112. ON A NEW AND SIMPLE METHOD OF INDUCING ARTIFICIAL RESPIRATION IN CASES OF ASPHYXIA FROM DROWNING, STRANGULATION, CHLOROFORM, &c.

By Dr. W. P. BAIN, Surgeon to the Poplar Hospital.

The author introduces a plan hitherto not known in this country, the invention of the celebrated Pacini, of Florence, which consists in placing the patient on his back on a table or bed, the operator having his abdomen against the head of the patient, placing his hands in the axilla on the dorsal aspect, and then pulling the shoulders towards him with an upward movement at the same time. The shoulders are then relaxed, then the former movement, and so on alternately. In many cases operated on by this method the air makes a loud noise when it passes the larynx, as in snoring.

The author was so impressed with the excellence of this plan that he determined on his return from Italy to make experiments on it, as suggested to him by its illustrious inventor. He had not long, however, proceeded with these before he discovered two modes considerably superior, and throwing also somewhat in the shade the labours of Marshall Hall and Silvester. In experimenting on the dead subject he employed an india-rubber tube, one end of which was tied in the trachea, and the other communicated with a small spirometer, upon the principle of Hutchinson's, so that the passage of air to and from the lungs could be easily observed by means of a scale showing cubic inches. He found that the simple process of raising the upper part of the thorax from the table by taking hold of the arms caused a considerable influx of air, varying with the angle that the arms made with the body. For instance, if the body were raised by the arms at an angle of 45° (towards the face) the inspiration would amount to, say, 20 cubic inches. If the body were lifted by the arms in a vertical direction, the amount would be 15 cubic inches, and if pulled up by the arms at an angle of 45° (towards the feet), the amount would be about 10 cubic inches. But by the first of these modes a quantity of air considerably greater than by Hall's or Silvester's plan was generally obtained.

The best and most simple method, however, which the author has discovered is founded upon those of Silvester and Pacini. He simply places his fingers in the axilla in their front aspect, with his thumbs over the outer ends of the clavicles, and draws, with a certain amount of power, the shoulders towards him. On relaxing his hold, the shoulders and chest return to their former position, and so on with alternate motion. In this case, therefore, there is only one movement to be effected instead of three, and he avoids the fatigue of having to bear the weight of the patient's arms as well, as is required by Dr. Silvester's method. It has the advantage also of being accomplished in a more rapid manner than any other plan. As far as the author's experiments have gone, the quantity of air inspired at each move rent by this plan is about 30 to Dr. Silvester's 20, and as the operation can be conducted with much greater rapidity, the author considers that at least twice the quantity of air can be inspired by this mode than by any other yet known; and he expresses a wish that a subject which is of such practical importance should be further investigated.

The paper was illustrated by lithographed tables, setting forth results of successive experiments with the various methods; and Dr. Bain explained that in the first experiment, the method of Silvester was first used, then that of Marshall Hall, then that of Pacini, then his own four methods in succession; and that the series was then recommenced with Silvester's method again.

Mr. BowLES said that the description of the Marshall Hall method as given by the author of the paper, was incomplete, and that, if practised as described, the method had not been fairly tried. Pressure on the spine when the patient was rolled into the prone position was an important element, and this had not been mentioned. In cases of drowning, the first thing to be done was to get rid of the water from the lungs it having been proved by the

experiments instituted by the Committee of the Society, that this water was the chief source of danger to life. The presence of water in the lungs of drowned persons had also been shown by Professor Casper. In the case of a patient brought to St. George's Hospital, and who died there shortly after arrival, water was found in the lungs churned into foam by the air introduced by the diligent practice of Silvester's method. In a case managed by Mr. Trollope, of St. Leonard's, the method of Silvester was first tried, and as the patient seemed to be losing ground, the Marshall Hall method was substituted for it. Water then flowed out of the mouth, and the patient ultimately did well. We do not usually find water in the mouth, because it escapes easily, even from the larger bronchi, during the transport of the patient; but it does not escape easily from the smaller tubes, and in them it may soon be churned into froth. There is no difficulty in the introduction of air into the chest, but the introduction of air is useless while the patient is in the supine position, and while water is retained. A person with suspended animation requires but little air, and any method will introduce enough, The important question is, By what method can the water best be got rid of? In conclusion, the necessity of perseverance, even in cases of apparent death, was dwelt upon by the speaker, and instances of recovery after prolonged immersion were related.

