the serous cavities remains pent up therein, and cannot, as in the case of exudations from the mucous surfaces, be at once got rid of, and the liability to mischief from prolonged contact with the membrane be thus obviated. Wherever exuded, the serous fluid, impregnated with urea, will probably act as a local irritant to the part with which it comes in contact; but, from the mucous surface, it is swept away as fast as poured out; while, in the serous cavities, and the cellular tissue of the integuments, or of organs, it necessarily remains until re-absorbed, and may readily be supposed to induce the inflammation which the serous membranes, the cutaneous cellular tissue, and the substance of cellular organs such as the lungs, are apt to undergo. The several peculiarities observed in the serous inflammations ensuing in the course of renal disease, may, probably, in a great measure, have their explanation in the view here taken of the cause of these secondary inflammations. The inflammatory process, as it occurs in this disease, differs in several respects from that arising spontaneously, or excited by any other cause than renal disease. In its mode of onset it is usually insidious, commencing and progressing with scarcely any of the general or local signs of inflammation, no pain, and no fever, and, therefore, often not discovered till after death, or detected during life by a mere accidental auscultation. It commences, too, very frequently, in one or more serous membranes simultaneously, and quite independent of any obvious exciting cause, such as exposure to cold, and, therefore, scarcely explicable on any other supposition than that of a contaminated condition of the blood. In duration it is usually protracted far beyond the ordinary term of existence of common inflammation.

The products of the inflammatory process are likewise different from those in ordinary inflammation. Instead of meeting, in fatal cases, with the evidence of acute inflammation, as afforded by vivid redness of the surface, and layers of firm, fibrinous lymph intermingled with pus, it is usual to find but little vascularity of the affected membrane, while the lymph is of a soft, curdy, flaky kind, floating in a pale milky fluid, and rarely deposited in tough laminated strata on the surface. Everything, in fact, tends to show that the inflammatory process is of a low form, and unattended by the characters of ordinary active inflammation. In part this peculiarity may be dne to the state of general debility and anæmia which the renal disease almost invariably induces; but it is probably also in great measure dependent on the cause which has given rise to the inflammation, namely, according to the view just stated, an unhealthy and irritating quality of the fluid exuded into the serous cavities, which fluid, like the serum of the blood, is more or less charged with the elements of the impeded urinary excretion. The fluid in the serous cavities being at all times, in renal disease, in an unhealthy condition, probably acts as a permanently local irritant of a more or less active kind, according to the amount of urea it contains. Hence may arise the peculiar dull, opaque, milky appearance of the various serous membranes, and the pale, slightly turbid, or flaky character of the fluid within them, met with so very frequently in fatal cases of renal disease, whether of the acute inflammatory kind, as after scarlet fever, or of the more advanced and degenerate form. When the serous fluid contains a considerable quantity of urea, in consequence either of rapidly-ensuing structural changes in the kidney, or of any sudden arrest of dropsy into the cellular tissue, or a catarrhal discharge from a mucous surface which had hitherto served in some measure to rid the blood of part of the excrementitious material accumulating within it, then the additional irritation thus produced lights up a more active inflammation in one or several of the serous membranes, and in this way may bring the disease to a fatal termination.

The several peculiarities just mentioned as belonging to the serous inflammations in renal disease are exhibited in the following few cases, which are of quite an ordinary kind. The following case, which is an example of inflammatory dropsy, probably consequent on the scarlet-fever poison, illustrates, among other points, the statement made above concerning the nature of the fluid usually found in the serous cavities in fatal cases of renal disease.

Case. Jane Robinson, aged 7, admitted into Mary ward, October 25, 1849, under Dr. Roupell, affected wtth extensive general anasarca. The surface of the body had the peculiar, pale, waxy appearance so common in acute renal dropsy, especially in children. She had a dry, wheezing cough, and a slight difficulty of breathing, explained by some mixed crepitations diffused through the lower half of each lung behind; but she complained of no pain; her aspect was bright and cheerful; tongue

nearly clean, appetite good, and the bowels freely open; her urine, however, was scanty, pale, turbid, and highly albuminous; examined microspically, it exhibited (a), a few blood corpuscles (b), a few fibrinous casts of urinary tubules, containing much granular material, with traces of corpuscles and nuclei (c), several free nuclei (d), large irregular masses of granular matter, and (e), numerous tesselated epithelium scales, separated and grouped-no oil. The child had been ill for about seven weeks, its ailment commencing with slight feverishness, unaccompanied by either rash or sore throat, but followed, in a week, with desquamation of the cuticle of the hands; the attack was not sufficiently severe to prevent its playing about; but in about three weeks its abdomen rather suddenly began to swell, and the dropsy then speedily extended to other parts. A week before admission, cough came on, accompanied with difficulty of breathing, which, at times, became very urgent. In a day or two after admission, with increase in the cough and difficulty of breathing, a distinct, though soft and churning pericardial rubbing sound was detected in the cardiac region, and it continued, with increased cardiac dulness on percussion, to within two days of the child's death, when it gradually became indistinct. During the eight days it was under observation in the hospital, the child's cough and difficulty of breathing continued, and the latter gradually became more distressing, in spite of the various measures applied for its relief. The last twenty-four hours of its life were spent in a state of great distress from the urgent dyspnoea.

