In Chronic Cases of Long Standing.—Sulphur, Calcarea-carbon., Silicea, Causticum, Bell., Cuprum-metallicum, Hyos., Stram., Veratr, Lachesis.

When the disease has arisen on repercussion of an old eruption or chronic discharge, Sulph., Caust., Calc.-carb., Stram., Laches.

GENUS VIII.-ASPHYXIA.-APNOEA.

This name was used by Hippocrates, and refers primarily to suspension of the heart's action (from a, without opvğia, to beat or leap.) But it is applied to a state of suspended animation, produced by arrest of the actions of respiration, which is soon followed by the cessation of the motions of the heart and other vital functions.

GENERAL REMARKS.-Asphyxia, when it arises from causes which operate slowly, begins with difficulty of elevating the thorax; anxiety; quick and short efforts to fill the lungs with air; gaping and stretching; vertigo; loss of consciousness and sensation; sometimes convulsive movements of the limbs and trunk; immobility of the muscles of the thorax, and abdominal muscles; weak and languid pulsation of the heart, absence of pulse at the wrist; face livid, tumid, injected, its veins distended; reddish violet hue of the hands, feet, and face; similar patches on other parts. On the final cessation of the circulation, asphyxia is complete, but animal heat and the absence of rigidity of the muscles remain longer than after death from other causes. These symptoms succeed each other with more or less rapidity according to the causes by which they are produced, and the more or less perfect exclusion of the air from the lungs. The duration of life is proportioned to the rapidity with which these causes operate; as the more slowly the state of asphyxia supervenes the longer the person retains the ability of being reanimated."

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Causes of Asphyxia.-Whatever cause may prevent the renewal of air in the lungs of a healthy person. Deficient expansion of the lungs from mechanical obstructions, external pressure on the chest; from injury of the pneumogastric nerve; from injury of the medulla oblongata, fracture, or dislocation of the spine in the cervical portion; paralysis of the nerves of respiration, or deficient irritabiilty of the inspiratory muscles as from the benumbing influence of cold; and the suspended animation of new-born infants.

The air may be prevented from entering the lungs by mechanical causes; as strangulation; submersion; foreign bodies in the air-passages. The air itself may be vitiated by the presence of deleterious gases; several causes of asphyxia are often in operation at the same

time.

PATHOLOGY.-The body after death exhibits a violet or reddish hue

of the countenance, and of other parts of the surface; warmth and flexibility retained long after death; the blood of the skin or vascular tissue exhibits unusual fluidity; eyes bright and prominent; mouth generally natural, sometimes distorted; veins and sinuses of the brain generally filled with dark fluid, or semi-fluid blood; brain otherwise natural; base of the tongue injected, tumefied, and papilla developed; mucous membrane of all the air-passages injected and red, becoming darker as we descend into the lungs; lungs distended; brown or blackish in color; parenchyma when cut and pressed gives out large drops of black blood; liver, spleen, and kidneys engorged with blood; veins of the heart, its right cavities, venæ cavæ, and other large veins engorged with black blood. (Copland Dict. Pract. Med. I., 170.)

1. Asphyxia from Submersion.—The first effects felt by a drowning person are an urgent feeling of anxiety in the chest; the pulse becomes weak and frequent; he struggles, rises toward the surface, the pulse becomes weaker, he again rises and perhaps throws out air from the lungs; in his efforts to inspire air is drawn in, and it excites cough and spasm of the glottis; as the respiration becomes less perfect the blood partakes more and more of the venous properties; it becomes narcotic and poisonous, as well as increased in bulk, thus pressing on the brain it occasions insensibility, loss of voluntary motion; the surface of the body assumes a livid color, the pulse ceases to beat, the sphincters are relaxed, and the body sinks to the bottom.

Appearances on Dissection.-Dilated pupils; clenched jaws; semicontracted fingers and thumbs; paleness of the face at first, followed by livid appearance of the skin; striking calmness and placidity of features; the point of the tongue is usually found in contact with the incisor teeth; in some cases froth is found about the mouth, sometimes within it, and, more rarely in the trachea; a peculiar liquidity of the blood is frequent, water is found in the stomach in nearly all cases of persons drowned, but not in those thrown into the water after death. (Augustine, Edin. Med. & Surg. Jour., 1837.)