Dr. SILVESTER remarked upon the possible injury to the parts entering into and surrounding the shoulder joints, as an objection to Dr. Bain's method. He thought it similar in principle to his own, but that it was safer to act upon the chest through the arms. He objected to frequency of artificial movement; and maintained that, if the movements were too frequent, air would not pass below the bronchi, as might be determined by the use of the stethoscope. Dr. Bain had explained in what order his experiments were to be read; and, so reading them, they seem to show that the power of introducing air into the chest increased in proportion as the efforts of the operator were continued. Dr. Bain had been less successful with his (Dr. Silvester's) method than the Committee of the Society; and he would himself undertake to introduce into the chest by means of it, not thirty or forty, but sixty, cubic inches of air. He was himself desirous to get rid of water when it was present, but did not believe that it usually entered the lungs. He had failed to introduce it even by injection; and, if it did enter, it could not be got out again either by the Marshall Hall method, or by position. The Marshall Hall method was not new, but had been used and reported upon by the Royal Humane Society a century ago. It was open to grave objections, and often seriously injured the patient.

Dr. HEADLAM GREENHOW observed that Dr. Bain's method was certainly the best, if excellence could be tested by the quantity of air that was introduced. He believed that water was distinctly inhaled into the langs in drowning, when people fell into the water in a state of consciousness, and made efforts to breathe. Water was not found in the lungs at post-mortem examinations unless they were made soon after death. It became absorbed or in some way disappeared. The period of immersion after which recovery would be possible would vary very much in different cases, and would be the longest where there had been no efforts to breathe (as when people were stunned when they fell into the water), by which water could be forced into the lungs.

Mr. CARTER expressed surprise that the best means of maintaining artificial respiration had not been adverted to by any speaker. This was the application of a Faradaic current to the phrenic nerves, where they pass over the scaleni muscles, according to the method described by Professor Ziemssen. By this means patients apparently dead from chloroform, and from the inhalation of carbolic acid and of coal gas, had been restored to life; and recently Pernice had applied the saine means successfully to new-born children, who could not be made to breathe in the ordinary way. One of the convenient galvanic batteries now made by Stöhrer and others should always be at hand when chloroform was being administered, or at places where deaths by drowning were liable to occur.

A Fellow suggested that Dr. Bain's plan might be used in the prone position, which would facilitate the escape of water.

Mr. JONES said that several years' experience as house-surgeon at St. George's Hospital led him to prefer the method of artificial respiration by intermittent pressure upon the parietes of the chest and abdomen. The difficulties of the Marshall Hall method were very great, especially with heavy or bulky patients. He related the case of a new-born child apparently dead, and tied up in a parcel with a ligature round its neck, but that eventually recov ered, to illustrate the importance of perseverance in efforts to restore suspended animation.-Lancet, Dec. 19, 1868, p. 799.

113.-CASES OF PLUMBISM.

By Dr. EDWARD CLAPTON, Assistant Physician to St. Thomas's Hospital.

[Some of the worst and most distinctive cases of lead poisoning occur in persons who handle lead in the metallic state, or who absorb it in some other form than the carbonate. In cases arising from handling lead the symptoms are generally those of arthralgia and hyperæsthesia of various parts, and sometimes of palsy of the extensors of the wrists, but seldom acute colic.] The following are a few of the cases (very briefly described) which have recently occured at St. Thomas's Hospital:

J. W., aged 39, an engine fitter, had been for a month or two engaged in fitting pipes by means of white lead. Symptoms were tympanitic abdomen, tenesmus, a white furred tongue, a slow small pulse, and a blue line along the gums. Had similar attacks twice previously from the same cause. Was ordered magnesiæ sulphatis 3ij., acidi sulphurici diluti mx., tincturæ hyoscyami mxx., aquæ mentha piperita j., ter die. Was soon well.

J. T., aged 33. Had been a leather-dresser until ten months ago, when he was employed in extensive white-lead works. Symptoms were nausea, constipation, enterodynia, neuralgic pains, especially in lumbar region, a brownish white fur on tongue, a small quick pulse, and a very distinct blue line, especially on the upper teeth, which were greatly decayed. Ordered hydrargyri subchloridi gr. ij., opii gr. ss. horâ somni. Magnesiæ sulphatis 3ij., acidi sulphurici diluti mxv., ex aquâ mentha piperita ter die. Was very ill for some days, and only slowly recovered under quinine and iron treatment.

