Various degrees of consciousness in extreme state

Special occasional symptoms

Differential diagnosis

ib.

. ib.

156

ib.

General rules of diagnosis

Ammonia in the breath not of peculiar diagnostic value.

Pathology of Uræmia

The blood

Alkalinity of this fluid

Changes in red corpuscles

Changes in the fibrine and serum

Case in which the serum was white

Increase of urea in the blood

Effusions common in uræmia

Congestion of vascular organs

Congestion may be followed by effusion of fluid containing urea

Morbid conditions of the kidney in uræmia

Pathology of the urine in uræmia

Cause and Causation of Uramic Coma

Uræmic coma the result of arrested secretion of urine

Symptoms caused by suppression of function of kidney

Synthetic uræmia identical in effects with uræmia from disease

What is the poison that produces uræmia?

Difficulty of the question, and proper mode of examining it

Composition of the urine

Certain constituents excluded as the causes of uræmia

Water in excess produces symptoms like those of uræmia

Results of injecting water into the peritoneum

Changes produced in the blood

Resemblance of symptoms to uræmia only partial

Excess of water not the true cause of uræmic coma

Is urea the poison ?

Different results from experiments on animals

Effect of administering urea by the mouth

Effect of injecting urea into the veins

Experiment by Dr. Hammond

ib.

Injection of urea under the skin

Post mortem appearances after injection of urea

Does the urea act unchanged, or does it undergo decomposition?

Is excess of ammonia in uremic blood constant and necessary?

Dr. Hammond's reply in the negative

Errors in Frerichs' hypothesis of carbonate of ammonia

Cases sometimes occur in which there is an excess of ammonia in

the blood

Does the exhibition of ammonia in large doses produce uræmic

symptoms?

Effects of injecting ammonia into the veins

Differences between urea and ammonia in physical characters and

action

Dr. Barker's experiment with carbonate of ammonia

Toxic effect of carbonate of ammonia on the human subject

Observations of Huxham

Comparison between ammoniacal and uremic toxæmia

Pathological state of animal poisoned by carbonate of ammonia

Conclusion from pathological appearances

Effects of urea and of ammonia on blood

Urea does not per se produce extra fluidity of blood
Summary of investigations of the cause of uræmic coma

. 177

. 179

ib.

180

ib.

ib.

182

ib.

ib.

183

The body resists fatal accumulation, unless the renal obstruction

is sudden and complete

Explanation of phenomena of acute uræmia

Congestions and exudations

Series of causes of death in uræmic poisoning

Urea a true narcotic poison

ib.

195

. 198

. 199

Relations of Uræmia to Forensic Medicine

Uræmia may be confounded with narcotic poisoning

With belladonna-poisoning

With opium-poisoning

With poisoning by cyanides

Consideration of cases in which, during uræmia, medicines are

given which increase the effects of the disease

Treatment of Uræmia

Consists in prevention of acute attack, and application of direct

210

Not to be checked if moderate

Simple astringents may be given if required

The foregoing rules applicable to several conditions in which

uræmia occurs

Treatment of attack of uræmic coma

Skin or bowels to be brought into action

Blood-letting when uræmic coma is fully developed

Remarks on blood-letting in past times, and the errors attending

Effect of abstraction of blood dependent on the degree of occlusion

of kidney

Tendency to fibrinous deposition absent in uræmia

Treatment when congestive symptoms are relieved

214

ib.

215

ib.

ib.

. 216

. 217

Cases of apnoea dependent on fibrinous concretion in the right side

of the heart.

Case dependent on disorganisation of the muscular wall of the right

side of heart

Case dependent on pericardial adhesion and ossification
Case dependent on tonic spasm of the heart

Case dependent on alkaloidal poison in the blood
Summary of conditions inducing cardiac apnoea
Diagnosis of Cardiac Apnea, Differential and Absolute
Differential diagnosis

From laryngeal apnœa

From bronchial apnoea

From pneumonic apnœa

Special symptoms distinguishing cardiac from all other forms of

apnœa

Diagnosis from tetanus

Air-passages free: muscles of respiration spasmodically contracted ib.

Coldness of body

Acute pain through chest

Muscular spasm and pain.

246

May exist long without inconvenience

Physical diagnosis denotes absence of pulmonic or valvular disease ib.
But the heart's action is irregular

Patient not conscious of this irregularity, though he sometimes
feels a symptom which he attributes to it

Dyspepsia precedes cardiac apnoea

247

ib.

248

Irregularity of cerebral circulation

Cardiac apnoea may not be fatal until some mechanical obstacle to

the circulation is presented

Case of long-standing cardiac apnoea with fatty deposit and

atheroma, fatal from suspension of the action of the tricuspid

valve by fibrinous filaments

Fibrinous deposits in a healthy heart

Situation and forms of deposit

Changes external to the heart: ossification; pericardial adhesion;

or serous effusion

Effect of these conditions in arresting circulation

Cardiac apnoea from spasmodic contraction of apparently healthy

heart

Condition of heart varies in cardiac apnoea dependent on poison

External surface of body generally blanched after death

Rigidity dependent on presence or absence of muscular contraction

at time of death

Venous congestion of internal organs generally present

ib.

249

ib.

ib.

. 250

ib.

ib.

251

But lungs may be bloodless, if the obstruction be in the right side

of the heart

Cause and Causation of Cardiac Apnœa

Predisposing cause either in the heart or in the blood

Exciting causes various

Profound sleep the most frequent exciting cause

Flatulency an exciting cause

Cardiac apnoea may occur without predisposing cause from the

introduction of poisons

Symptoms during attack reducible to muscular spasm, pain, and

reduced temperature .

Conditions necessary for perfect balance of muscular force

Demonstrative experiments

Symptoms of cardiac apnoea may be imitated by galvanism

Lessons from observation and experiment

260

ib.

ib.

Cardiac apnoea excited by any cause depriving the heart of supply
of blood by coronary vessels

Reasons why voluntary and involuntary muscles are not equally

implicated in all cases of sudden arrest of the heart's action. 264

Resumé of cause of cardiac apnoea

Treatment of Cardiac Apnoea

Treatment not likely to be effectual when attacks have been

decided

Predisposition may be reduced when paroxysms are slight

Intemperate habits to be reformed

But alcoholics not to be suddenly and completely removed

Tendency to deposit of fat to be reduced by change in dietary

Reduction of sugar

265

ib.

ib.

ib.

ib.

ib.

Mercury and digitalis to be specially avoided

Alkalies indicated where there is deposit of fibrine

Treatment during paroxysm

Air, sitting or semi-recumbent position, and warmth

Caloric necessary to muscular relaxation

Heat best applied through the stomach

Antispasmodics may be used with caution

Direct sedatives dangerous

Artificial respiration the only resource in extreme cases

. 267

ib.

ib.

ib.

. 268

ib.

ib.

269

. 269