had perhaps better said that greater difficulties may be presented. Still, there are distinctions in cases where the effects of the alkaloid strychnine are extended over a long period of time. These distinctions consist first in the character of the spasm ; the spasm in cardiac apnea being from the commencement of the attack mainly directed to the chest, while in strychnine tetanus, as in ordinary tetanus, the spasm assails the muscular system more generally, convulsing the body in all its parts. Again, as we have before seen, in cardiac apnea the paroxysm, however long it may continue, does not recur when it has once subsided; while in strychnine tetanus the paroxysms are repeated in most cases, an entire subsidence of spasm taking place between each. Lastly, in fatal cases there remains, of course, the chemical test, which in cardiac apnea will necessarily yield negative results ; while in strychnine tetanus it will as necessarily yield affirmative evidence of the presence of the specific poison in either the blood, the tissues, or the excretions.

In any given case of poisoning by strychnine, in which the symptoms from their commencement to their fatal termination should consist of one prolonged and unbroken spasmodic representation, it might be next to impossible to determine from the observation of them alone the precise difference between strychnism and cardiac apnea. In such a case, therefore, the solution of the question involved must be determined by the pathological and chemical investigations instituted after death. If, on such inquiry, the cause of death should have been cardiac apnea, there will in the majority of cases be found sufficient evidence of disease, either in the walls of the heart, or in the condition of the blood, of the great blood-vessels, or of the coronary vessels, to account for what has occurred; while the absence of strychnine on chemical research will determine the diagnosis. In strychnine poisoning, on the other hand, the detection of the poison, whatever may be the state of the circulatory system, will be sufficient in itself to secure a direct affirmation of the cause of the symptoms, and the nature of the death.

There is only one other disease which might be confounded with cardiac apnea; namely, hysteric spasm. Here, however, the antecedent history of the hysteric paroxysm, the character of the paroxysm itself, its peculiar intermittent type, its connection with partial syncope and unconsciousness, its freedom from intermission of the circulatory pulsation, its occurrence, in short, without evidence of disease of the heart, and its comparative freedom from danger, will usually free the practitioner from any doubt of having mistaken it for its more formidable rival cardiac apnea.

Absolute Diagnosis. The absolute diagnosis of cardiac apnea during the paroxysms may be stated thus. It is an apnæa with open air-passages; not panting breathlessness, but suppressed breathing. The struggle for breath is due to spasmodic contraction of the

muscles of respiration, and consequently is marked by no rapid effort of those muscles to overcome a difficulty in the respiratory tract. The apnea is described by the patient, if he can express himself, as arising from without, as from external pressure, as though his chest were compressed and stiffened. There is darting pain through the chest-cramp. The other parts of the muscular system, if they are involved, are cramped, not convulsed. The mind is usually unaffected. During the paroxysm there is either irregularity or prolonged absence of the pulse; and the same condition, of necessity, is presented by the heart.

The surface of the body is cold and pale ; the countenance stormed with anguish, but not incessant; if the spasm permit, there is constant movement on the part of the patient in the effort to obtain relief.

There is always pain of the acute kind more or less marked. The pain is most frequent and most lancinating between two well defined points the lower part of the sternum, through the chest, towards the last dorsal vertebra : with this pain the breathing is locked up. I believe this pain to depend on spasmodic contraction of the diaphragm.

There is generally more or less of muscular spasm and pain in other parts of the body. In some cases one limb is thus affected, as one arm, which during the whole seizure may be in a state of intense suffering, with more or less of rigidity: in other cases, where the seizures are very severe, this spasmodic

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