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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.

224

ESSAY VII.

ON CARDIAC APNEA.

By the term cardiac apnoea, 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 apnoea, the entrance of air into the lungs may be entirely unobstructed; for it is, as its name implies, an apnoea 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 apnoea 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

of the body, depending on an obstruction to the entrance of air into the lungs, pertain solely to dyspnoea and apnoea. These definitions of syncope and of apnoea are imperfect. Syncope, in its pure form, is not attended by any difficulty of the respiration; neither by dyspnoea nor by apnoea. The respiration fails in syncope from want of power in the muscles; but this failure is general in the muscular system, and does not stand out as marked by any special embarrassment of the respiratory mechanism. Apnoea, in its turn, embraces all conditions in which the respiration is embarrassed, and in which the patient feels an inability to respire with natural freedom. Apnoea may, consequently, be divided into several varieties, and designated according to its cause. Thus, if it should arise from obstruction in the larynx, the apnoea would be "laryngeal;" if in the bronchial tubes, "bronchial;" if in the structure of the lung, "pneumonic;" if from arrest of blood to the lungs, "cardiac." For be it observed that the apnoea from arrest of blood on the right side of the heart has, for its essential character, a disturbance between the normal relations of air and blood. The blood inspires and expires; and the production of apnoea is as perfect and as obvious in effect when the blood is cut off from the air, as when the air is cut off from the blood. Such differences as exist in the forms of apnoea are, it is true, definable and objectively striking, but essentially the forms are all alike in effect.

I purpose in the following essay to bring into one

view cardiac apnoea, under whatever circumstances it may arise; to follow it as a distinctive indication into those various forms of disease in which it may develope itself; and to show that, in whatever disease it is recognised, it has one essential cause and a specific importance.

OBSERVED FACTS AND ANALYSES.

A male child, seven years of age, was seized with symptoms indicating laryngeal inflammation. The attack was slight; and, after the application of two leeches to the throat and the administration of antimony for a few hours, the inflammatory signs seemed entirely broken. I left the child on the second evening much better, breathing freely, and playing in its bed. Soon afterwards it fell asleep, but awoke at four on the third morning, uttering a scream. When the parents turned to it, they saw that it was pale as marble. Its face and hands were cold; the efforts at breathing were terrible; and the action of the heart. was such that the movements of the bed-clothes indicated every pulsation. I was summoned, and arrived to see these symptoms in all their fatality. I questioned the little sufferer if he were in pain; he pointed to his chest as the seat of the oppression. Constantly restless, he would raise himself on his elbows to fix his chest, and fill it by one long and painful gasp. The stethoscope showed that there was no obstruction anywhere to the entrance of air to the lungs. The first sound of the heart was faint, the second clear; but the action was irregular and

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