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 apnoea 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 apnœa 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 apnoea 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 apnoea. In such a case, therefore, the solution of the question involved must be determined by the pathological and chemical investi

gations instituted after death. If, on such inquiry, the cause of death should have been cardiac apnoea, 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 apnoea; 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 apnoea.

Absolute Diagnosis. The absolute diagnosis of cardiac apnoea during the paroxysms may be stated thus. It is an apnoea 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 apnoea 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

condition may extend throughout the whole of the muscular system, causing a general tetanic constriction.

In prolonged cases of cardiac apnoea occurring in children, as in examples where the symptoms arise from fibrinous deposit on the right side of the heart, there is very frequently emphysema of the lungs progressing to such an extent that the chest-wall is raised anteriorly: in the cases specified, the occurrences named are certain indications of cardiac obstruction in the right cavities, and of apnoea dependent upon that cause.

In all cases of death from cardiac apnoea, the final act is one of persistent muscular contraction; the heart first failing, the muscles of the chest become fixed from tonic spasm; the voluntary muscles follow next; and the whole body, left more or less rigid, may pass into rigor mortis without any intervening relaxation of the muscular organs.

With these symptoms of cardiac apnoea during the manifestation of an acute paroxysm, we must not fail briefly to recall those which are preliminary, in chronic cases, and which may be said to give the idea of a predisposition to an acute attack. One of the earliest symptoms, then, of impending cardiac apnoea, a symptom which is often experienced for years before the disease marks itself out in its determined character, is a sensation of sinking and exhaustion over the region of the heart. This sensation comes on upon very slight exciting causes: such as

deprivation of food, worry, a little overwork, or any excitement. A determinate act of the mind to bear up against this sensation will sometimes temporarily relieve it: a glass of stimulant taken with warm water will always relieve it: a moderate meal will do the same; or lying in the recumbent position. In some persons these exhaustive signs occur at particular times of the day; as at noon, or in the evening, or at the period of going to rest.

For many months, or even for years, the central exhaustion thus depicted may cause no serious inconvenience. The subject of it may become irritable and excitable, or perhaps melancholic, distrustful, and complaining; but those about him attribute these indications to nervousness or mental irritation. At length some telling event corrects this error: it is seen that the patient often becomes struck with faintness and pallor; that he cannot sleep at night; that his faculties are at times unsteady; and that a small amount of exertion produces breathlessness and objective anxiety. Upon these changes there is quickly engrafted an unmistakable acute apnoeal paroxysm, and the extreme extent of the disorder is revealed.

The physical diagnosis, in examples such as are now cited, is often, if it be put into practice, exceedingly trustworthy, and capable of shedding a light, too truthful to be happy, over the prognosis of the case. The first fact that strikes the auscultator is an absence of any pulmonic disease of a kind adequate to the production of the general symptoms; for, as a