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their mother before becoming seriously ill. Both children were now insensible and violently convulsed : their skins were slightly discoloured to a light copper hue all over the surface. The pupils were fixed and dilated. Scarlet fever was present at this time in the neighbourhood; and my mind was perplexed with the doubt whether these children were suffering from uræmia, or from some poison taken by the mouth. After a little time I observed that in one child there was, with the convulsions, a distinct attempt at vomiting. I at once acted on the suggestion supplied, gave a dose of sulphate of zinc, tickled the fauces, and produced in this child free emesis ; there were brought up portions of leaves of some plant and small seeds. I turned to the other child, and treated it in the same way with similar results. After the vomiting both children rallied, and next day were well. They recorded plainly enough the cause of their symptoms; they had gathered and eaten the leaves and fruit of the atropa belladonna. I went with them to the place where they had gathered the poison, and saw the plant from which they had eaten.
This case is not irrelevant to the present essay. It indicates the analogy which exists between the symptoms of scarlatinal uræmia and those of poisoning by belladonna, and the possible mistake that may be made in the diagnosis.
I have yet a record of another case where an aged man, suffering from albuminuria, was subjected frequently to attacks of diarrhea, attacks which were, in truth, compensatory in their natural intentions. During one of these diarrhæal periods, he had a few repeated doses of grey powder combined with Dover's powder, with the effect of intense and rapid saliva- . tion. He recovered from this condition slowly. Twelve months later, having been exposed to wet in superintending the repairs of some house properties, he took what he considered to be a cold, and suffered again from copious diarrhea. Once more the grey powder and Dover's powder were administered, this time on the prescription of a physician, who, having no cognisance of the condition of the patient's urine, treated him simply for diarrhæa. Once more, but with greater rapidity, the mercurial ptyalism was developed, attended with profound coma and frequent convulsive attacks. On the third evening of the illness of this gentleman, I saw him with his own medical adviser, and passed the night in attendance. The symptoms were unmistakable and most severe; the body was generally warm, and at times hot; the coma was profound and the breathing heavy; the pupils were slightly dilated, and fixed. The effects of the mercury were such that the gums were enlarged throughout the whole of their surface, the lips were swollen, the teeth were loose, and saliva was constantly exuding from the mouth. About every two hours, the scene of deep repose was changed by the occurrence of a violent convulsive paroxysm. The convulsion commenced in the muscles of the face, then extended to those of the neck
and trunk, and at last to the limbs. I should compare the attack rather to a shaking of the whole body than to an epileptiform seizure; for in epilepsy some one part of the body is usually fixed, while the limbs are cast about; but here body and limbs together were ruthlessly disturbed as by a general and evenly disposed shock, in which not a single muscle escaped. The attacks lasted about fifteen minutes and then subsided; the coma, which had never relaxed, remaining again sole lord of the evil. The pulse was full and slow-even during the paroxysm this did not vary: the respiration was slow and deep, but the vesicular murmur was clear. The bowels were at this time constipated, the mercurial opiate having done its astringent mission only too well. At times a little urine was passed in a semi-voluntary manner, and on examination was found to be so charged with albumen, that it formed a coagulum shaped to the iron spoon in which it was heated. When a firm grasp was made over the loins, the patient shrank as though this part were tender to the touch, but elsewhere no expression of pain was elicited by pressure. The symptoms being urgent and apparently hopeless, I advised with my medical colleague the free abstraction of blood. This agreed to, we cupped freely over the loins; and, the coma remaining, we next removed twelve ounces of blood from a vein in the arm. It is the fact that, while this blood was flowing, the patient for the first time in seventy hours became sensible, sat propped up by pillows, recognised all his friends, remained conscious after the venesection
for several hours, took some beef-tea, and arranged certain business matters which had been pending for his decision. Early on the fourth morning, the friends of the patient called in a third opinion, that of an eminent physician since deceased. It was unhappy that, when he came, while he agreed with me as to the pathology, he and my other colleague differed from me in respect to treatment. I insisted on following up the venesection by a gentle series of saline purgatives, containing small doses of colchicum; being guided in this suggestion by the belief that the original diarrhæal flux was an eliminative act, and ought to be reinduced. My friends thought otherwise; and, as the difference between us was very wide, and I was in a minority and the junior of the consultants, I thought it best, as it was my duty, to retire in an amicable way from a case, in the management of which I could not conscientiously take part on a common understanding. On the evening of the day in question, the patient relapsed into the comatose condition, and on the following morning died in one of the convulsive paroxysms. It is possible that the same result would have occurred under any circumstances, for an active purge might, as my colleagues thought, have induced a fatal diarrhea ; but, taking all in all, I have always regretted that that risk was not accepted, and that an effort was not made to relieve steadily the congested imperfectly acting kidneys by exciting a demand on another emunctory surface.
I have thus adduced eight cases; in six of which
there was positive uræmia; in two, simulated uræmia from the effects of a narcotic poison. The uræmic patients were of widely different characters, presenting gradations from infancy to old age. In the three youngest examples, the disorder was a result of scarlatina; but in one of these the original disease had long passed away, while in the remaining two it had scarcely laid its hand on its victims. In the woman of middle life, the uræmic state was the direct result of alcoholic intemperance, syphilis, and perhaps mercury_trinity of disease-makers. Of the two men advanced in life, both suffered, previously to the final attack, with manifestations of intestinal derangement; and one was twice salivated by doses of mercury, which even to children are considered as innocuous. All the six cases ended fatally, the fatal symptoms being closely identical. In each example the comatose symptoms, from their first appearance to their termination in death, were included in a period of time, the extreme duration of which was eighty-three hours. In four of the cases the fatal illness was with the first attack, and in two with the second. In these last two cases, recovery from previous seizures had occurred; in one apparently under the direct influence of treatment, in the other spontaneously, and in spite of mercurial ptyalism. The cases thus given, selected from many others, afford illustrations of all the typical forms of uræmia.