Orfila says the lungs become of indigo color, and brownish after exposure to air; the right cavities of the heart, the pulmonary veins and arteries and veins are filled with black blood, and retaining less contractile power than those of the left side; the color of the viscera is the same as after death from asphyxia otherwise produced. (Report to Royal Acad., Paris.)

PROGNOSIS. The period after which reänimation may be procured varies from five minutes to three quarters of an hour. (Copland.) In one case, mentioned by Dr. Lee, resuscitation was effected after submersion for forty-five minutes. In ordinary cases restoration cannot be hoped for after submersion of over ten or fifteen minutes.

2. From the poisonous effects of the vapors of burning charcoal

In cases of suffocation from breathing the vapors of burning char coal, death generally results from the poisonous action of carbonicacid-gas, though in some instances some unknown noxious vapor is developed in the process of combustion.

First Degree of Asphyxia.-Symptoms.-The symptoms produced by carbonic-acid-gas are well marked, but not entirely characteristic, as they in some points resemble the effects of apoplexy. The person exposed experiences an intense throbbing headache, with weight and heat, especially about the occiput; strong pulsations, and sense of tightness across the temples; vertigo; increased action of the heart; and, often violent palpitations; confusion of ideas; partial failure of memory; nausea; hysteric sobbing.

TREATMENT.-Remove instantly from the vitiated atmosphere: place in a current of cool air in a recumbent position; apply bottles of hot water to the feet, if cold; cold water to the head. The symptoms pass

off in a few hours.

Second Degree of Asphyxia from Poisonous Vapors.-Exposure to the vapors of burning charcoal when continued for a longer period produces: Buzzing noise in the ears; partial or total loss of vision; an undefined feeling of dread or horror, followed by an irresistible disposition to sleep, or fainting. In a short time all power of volition is lost. The pulse and heart, which recently beat rapidly, (sometimes from 100 to 200 per minute,) fall to 40 or 50; the breathing becoming more slow and laborious; surface cold and livid; lips blue or violet, the eyes still retaining their lustre. As the symptoms increase in violence there are tetanic convulsions, and raging delirium; white or bloody foam from the mouth and nose, followed by vomiting and death. In some cases the tongue is clenched firmly between the teeth, producing suffocation.

Pathology. After death, "the countenance," says Dr. Golding Bird, retains the expression of placid calmness, resembling sleep, "the body sprinkled with livid, bluish, or reddish-brown spots; limbs flexed, or rigid fingers, often irregularly bent or stiff; arms extended or thrown across the chest," after tetanic spasms; animal heat generally greater than after death from other causes; in some cases the putrefaction is also said to be more rapid; the tongue clenched between the teeth, (except after vomiting,) mouth covered with white or bloody foam; face livid and bloated, or pale; eyes lustrous, sometimes injected; pupils generally dilated; the whole appearance that of calm repose without any distortion; interior of the nostrils lined with a black, smoky deposit; the abdomen generally distended with air. (Louisville Medical Journal, Sept. 1840, p. 217.)

3. Asphyxia from Strangulation.-The first effect of the tightening of the cord around the neck is the suspension of respiration and

the engorgment of the brain with blood, on the occurrence of which sensibility begins to decrease; epileptic convulsions, more or less marked; "turgidity, suffusion and lividity of the face, shoulders, chest, arms, and hands; the eyes are open, the features distorted, tongue thrust out of the mouth; external muscles of respiration firmly con. tracted, hands clenched, sphincters relaxed. When the air is not perfectly excluded the sufferings are prolonged; engorgement of the head and face greater, brain more congested, lungs less so." In nearly all cases of death by strangulation, life is suspended by the cessation of the action of respiration, though the engorgement of the brain shortens the process and lessens the suffering, which, however is very great for a short time; dislocation of the cervical vertebra is common in public executions, though rare in suicides. The action of the heart becomes more rapid as the death-struggle progresses, and remains a few minutes after the breathing ceases. In one case it rose from under 100 per minute to 120 three minutes after respiration was suspended, then to 155, and five minutes afterward was imperceptible. The air in the lungs extracted from the trachea was without oxygen, though the breath before the execution contained 17.84 parts oxygen in 100. Carbonic-acid gas increased from 2.609 before, to 7.7 after execution; and nitrogen increased from 79.551, to 92.3.