C. D., aged 32, a painter. Suffering from a combination of plumbic neuralgia and gonorrhoeal rheumatism. Had for a long time aching pains in various parts, and recently contracted gonorrhoea. Has now slight gleet and intensely acute pains in the joints. Deep blue line on gums. Ordered potassii iodidi gr. iij., liquoris potassæ mxx., pulveris cubeba Oj., mucilaginis acaciæ 3ij., ex aquâ ter die. Pulveris ipecacuanha compositi gr. v. omni nocte. Required no alteration of treatment, and was well in three weeks.

J. S., aged 43, a man cook. Suffering from a severe attack of icterus of a week's duration. Employed in an underground kitchen of a London railway terminus, where there are a number of leaden pipes conveying steam. Had suffered severe tormina and constipation for several days before being jaundiced. A deep blue line on the gums. There was no other way of accounting for the introduction of lead into the system except by the steam escaping through several holes in the leaden pipes. Ordered pilule hydrargyri gr. v., extracti hyoscyami gr. v. statim. Haustas sennæ compositi 3ij., post horas quatuor. Magnesia sulphatis 3j., soda bicarbonatis gr. x., ex aquâ menthæ piperita ter die. A hot bath. For several days the griping pains increased and the jaundice did not lose its intensity. On the following week was ordered hydrargyri subchloridi gr. ij. alterâ nocte. Magnesia sulphatis 3j., infusi rosa acidi 3j., ter die. After this he rapidly recovered.

A short time ago two other cases of a similar character attended as outpatients-viz., cooks employed in a kitchen at another London terminus, both of whom had dropped wrists, general debility, and an ictero-plumbic appearance. They both stated that they were obliged to inhale steam all day which escaped from leaden pipes.

J. K. aged 49, a labourer. Suffering from acute colica pictonum of five days' duration; the third attack, His occupation entirely consisted in

making leaden pipes, and involved constant standing over molten lead. The present attack was preceded for two days by vertigo, languor, anorexia, and slight alvine flux. Acute constipation, attended with great pain, then set in. Blue line very distinct. Ordered magnesiæ sulphatis 3ijss., infusi rosæ acidi 3jss., ter die. Pilula hydrargyri gr. v., pilulæ rhei compositæ gr. v., alterâ nocte. For several days he became much worse, and recovered very slowly under the influence of sulphates and tonics.

G. H., aged 20, a painter. Suffering from epileptic fits, occurring about once in a fortnight, severe in character, and of three years' duration. A distinct blue line on the gums. Ordered zinci sulphatis gr. ij., ferri sulphatis gr. ij., magnesiæ sulphatis 3 ss., ex aquâ mentha piperita ter die. Subsequently the sulphate of zinc was increased by degrees to twenty-four grains for a dose. The sulphate of magnesia was reduced to fifteen grains, and then omitted. There had not been a single fit whilst under treatment a period of five months-and the blue line almost entirely disappeared.

W. D., aged 32, a painter. Had for some time laboured under frequent attacks of cephalalgia and vertigo, and twice from epilepsy. Had several attacks of colic during the last ten years. Is very feeble, and has an exceedingly plumbo-cachectic appearance. Ordered potassii iodidi gr. vj., syrupi ferri iodidi 3j., infusi calumbæ 3jss. ter die. Improved rapidly in all respects, and will probably be soon well.

A case of insanity, of two years' standing, in a painter, came under my notice the early part of this year, and was similarly treated. He was well, and able to resume his ordinary duties in three months. He had never suffered from obvious lead disease, but a blue line denoted the existence of lead in the system.

In considering the treatment of cases of lead poisoning, we are naturally led to reflect on the exact modus operandı of their chief remedies—the sulphates and iodides. In the one case we are supposed to render the lead more or less inert by inducing its most insoluble form, and in the other to eliminate it after having first rendered it as soluble as possible. It is not, however, as a simple iodide that the lead is thus rendered soluble, for we know that the iodide of lead is an insoluble salt, but as a double salt-probably the iodide of lead and potassium, which is very soluble. The actual condition in which lead exists in the system after absorption is not easy to determine. As regards the inhalation of the particles of carbonate of lead, any organic acid will set free the carbonic acid, and form a soluble salt, which is taken into the circulation, or perhaps the carbonate is rendered soluble in the lungs by excess of carbonic acid. When the metal is constantly in contact with any portion of the skin, especially if there be any degree of friction, as we find in plumbers, compositors, &c., it is either absorbed in a molecular state or becomes acted upon by some organic acid, or it may be absorbed through an abraded surface. It was probably by the action of some organic acid that the piece of leaden bullet in the cheek in the case already alluded to was acted upon, and thus induced so intense an attack of lead-poisoning, the bullet not having become regularly encysted as generally happens. There was no other way of accounting for the introduction of lead into his system. Cases have been recorded in which colic was produced by leaden bullets having been swallowed. The fact is that lead has a greater affinity for animal matter, as well as a stronger tendency to combine with organic acids, than perhaps any other metal has. Witness the way in which various animal tissues, colouring matters, neutral matters, and organic matters generally are so readily thrown down by subacetate of lead. Thus it is, no doubt, that the blood deterioration is induced. The action of the lead on the various principles in the blood day by day exerts this influence, until at last the true saturnine cachexia is developed; and as soon as this has reached the utmost limit of which it is capable, the lead begins to be deposited in various solid tissues, as the brain, liver, muscles, and skin, either in the form of suboxide or of the metal itself in a molecular state. When redissolved, and again circulating in the system, as by the action of iodides, it is by the intestinal canal and by the skin, the latter especially, that the effort of elimination is exerted; but still the

