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 diarrhoeal 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 diarrhoea; 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.

DIAGNOSIS OF URÆMIA, ABSOLUTE AND DIFFERENTIAL.

The symptoms of uræmia are so closely allied to those presented in other forms of disease, that it would lead me into an almost impossible task to attempt a differential diagnosis applicable to every case. I shall therefore endeavour first to establish, as near as can be, an absolute diagnosis. Such differences as may exist between uræmia and certain other allied diseases may then be noticed with rapidity, and with a certain degree of precision.

Absolute Diagnosis. I should include in the following symptoms the nearest verbal description of simple uræmia.

There are almost invariably some premonitory signs. These consist of sleepfulness-an irresistible desire to sleep at almost any time and place. With this there may be paralysis of sensation in extreme parts, as in the hands, lips, or feet. In one case with which I was acquainted, this sign frequently occurred long before the decided and final attack: the patient said he felt as if he were treading on wool, and his feet seemed to give way, although he could stand on them steadily and use them as well as ever, when he made an effort to that effect. Or, again, there is a confusion of the mind, transitory in its character, and conveying the impression that objects near at hand on which the sight is fixed are receding or dissolving. There is no vertigo, and no oppression with this peculiarity, but a feebleness and listlessness. There may also be vomiting, sometimes very severe; and in one

example I knew the ejected matter to be charged with blood, the hæmatemesis occurring at least twice as a premonitory sign. There may be occasional relaxation of the bowels, which relaxation gives relief and renders the mind clearer for a time, if it be not too profuse and too continuous. Lastly, there is very commonly a peculiar fœtid condition of the breath, a sickening odour more like that caused by sulphide of ammonium than aught else. condition yields ammonia largely.

The breath in this

Persons affected with a tendency to uræmia suffer exceedingly from cold; they feel the influence of a fall in the thermometer acutely, and the symptoms of the uræmic coma have often their date from such a declination of temperature. The action of cold in this case is evidently upon the skin and pulmonary membrane primarily, and by reflection on the kidneys, leading to congestion and obstruction. Again, these sufferers, more than others, feel the effects of a hearty meal, especially if that consist largely of nitrogenous foods. I believe that in many cases the so-called apoplexy occurring after a meal, and remaining for many hours before ending either in death or recovery, is uræmic in character.

Patients disposed to uræmia are further dangerously susceptible to the action of certain medicines. The smallest mercurial dose seems sufficient in them to shut off the renal secretion and excite the acute uræmic paroxysm. Mercury, however, is not the only drug productive of this evil. I have seen, with exception of the ptyalism, exactly the same effects