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acid in the breath. The case terminated favourably by free diaphoresis in about three hours.

These, taken as the symptoms arising from a small dose of the cyanide, present many features not unlike those of uræmia rapidly developed. But there are differences which would make the effects of the cyanide clear; there would seem to be less frequent convulsion, greater coldness of surface, and less determinate coma than in uræmia. Besides these facts, in the matters vomited the presence of hydrocyanic acid would be readily detectable.

After death from poisoning by the cyanide of potassium, the pathological indications presented and the chemical analysis which would be instituted, would alike tend to determine the poison. For the cyanide of potassium produces an universal redness and intense congestion of the alimentary surface of the œsophagus, stomach, and superior part of the small intestine; while the tests for the hydrocyanic acid, if the parts have not undergone long decomposition, testify sufficiently the nature of the destructive agent.

So much for cases in which the medico-legal question to be solved consists in the determination of uræmic poisoning, against the effects of other narcotic and irritant substances; but we have yet to consider, in a forensic point of view, another class of cases in which, during the existence of an uræmic condition actively presenting itself or remaining latent, agents are given as medicines which hasten

the effects of the natural disease, and induce, by this indirect means, a fatal result.

Instances are frequently occurring in which the administration of medicines to meet special symptoms of a simple kind, have led to results which have, by the public and even by the profession itself, been attributed to an injudicious application of the remedies employed. Thus, the administration of opium to check a diarrhoea or to soothe pain, produces now and then, although the dose administered shall have been properly apportioned according to general experience, a fatal coma. We say when such examples occur, that the patient suffers from a peculiar constitution or idiosyncrasy; and we extend again the same explanation to cases in which salivation follows. the administration of a moderate, or even small, dose of mercury. But we have seen enough, I

think, in our present studies respecting uræmia, to read off the meaning of these idiosyncrasies, and to substitute a reality for a name. We have seen that, whenever the uræmic diathesis is present, then the effects both of opium and of mercury are intensified; and the conclusion I would draw from such information is, that in all cases where death succeeds upon the administration in an ordinary dose of a common narcotic or a mercurial medicine, it should be the business of the expert to inquire into the condition of the kidney; to test for albumen any urine that may have been passed by the patient, or retained in his bladder; to examine even the blood for urea; to examine any effused serous fluid for the same substance; to

compare the general symptoms, and the morbid changes, with the absolute signs and sequelæ of uræmia—and in every particular to endeavour to ascertain the relationships that may exist, between the influence of the exciting agent, per se, and the diathesis under which the patient has laboured.

So many examples have occurred within these last few years, in which great obscurity and contradictions have arisen in reference to the poisonous properties of particular and common remedies, that too much stress cannot be laid on the importance of the practical inquiry here pointed out, in all future cases similar or identical in character.

TREATMENT OF URÆMIA.

The treatment of uræmia embraces two distinct heads; the prevention of an acute attack, and the application of direct measures on occasions when acute symptoms have, from any cause, been set up.

The principles of prevention in every case where uræmic coma threatens those who are suffering from chronic renal disease, are few, simple, and effective. The first great element in the treatment consists in securing, as far as is possible, a free eliminative action of the skin. Towards the fulfilment of this object, the skin, over its entire surface, should be kept scrupulously clean, by at least one daily ablution. In such ablution it is not requisite to subject the patient to extremes of cold or of heat, nor to violent rubbings, rinsings, and such like water-bath ceremonials. It is sufficient for all purposes if the patient

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will keep every part as clean as he does those parts which are exposed to the light. A pail of cold or tepid water in a common bath is all-sufficient; neither need the washing be a long or formal process. To step into the water ankle deep, with a good glovesponge to wash the surface freely and carefully, and to dry effectually with a rough towel, these are the requirements, and these alone. The whole proceeding is a matter of ten minutes, and, carried out night and morning, is no great encroachment either on time or labour.

Granting, however, that the ablution can be made once only in the day, it had better be conducted at night than in the morning; for during the day a free accumulation of foreign and excreted matters takes place on the skin, to sleep in which is most unwholesome and injurious. During the night this accumulation is trifling in comparison, but still it is better to remove it also in the morning.

Coincidently with free ablution, active exercise of the body is essential; and of all exercise, that on foot is the best. The exercise, in point of duration, may be prolonged, but it should always be so tempered as not to subject the patient to sudden alternations from heat to cold. Nor should the patient, when he has taken a walk or performed any muscular effort to produce a warmth of the surface, linger about in cold, or chilled, or damp air.

In extreme cases, where the suppression of the renal secretion is such as to demand a greater secreting force for the skin, the hot-air bath may

prove very valuable; nay, the immediate risk of an impending comatose attack may be warded off, I believe, by the diaphoresis which the hot-air bath induces. Enthusiastic advocates of the bath, who teach that it is intended to supplant exercise in all who can afford to pay for it, would urge, and do urge, that the said bath is the only remedy in the class of cases now under discussion. I demur to this extreme doctrine; for I know that, in the majority of cases, the simple influences of ablution and exercise constitute the first preventive agencies, and that, so long as the skin maintains a genial function by such agencies, so long all that can be done evenly, and therefore safely, is achieved. But in saying this, I hold no reserve against the bath, in instances where rapid excretion is required. I am not sure, certainly, by what surface the excretion is, in every case, best effected, whether by the alimentary or the cutaneous surface; but in the majority of instances, perhaps cutaneous elimination is the readiest to be excited, the most pleasant, the least irritating, and as a measure for the discharge of urea, the most effective.

The diet of the patient threatened with uræmia should be of the simplest character. Alcoholics in moderate quantities do no harm, but, as it seems to me, good; for they keep the surface of the skin free, and to the circulation supply a gentle stimulus which is much required. All highly seasoned foods should, nevertheless, be avoided, and an excess of nitrogenous foods equally so. Animal food should not be taken.

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