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last, as by an inevitable tendency, in the conception that the remedy, to be useful, could not be carried too far. Thus it was brought into general discredit by the effort to make it do too much.,

In these days we have departed from the principle of studying remedies in detail, to study symptoms and pathology in detail; and this departure is good and safe. But it should do more than it has done: it should lead us rationally to apply every means of cure that may seem suited to every given form of disease, and to classify the specific remedies for our diseases as accurately as we tabulate the signs by which the diseases are known, and the organic devastations by which their course is marked.

Returning to uræmia: when the coma is profound and death is imminent, and the diagnosis is sure, the remedy is blood-letting. The remedy should rarely be applied more than once, but then boldly, until in truth the oppression is relieved and the consciousness shows proofs of return. Let there be no local bleeding or half-measure; that is merely taking away the life-element without object, without, for an instant, setting the body at liberty from the poison ; but let a vein be opened by a free incision, and let the blood flow, until not the quantity taken but the effect produced determine the cessation of the current. We have had an illustration in point, bearing immediately on this advice. In the case recorded in pages 142-4, a child was relieved at once by one copious disgorgement of blood; but when this same child, some weeks later, was seized in the same manner, and treated


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this time by local blood-letting; the treatment was followed, not by relief from the symptoms, but by transition to death; the depressing effect of the slow exudation of blood acting probably with the poison.

But while I thus advocate the use of free venesection in extreme cases of uræmia, it is not rational to hold out the belief that the remedy is certain in every case. We may learn, from experiment, an important fact in reference to the remedial value of blood-letting in uræmia. If a dog, in which the function of both kidneys is suppressed, be bled when the uræmic symptoms appear, he will for a time rally from them; he will take food, lose his convulsions, and, in fact, temporarily recover. Again the urea and the water will accumulate ; again the symptoms will present themselves, and again they may be relieved by the abstraction of blood. Life can thus be preserved twice, and even three times as long as would be the case were the animal left simply to its fate; but the remedy is not potent to cure, because its frequent repetition is itself a fatal procedure. Thus, in this experiment, the remedy is palliative only. But if another similar animal, in which the function of one kidney is arrested, be bled when the symptoms of uræmic coma and convulsion have appeared, they will disappear on the abstraction of blood; if they reappear, the symptoms may once more be relieved by venesection; and now, if the bleeding be effectually done, the relief will often be permanent. The one remaining kidney, freed from its con

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gestion, will recommence its action, and recovery will begin in earnest.

In the case of the human sufferer subjected to the uræmic poison, the effect of abstraction of blood will turn, as in the experimental cases, on the degree of occlusion in the kidney. If both kidneys be so far diseased beyond mere congestion, from structural degeneration or tubular blocking, that secretion is entirely checked, we cannot expect more than temporary relief from abstraction of blood; but in truth such extreme changes are exceptional, and therefore is blood-letting a rational and proper remedy in all cases, selected according to the principles which I have endeavoured now to supply.

Further, in uræmia, one of the great dangers of venesection, frequently encountered in certain forms of active disease, is not to be feared. In inflammatory disorders, for which venesection has been so egregiously extolled, and yet so loudly condemned, the tendency of the blood is to fibrinous deposition, and the tendency of abstraction of blood, unless performed very early indeed, is to the same result. Hence, blood-letting in inflammation destroys not by absolutely emptying the system of blood, as is commonly thought, but by producing a deposit of the fibrinous part of the blood in the heart, which deposit mechanically arrests the circulation. In uræmia, this tendency of the blood to deposition (except there be inflammatory complication) is absent, and therewith the danger, incident in other cases to the removal of blood, is absent likewise.


Finally, when in uræmic coma blood has been drawn and the congestive symptoms have been relieved, and the consciousness has returned, it remains still to relieve the kidneys of extra work, and to save them from congestion, by continuously keeping up a free but safe eliminative action from the cutaneous and alimentary surfaces. If the patient be rendered feeble, he may be supported with good food, with steel, and even with wine; but moderate over-secretion must never be checked, under the fear of the depression it may cause; for now vicarious elimination is a substantial aid to life, and a purgative or diaphoretic, used within reasonable bounds, is virtually a tonic remedy.

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By the term cardiac apnea, I mean a form of breathlessness often terminating in death, which is due to the fact that, in the cases in which it is presented, the pulmonic current of blood is being withdrawn from the air. In this apnea, the entrance of air into the lungs may be entirely unobstructed; for it is, as its name implies, an apnea commencing exclusively in the circulation, and at the heart. The symptoms by which this form of breathlessness is characterised, have been noticed at different times by various names : such as, “angina pectoris," “cardiac asthma," "spasmodic respiration,” and “syncopal asphyxia.” But these terms have only served to connect the symptoms with some particular form of disease, and have been introduced without any specific attempt to define the exact cause of the symptoms as symptoms, sui generis.

Further, cardiac apnea has often been confounded with syncope, from an impression, very generally diffused, that whilst all failing states of the body, depending on arrest of the blood in its circuit, pertain solely to syncope, so all failing states


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