28 DISEASES OF THE KIDNEY. 



this disputed point ; but, at all events, enormous hypertrophy of the 

 neart sometimes occurs even in the second stage of Slight's dis- 

 ease, and assuredly the circulatory disturbance of the kidney is not 

 the sole cause of it. As is well known, the signs of the enlargement 

 are not very striking, but, by paying attention, we can often detect an 

 augmented heart-shock, or, in its absence, hear remarkably loud car- 

 diac sounds. 



In a great number of cases, the symptoms of the so-called uraemio 

 poisoning do not appear at all throughout the entire course of the com- 

 plaint. Sometimes they develop slowly and gradually; sometimes 

 they come on very suddenly. At times (but not always), the attack is 

 preceded by a decrease in the secretion of urine, and in rare instances 

 it has happened that, during or immediately prior to the appear- 

 ance of the uraemic phenomena, the normal flow of urine has been 

 largely exceeded (Liebermeister). It is a suspicious sign when pa- 

 tients complain of severe headache, and become languid and apathetic, 

 and still more so, if these symptoms be accompanied by vomiting, 

 which occasionally is so very obstinate as to awaken apprehension of 

 serious disorder of the gastric mucous membrane. All these symp- 

 toms may subside again, without evil consequence ; in other cases, 

 however, the drowsiness increases to a deep stupor, or convulsions of 

 an epileptic or more rarely of a tetanic character may arise. Even 

 when the convulsions have not been preceded by drowsiness, they are 

 usually followed by a condition of deep coma with stertorous breathing. 

 The fits recur at longer or shorter intervals, the stupor meanwhile con- 

 tinuing to grow deeper ; and the patient may finally succumb to gen- 

 eral paralysis. It is not at all rare, however, for the fits gradually to 

 become less frequent, the intervening stupor less profound, and for the 

 signs of " uraemia " to disappear, perhaps not to recur for weeks or 

 months. In a previous section, we have already acknowledged that 

 we are unacquainted with the nature of the poison causing uraemic 

 intoxication. There is a second difficulty in explaining the uraemia of 

 parenchymatous nephritis, since certain well-attested cases of uraemia 

 poisoning have been observed, in which there was no suppression of 

 urine. If the urea and other material to be eliminated from the blood 

 pass into the tubules by a process of pure endosmosis, it remains in- 

 explicable how these materials can accumulate in the blood when the 

 urine is secreted freely ; hence we must assume that the epithelium 

 of the urinary tubules has some important influence over the secretion 

 of urine, and therefore that its disease or death may occasion an ab- 

 normal state of the blood, even though the kidneys continue to dis- 

 charge a sufficient quantity of liquid. Moreover, I think that it would 

 be going too far to attribute all the grave nervous symptoms which 



