forcing air in this manner, the expired air finding exit through a side tube.

We give Dr. Fell the credit of introducing the term, "Forced Respiration." Although the method of Dr. Fell requires an operation and is occasionally embarrassed by bleeding from the wound, he has reported some remarkable results from forced respiration in the treatment of opium narcosis. He has demonstrated to the world that it is possible to save the majority of bad cases of narcosis, if this method is instituted in time.

There is no doubt that forced respiration is the future treatment for all cases in which what is known as artificial respiration is recommended, and these cases are quite numerous; in a visiting list, for instance, respiration is recommended in anesthetic syncope, poisoning from aconite, belladonna, chloral, conium, hydrocyanic acid, nux vomica, opium, etc.; poisoning by inhaling various gases, and drowning. All these cases die from asphyxia, or a surcharging of the blood with carbonic acid; this may be secondary to paralysis of the respiratory center, but it is the ultimate cause of death. But if air can be supplied in these cases, ninety per cent. will recover, if taken in time, for we thus arterialize the blood until the poison is eliminated; time alone is required. One who will watch a case treated by forced respiration, will be surprised at the effect produced and the comparatively short time it takes to resuscitate by this method.

Being impressed with the value of forced respiration in this class of cases, I have devised a simple respirator, which does away with any operation, is easily applied to any patient, works automatically, and through which one can take a natural respiration, if need be. It consists of a heavy rubber cup which fits over nose, mouth, and chin, and is retained by hand or straps around the head; in this cup is a brass tube which connects with the bellows by a rubber tube about five feet long. Inside the brass tube is a valve which is so constructed that it allows air to pass it when the bellows is collapsed, which air readily enters the lungs through the nose and mouth. The tension of the column of air on the way to the lungs, is the factor which keeps the air from creeping to the outside through. the exit valve which opens just back of the cup. As soon as the operator sees he has caused a good inhalation by pressure on the bellows, he stops, the exit valve opens automatically, and the air in the lungs is readily exhaled.

The above cut shows the respirator in operation. The respirator cup, being made of rubber, readily conforms to any face, except the smallest infant; it may be held on the face by hand or by straps, as shown in the cut; the bellows is of sufficient size to inflate the lungs. By this device air is forced into the lungs, but is expired naturally, that is, from the natural resiliency of the chest wall and diaphragm, and elasticity of the air cells. It resembles natural respiration in that expiration is a passive act. Occasionally it may have to be supplemented with pressure on the thorax, to cause a complete exhalation. It has been argued that no form of bellows should be used; in fact, medical works advise against the use of any kind of bellows, lest the lung cells be bursted. In a healthy lung there is no danger of this whatever. The amount of pressure required to force high notes on the smaller musical wind instruments, as the cornet and clarionet, is vastly greater than is ever required to fill the lung with air by forced respiration. True, we increase the pressure in forcing air into the lung, but this pressure is never very great, never, probably, reaching two atmospheres.

None of the cases of Dr. Fell and myself have resulted in any form of lung trouble whatever. Taking one of Dr. Fell's worst cases, where respiration was forced for over twenty hours, after tracheotomy with the attending hemorrhage, without any trouble. resulting, we should be ready to strike out the warnings of some of our medical books against the use of bellows, forever.

We only want a good respiration; the bare chest will always, by its motion, be a sufficient guide to this, and even if we get a

little more air into the lung than is taken in in a natural respiration, no harm is done. The rate of respiration we should make to conform as nearly as possible, to the natural, say fifteen or eighteen per minute.

The cases I report have been the only ones poisoned by morphine in this city since my respirator was completed. I attended two cases before I had conceived the idea of its construction, to both of which I gave the orthodox amount of atropine, but the breathing became less frequent and shallower until, finally, both died; they could undoubtedly have been saved by forced respiration.

It will be noticed in two of the cases reported that the bowels became tympanitic. This in no way interfered with the respiration, and readily passed away. I see no reason why, in the event of forcing respiration for many hours by this method, a sponge, lubricated with vaseline, and anchored to a fish line, could not be pushed down the esophagus by the aid of a probang, and held there. Indeed, I had everything ready to try this in the first case reported, but as the condition of tympanites did not seem to interfere with respiration in any way, it was not done. I speak of this merely as a suggestion; it might be the better thing to do where respiration was forced for many hours.

It might afford the drum membrane some protection to place pledgets of cotton in the external auditory meatus.