lead cannot attain any form which can be completely exhaled by the skin, and so is deposited in its tissue. We know that sulphureous baths will cause the surface of the body to be discoloured in the most marked manner, and this doubtless is the reason. Not long ago I tried the effect of the sulphureous bath in two cases of chronic plumbism of a severe character, the one having been treated with iodide of potassium, the other with tonic and purgative sulphates. In the former instance, the skin was here and there decidedly blackened, in the latter not appreciably so. In the former, the lead was no doubt freed from various internal organs by being rendered more soluble and directed to the skin; in the latter, fixed in a still more insoluble form. Very much has still to be learnt in respect of these points, but unfortunately the means of investigation are limited. The great requirement of the day is a right knowledge of the chemistry of the living fluids, both in health and in disease, and also of the chemical changes which the various medicinal substances undergo in the living organism. I hope that the new Clinical Society will give an important impetus to investigations of this nature. As to the blue line on the gums in plumbism, I have seldom found it absent except in those who have lost their teeth. It is often continued along the teeth for some distance, and much more distinctly so in the case of decayed teeth. It has a very different appearance from discolorations from other causes. In several oil- and colour-men I have noticed a deep mahogany-coloured stain on the gums and teeth. In a recent communication I have shown that those who suffer from the poisonous effects of copper have a very distinct green stain on the teeth, and this has subsequently been amply verified by the attention of several others being directed to this point and by my examination of many other workmen in connexion with copper and brass works. I find that the powder which the artificial flower makers use, and which produced symptoms of copper-poisoning, with a deep green stain, in a case which I described, is emerald green or aceto-arsenite of copper. The diagnosis of paralysis from lead poison is always easy. In nearly all cases the history readily elucidates the cause, and there is the blue line on the gums; but the chief distinction is that in all other forms of paralysis there is more or less anæsthesia as well as loss of motive power; but in that from lead there is more or less hyperesthesia. I have at the present time under my care an out-patient suffering from dropped wrists, having precisely the appearance as though of plumbic origin, but in reality induced by a violent blow on the back of the neck. He has considerable loss of sensation in his arms, as well as loss of motion. With respect to the treatment of chronic cases, then, the great object is to get the lead out of the system. Nervine tonics, galvanism, chalybeates, and blood restorers are all useless unless some mode of elimination has been previously or is simultaneously effected. Iodides, purgatives, and sulphureous baths are the most reliable, though the latter are difficult of application. Some cases of dropped wrists are exceedingly obstinate, but galvanism, iodide of iron, and purgatives seldom fail in effecting a cure. I do not at all approve of the plan of placing the arms and hands in splints for the whole day, as is the fashion, as I am convinced that frequent friction and gentle exercise of the muscles of the arm form a most important element in treatment. As to acute lead colic, which consists in paralysis of the muscular fibres of the intestine with acute irritation of the sensory nerves, there can be no doubt the sulphates, anodynes, and purgatives are the right remedies. The sulphates are obviously for the purpose of diminishing the solubility of the lead, and this, we know, is equal to diminishing its poisonous influence. Such purgatives should be given as castor oil, which as an oil may also assist in combining with the lead in a form the more easily eliminated, or as those which increase alvine secretions-e. g., mercury, salines, &c., the abdominal pain being greatly increased by such purgatives as act only on the muscular coat-e. g., colocynth, aloes, senna, &c. Patients may be thus cured of colic, but not of plumbism, as long as the lead remains. To rid this, iodides, purgatives, tonics, and baths must be persevered with for some time. Sulphates, therefore, are more appropriate for the treatment of acute cases, and iodides for chronic. I have seen more than one case in which iodide of