On the cause of the extinction of life in Asphyxia.—Dr. Paton of Canada, concludes from a series of well-conducted experiments: "That the time required to produce asphyxia in an animal varies according to its physiological condition, and the rapidity with which the function of respiration is effected, and that the power which a cold-blooded animal possesses of resisting the deprivation of oxygen depends on the state of its system at the moment. For during the warmest period of the season, when the functions of the body are carried on with the greatest energy, if, respiration be simultaneously arrested in the skin and the lungs of a cold-blooded animal, it will die almost as soon as a warm blooded one; so powerful is the effect, that it seems to act almost like concussion of the brain. Insensibility is produced, and at the same time, the action of the heart is depressed.

"What is the immediate cause of the insensibility that is thus produced? It does not arise from the deficient supply of blood to the heart and the brain, for the heart continues to beat, and dark venous blood to circulate through the arterial system long after the animal has become insensible; and if the non-aërated blood had been finally arrested in the capillaries of the lungs or the skin, the seat of the respiratory process in cold-blooded animals-or so arrested that it could not be sent forward to the heart in sufficient quantity to maintain the circulation, these phenomena could not have been witnessed. But we have seen from experiment VI. that at the time asphyxia was in

duced, the heart continued to beat at forty pulsations per minute, and, in another experiment the dark venous blood passed along the arch of the aorta when the pulsations of the heart were only thirty per minute, the animal remaining in a state of deep insensibility. Whereas, if an animal die from another cause-when the function of respiration is not affected, the pulsations of the heart may be reduced to ten or twelve per minute, and yet we have distinct evidence of sensation on irritation applied to the integuments. From these facts it appears, that it is not from the deficient action of the heart or diminished supply of blood to the brain, that insensibility, the first stage of asphyxia is produced."

In other experiments it was seen, that "in resuscitating an animal from asphyxia, the action of the heart may increase, and the circulation of dark venous blood be maintained with considerable vigor, but insensibility is not recovered from till there is a greater influx of arterial blood to the brain. In experiment 1, the pulsations of the heart rose as high as forty-two per minute, and remained at that rate for a considerable time: but it was only after the respirations became more frequent and a greater amount of oxygen was consumed, rendering the blood more highly arterialized, that the first signs of returning sensibility were witnessed a fact which seems to prove that in asphyxia insensibility is produced by the action of dark venous blood on the brain."

"What is the immediate cause of death in asphyxia, or on what does the failure of the circulation depend?"

The experiments show that "shortly before the action of the ventricle ceases, the blood begins to accumulate in the large veins around the heart and after the circulation has been finally arrested, both the auricles, the vena cava and pulmonary veins remain gorged with dark venous blood, whilst the aorta is comparatively empty, indicating that there a stop had been put to the general circulation. For if the blood passing through the lungs had been ultimately arrested in their capillaries on not meeting with oxygen, we should expect to find at the moment of death the pulmonary veins and the left auricle nearly destitute of blood, but the reverse is the case. And, on the same principle, if the circulation of the cutaneous capillaries had been equally impeded, neither the right auricle nor the vena cava would have been distended with blood. Whatever then may be the effect which the non-supply of oxygen exerts on the function of respiration, dark blood still appears to circulate till it is ultimately arrested at the heart; and the whole of the phenomena presented to our view seem to indicate that the failure of the circulation depends on the ventricle ceasing to perform its functions, and transmit the blood forwards."

But "what is the cause of the cessation of the movement of the ventricle? When unaërated blood circulates through the body, the