About ten minutes from the commencement of artificial respiration we noticed a single weak spasmodic contraction of the diaphragm, the feeblest possible effort at natural respiration. Simultaneously, very distant weak reduplicated cardiac pulsations, numbering about 150 to the minute, became evident to the stethoscope. The reduplication implied that the two sides of the heart were not acting synchronously, owing to obstruction to the pulmonary circulation induced by the asphyxiated state. Artificial respiration was steadily maintained, and during the next half hour spasmodic contractions of the diaphragm occurred at gradually diminishing intervals, from once in three minutes to three or four times a minute.
These natural efforts were artificially aided as far as possible. At 5:45 P.M. natural respiration was fairly though insufficiently established, the skin began to lose its deadly hue, and titillation of the fauces caused weak reflex contractions. Flagellation with wet towels was now freely resorted to, and immediately the natural efforts at respiration were increased to twice their previous number. The administration of a little brandy and water by the mouth failed, as the liquid entered the larynx. Ammonia was applied to the nostrils, and the surface temperature was increased by warm applications and clothing. At 6 P.M. artificial respiration was no longer necessary. The heart sounds then numbered 140 to the minute, the right and left heart still acting separately. A very small radial pulse could also be felt. At 6:45 P.M. the woman was put to bed, warmth of surface maintained, and hot coffee and beef-tea given in small quantities.
Great restlessness and jactitation set in with the renewal of the circulation in the extremities. An enema of two ounces of strong beef-tea was administered at 10 P.M. The amount of organic effluvium thrown off by the lungs on the re-establishment of respiration was very great and tainted the atmosphere of the room and adjoining ward. The pupils, previously widely dilated, began to contract to light at 11 P.M. Imperfect consciousness returned at 5 P.M. the following day (Dec. 1), and about an hour later she vomited the contents of the stomach (bread, etc., taken on Nov. 30). Small quantities of beef-tea were given by the mouth during the night. At 9 A.M. air entered the lungs freely, and there were no symptoms of pulmonary engorgement beyond slight basic hypostasis; the pulse remained at 140, and the heart sounds reduplicated; she was semiconscious, very drowsy, in a state of mental torpor, with confused ideas when roused, and she complained of rheumatic-like pains all over her.
The temperature was 100.2°; the facial expression more natural; the tongue remained somewhat swollen and sore; she was no longer restless; she took tea, beef-tea, milk, etc., well; the functions of the secreting organs were being restored; she perspired freely; had micturated; the mucous membrane of the mouth was moist, and there was a tendency to tears without corresponding mental depression. The patient was ordered a mixture of ether and digitalis every four hours. On December 2 the pulse was 136, and the heart sounds reduplicated. The following day she was given bromide of potassium in place of the ether in the digitalis mixture. On the 4th the pulse was 126; reduplication gone. On the 6th the pulse was 82, and the temperature fell with the pulse rate. She was well enough to get into the ward for a few hours. Her memory, especially for recent events, was at that time greatly impaired. On the 12th she still complained of muscular pains like those of rheumatism. Apart from that, she was enjoying good bodily health.
A curious fact in connection with this case is that since this attempt at suicide she has steadily improved mentally, has lost her delusions, is cheerful, and employs herself usefully with her needle. She converses rationally, and tells me she recollects the impulse by which she was led to hang herself, and remembers the act of suspension; but from that time her memory is a blank, until two days subsequently, when her husband came to see her, and when she expressed great grief at having been guilty of such a deed. Her bodily health is now (June 30, 1884) more robust than formerly, and she is on the road to mental convalescence.
Remarks.—The successful issue of this case leads me to draw the following inferences: 1. That in cases of suspended animation similar to the above there is no symptom by which apparent can be distinguished from real death. 2. That in artificial respiration alone do we possess the means of restoring animation when life is apparently extinct from asphyxia, and that, with the tongue drawn well forward and retained there by the hand or an elastic band, the Silvester method is complete and effective. 3. That artificial respiration may be necessary for two hours or more before the restoration of adequate natural efforts, and that the performance of the movements ten times to the minute is amply sufficient, and produces a better result than a more rapid rate. 4. That galvanism, ammonia to the nostrils, cold affusion, and stimulants by the mouth are practically useless in the early stage. 5. That on the re-establishment of the reflex function we possess a powerful auxiliary agent in flagellation with wet towels, etc. 6. That centripetal surface frictions and the restoration of the body temperature by warm applications aid recovery. 7. That the heart, if free from organic disease, has great power of overcoming the distention of its right cavities and the obstruction to the pulmonary circulation, although its action may for a time be seriously deranged, as evidenced by reduplication of its sounds. 8. That when the heart's action remains excessively feeble, and the right and left heart fail to contract synchronously, it would be justifiable to open the external jugular vein. 9. That during recovery the lungs are heavily taxed in purifying the vitiated blood, as shown by the excessive amount of organic impurities exhaled. 10. That restlessness and jactitation accompany the restoration of nerve function, and that vomiting occurs with returning consciousness. 11. That pains like those of rheumatism are complained of for some days subsequently, these probably resulting from the sudden arrest of nutrition in the muscles.
Chartham, near Canterbury.
—Lancet.