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Blood-letting when uræmic coma is fully developed

Cases illustrating effects of blood-letting

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

the practice.

Free blood-letting indicated in uræmia

Not a certain remedy in all cases

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Effect of abstraction of blood dependent on the degree of occlusion

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

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

Dyspepsia precedes cardiac apnoea

Irregularity of cerebral circulation

Pathology of Cardiac Apnœa

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Cardiac apnoea not exclusively connected with disease of coronary

arteries

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

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Changes external to the heart: ossification; pericardial adhesion;
or serous effusion

Effect of these conditions in arresting circulation

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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

CLINICAL ESSAYS.

ESSAY I.

ON SUBCLAVIAN MURMUR.

The

IN conducting auscultatory examinations of the chest, the physician now and then meets with a passing murmur under one or both clavicles. To the inexperienced, it is difficult to determine whether the sound is connected with respiration or with the circulation; for it obtains in many cases that the sound, which seems arterial, is so peculiarly associated with the respiratory act, that its source assumes a double character. sound has been described by few authors, but it is known to most persons who are extensively engaged in stethoscopic inquiries. I once heard Dr. Kirkes read a concise paper on the subject; Dr. Sibson has also referred to the murmur in explanation of its origin; and Dr. Thorburn, in the British Medical Journal for June 18th, 1859, has entered into a description of it in a paper entitled "A Peculiar Auscultatory Phenomenon". Dr. Thorburn, in certain doubts which he offers as to the origin of the

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sound, expresses what is, I believe, a general feeling. I shall endeavour in the succeeding observations to clear up the obscurities of the phenomenon, and to exhibit it in its true and simple light. The importance of the labour, in a diagnostic sense, I cannot better explain than by stating the fact that, within the last three years, four cases have been referred to me as cases of aneurism in the thorax, which have proved on further examination to be nothing more than well marked examples of subclavian murmur; cases, as we shall hereafter see, very innocent in their nature when compared with aneurismal disease.

I will follow out the description of subclavian murmur from its history, as it is written in the natural facts.

OBSERVED FACTS AND ANALYSES.

In 1856, a young man came before me at the Royal Infirmary for Diseases of the Chest, complaining of great lassitude, thirst, flatulency, depression of spirits, and palpitation of the heart. He was a tall, thin, anæmic man, by trade a cabinet-maker, and evidently of an irritable and what is popularly called "nervous" temperament. On examining his chest, I was surprised to hear under each clavicle a sharp loud murmur, synchronous with the systole of the heart, and resembling closely an aneurismal bruit. Tracing the murmur downwards towards the heart, I found it becoming reduced; whilst over the heart it was absent altogether. Each cardiac sound was clear, well defined, and natural. I followed out the courses of

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