best during a paroxysm of cardiac apnoea. This is very simple. The first point in practice, is to give the patient plenty of air; the next to place him in the sitting or semi-recumbent position; the third to apply to him as much warmth as can conveniently be borne. I have shown that the spasm in these cases depends on the removal of blood from muscle; if I had chosen to have gone further into the physiological question, I might have proved that the deprivation of blood from muscle produces spasm, because, under such deprivation, the muscle loses that force upon which its relaxation essentially depends, caloric. This is the great law which, remembered, governs the whole of the treatment-That without a due measure of caloric a muscle must be spasmodically contracted. It is right, therefore, to infuse warmth by every possible way, by the friction of the warm hand of another person over the contracted chest, by the application of a hot sinapism, by securing for the patient a warm air for inhalation, and by administering fluids heated to a degree such as can be tolerated. is the customary, I had almost said the instinctive act, of bystanders who witness paroxysms of cardiac apnœa, to give to the sufferer a glass of hot brandy and water or other stimulant; and the immediate success which usually follows this practice is a guarantee of its worth. But it should be remembered that it is not the alcoholic which produces the immediate relaxation, but the diffusible caloric conveyed by the water; and that if the It alcoholic is not at hand, it is good practice to give the heated water without the alcoholic. From what has been said respecting the administration of caloric during cardiac apnoea, it might be suspected that the warm water bath would be the remedy par excellence. There are, however, disadvantages in recommending this: in the first place, it cannot often be obtained in the emergency; in the next place, it does not immediately supply caloric to the internal organs; and in the third place, by largely dilating the vessels of the external surface, it impedes rather than increases the actual force of the circulation. I do not say that in prolonged cases of spasm it should not be tried; but unquestionably the readiest way of supplying caloric to the diaphragm and heart is to throw it into the stomach; there it diffuses quickly, and communicates its relaxing property to all the surrounding muscular organs. It has been customary in cases of cardiac apnoea to administer what are called antispasmodics, such, for instance, as ammonia, musk, valerian, sulphuric ether, and chloroform. Physiologically, it is entirely false to call these remedies antispasmodics; for, injected into muscle, they have no power of producing relaxation; on the contrary, they are excitants of muscular action, and paralyse by exciting overaction. But there are few examples of cardiac apnœa in which there is not during the paroxysm distension of the stomach from flatus; and in these instances the stimulus, by exciting the stomach to contraction, causes the displacement of the distending air, and indirectly relieves largely the breathing and the circulation. Hence these substances may be administered with good effect, but they should never be carried so far or repeated so often as to over-stimulate the muscles of respiration or the heart itself. Direct sedatives, such as opium and hydrocyanic acid, are dangerous remedies during an attack of cardiac apnœa; so, likewise, is alcohol a dangerous remedy if pushed to any extent. moment. In extremis, artificial respiration is the only resource; the air should be gently introduced into the lungs, and, whenever practicable, should be raised in temperature to a degree equal at least to that of the body itself, 98° Fahr. A simply constructed and portable instrument for quickly warming the air to be used in artificial respiration is a desideratum at the present The simplest apparatus of the kind is one devised by myself and depicted on figure 1 of plate Iv. It consists of a small zinc bath, in which are immersed a few yards of fine tubing communicating by one common outlet for admission of air and another common outlet for exit. The opening for the entrance of air in a pair of double-acting bellows (fig. 2, plate IV) is attached by India-rubber tubing to the exit tube of the bath, and the bath itself is then filled with boiling water; in this manner, as the bellows play, the air is drawn through the tubing immersed in the heated water, and is itself very effectually warmed. But the apparatus is cumbersome, and is not, I fear, applicable as yet to the immediate wants of the busy medical practitioner. FINIS. |