CASE I, Mr. S.—Took about eight grains of morphine, at 8 P. M., August 19th, 1889. He had been drinking to excess, and, as he had often bidden his friends good by, saying he was going to end himself, when under the influence of alcohol, this threat was taken as the others, without notice. A brother, however, had discovered an empty powder paper, which would have originally held ten or twelve grains of morphine. In a glass near by was also a little white powder, adhering to the sides. He took it to Dr. W. S. Dick, to examine, who immediately pronounced it morphine. He visited the patient a few minutes after he had taken it. Mr. S., when confronted, denied having taken the powder, saying he had thrown the contents of the glass out of the door. This story was believed, and the brother and patient went to bed (the latter lying down on a lounge, down stairs), Dr. Dick leaving for home. Fearing all might not be right, Dr. Dick called again at 11 o'clock, three hours after the drug had been taken; and, upon gaining

admittance, found he had a severe case of morphine narcosis on hand. At this time the patient could not be aroused; there was no perceptible movement at any time, of the limbs; face cyanosed ; pupils contracted to pin points; pulse, 140; respiration, about two per minute, jerky and shallow. One-sixtieth grain atropia was administered. Dr. J. F. Baldwin was then summoned, who, being interested in forced respiration and knowing I had a device for producing it, kindly sent for me. I arrived at 1:39 A. M. The pulse was now 138; respiration, 1 per minute; cyanosis, deep. There had been no vomiting, and a stomach siphon could not be introduced. The respirator was soon applied and worked very well.

2:30 A. M.-Apparatus had been used almost continuously. Upon removal, no sign of voluntary effort at respiration for three minutes; he then began, at the rate of 1 per minute. Respirator again applied, and respirations forced to about 15 per minute, very full and deep.

3:30 A. M.-Respirator again removed and fully two and a half minutes elapsed before a breath was taken. The latter was of the Cheyne Stokes variety. Surface of body warm and skin of a natural color; respirations now once in forty-five seconds. Up to this time he had taken two one-twentieth grain doses of atropia, hypodermically. We now saw some improvement, although there had been no voluntary movements whatever. Respirator re-applied, bowels becoming tympanitic from air.

4:20 A. M.-Sudden movement of hands and feet, followed by an effort to get the respirator cup from the mouth. On its removal, he, in a dazed manner, asked for a drink of water, and drank some. Immediately he agian went off into a sleep, but could be aroused by violent shaking. Pulse, 130; respiration, 8 or 9 per minute. Respirations increased slowly, in frequency; and at 10 A. M. he was clearly out of danger.

CASE 2. Ethel J., age twenty months; swallowed ten one-eight grain morphine pills, at 4 P. M., August 26th, 1889. Emetics did not act, and, after being walked about the yard, tossed, whipped and given all sorts of torture, she sank into a deep stupor. Pupils contracted to pin points. By 7 P. M. she had taken one-fortieth grain atropia, given her by the physicians in charge, Drs. C. F. Turney and D. R. Kinsell. Dr. Kinsell going home now, Dr. Turney assumed

charge of the case, and kindly sent for me to use the forced respi

rator.

I arrived at 8 P. M. The child seemed to be beyond all hope. Skin, cold and clammy; pulse, too weak and rapid to count; respiration, about 10 per minute, very shallow and incomplete; marked stertor; pupils enlarged somewhat after the atropine. Forced respirator was applied immediately, and kept up for about fifteen minutes, with no apparent benefit. The apparatus was again applied for a few minutes, when relatives interfered and demanded that we should stop torturing the child; Dr. Kinsell, the family physician, had said the child could not live, and they wished to see it die in peace. We, finally, got consent to use it for a half hour; the child was not dead, and all efforts at resuscitation should be used. At the end of twenty minutes the respirator was removed, and, after a short interval, natural respiration began at about 15 per minute, but shallow and stertorous, and gradually decreasing in frequency, so that at the end of two minutes they fell back to 10. Some improvement was apparent, and the friends now consented to further treatment.

9:00 P. M.-Respirator had been used for fifteen or twenty minutes. Upon removal, after an interval of a half minute, respiration began at the rate of 20 per minute. Body growing warmer; cyanosis leaving. Forced respirator now used at intervals of fifteen or twenty minutes, whenever natural respiration lags.

10 P. M. Respiration, 22 per minute; pulse, about 200, stronger. Forced respirator used once or twice between 10 and II o'clock. Everything points to recovery. No movement of body has been detected.

11 P. M. Respiration, 26 per minute, strong, full; occasional twitches of muscles noticed. The child endeavored to cry soon after.

Between this hour and 12, the child cries and takes nourishment. Respiration continues strong and ranges about 26 per minute; abdomen quite tympanitic. The child fully recovered; no lung trouble intervened.

CASE 3. Mrs. M; afflicted with neuralgia of stomach; was in the habit of controlling pain with morphine. On this occasion she had taken about two and a half grains without relief, during ten hours. A physician was then summoned, who gave one-fourth of a