On examination after death, the kidneys were found larger than natural; the cortex extremely pale, though variegated with a few star-like blood-vessels; the. medullary portion of a deep red colour. Through the capsule, but more distinctly on its removal, there were observed on the surface of each kidney, numerous closelyset, minute, pale yellow specks, like so many fine grains of sand. On section, the cortex appeared filled with the same yellowish-white material of which these specks consisted; the cut surface had the peculiar dull, yellowish-white, streaky appearance not inaptly compared to the section of a parsnip. Examined beneath the microscope, portions of the cortical structure exhibited the urinary tubules crowded and distended with granular matter and epithelial cells; the Malpighian capsules were similarly ⚫ distended; while, over the field, were numerous large circular masses of granular material, which appeared to represent the minute grains seen with the naked eye on the cortex, and probably consisted of separated Malpighian bodies, with granular matter enclosed in the capsule. The pericardium contained about 3 ss. of turbid, whey-like fluid; while a few firm granules adhered to the root of the great vessels. In each pleural cavity were about six ounces of similar pale, turbid fluid; and about a pint of the same existed in the peritoneal cavity. There was no undue vascularity or recent deposit of lymph in any of the serous membranes. The heart was much enlarged, especially the left ventricle; the valves were all healthy. The lungs were pale, solid, and heavy, from extreme edema of the pulmonary tissue, though crepitant at all parts. Nothing worthy of note in relation to the case was observed in any of the other organs.

Here, in a recent attack of acute renal dropsy, the fluid in all the serous sacs presented the pale, milky character mentioned as being so generally observed in renal disease, even independent of any decided evidence of inflammatory action. The fluid, differing as it does from that transuded in cardiac dropsy, is evidently in an unhealthy condition, and may, in consequence, be supposed likely in time to induce irritation and inflammation of the delicate structure with which it remains in contact. Besides the illustration which this case seems to furnish in regard to the point just mentioned, it affords important information respecting the pericardial friction-sound perceived so distinctly during several days in the child's life-time; showing that this sign, when occurring in dropsy after scarlet fever, does not invariably indicate an active inflammatory process, to be combated by antiphlogistic measures; for there was no increased vascularity of the pericardial surface, or product of inflammation within its cavity, found after death. The cause of the friction-sound in this case must remain matter of speculation; possibly it depended on some dryness and roughness of the surface existing previous to the exudation of the serum found after death; for as yet we have no evidence that mere serum in the pericardial cavity can give rise to a perceptible rubbing sound.-Med. Times and Gaz., June 25, 1853, p. 643.

59.-On Diabetes Mellitus. By M. SCHUTZENBERGER, Strasburg.-[From a case related by this gentleman, this disease may, by appropriate treatment, not only be arrested, but the patient restored to comparative health. The author concludes by the following rules and deductions:]

1. Glucosuria is not an incurable disease, and although the tendency to relapse is certain, it is possible, by perseverance, not only to remove the sugar from the urine, but also to bring the patients so far as to bear a varied diet, in which feculent substances may enter without causing a relapse.

2. The amount of glucose excreted by patients is sensibly proportionate to the quantity of feculent matter added to the food, and it is possible to discover errors of diet by the increase of the glucose in the urine. The quantity of urine is equal to that of the fluid ingested, and the latter also proportionate to the amount of the feculent substances taken into the economy.

3. Diet forms the principal part of the treatment of glucosuria; the food ought chiefly to consist of milk, fatty substances, butter, oil, eggs, and meat.

4. The entire banishment of feculents seems necessary to make the sugar disappear completely.

5. Small quantities of bread, viz., about three ounces per diem, are generally well borne, and do not excite a fresh secretion of sugar when once it has disappeared.

6. The powers of assimilation increase gradually, and it is possible, by means of chemical analysis, to ascertain the extent to which the peculiar diet and medicine ought to be carried.

7. The effect of diet is powerfully assisted by the use of certain therapeutic agents, and especially by opium, in increasing doses, and by alkaline drinks. In this affection the tolerance of the opium is very great.

8. It is certain that the glucose is formed in the alimentary canal, and that the absorbents generally take it up, so that solid motions come to contain no sugar.

9. Purgatives may cause a diminution of glucose in the urine, as more or less of the sugar which would have passed into the urine is carried away by the liquid stools.

The author does not enter into any theoretical discussion touching glucosuria, as his object was merely to call attention to a series of interesting and instructive facts.-Lancel, Aug. 6, 1853, p. 120.

60.-CASE OF DIABETES.

[This case was related by DR. HENRY KENNEDY, at a meeting of the College of Physicians in Ireland. It is in the words of the patient himself.]

"I first consulted Dr. in London in 1851. He immediately forbad me sugar, vinegar, bread, cereal food, or anything containing sugar. He ordered me half-ounce doses of liquor potassæ three times a day, and which, in six weeks, caused an immense deposit of the sulphates in my urine,-its specific gravity being often as high as 1040. At this period I lost flesh at the rate of 71b. a fortnight, and was otherwise much reduced. I left off the medicine, found myself the better of having taken it, and shortly after became stationary in weight,-about sixteen stone. My diet at this time was very tiresome; and in August, 1851, I again saw Dr. to try if he would alter it. He allowed me maccaroni, and a vegetable product called manna croup. I used these, and in addition ate bread very moderately, and also potatoes. When March, 1852, arrived, I found myself going back again; the urine heavier, and when tested with liquor potassæ fully as dark as the strongest coffee. I had been warned about the use of particular kinds of food, and since then have never tasted them; and my urine is now about 1022, and contains but a trace of sugar. My attention was first called to my own case by anomalous pains, which I could scarcely describe, and which were at first made light of. I had also a total loss of venereal appetite. The singular part of my case is, that I have never made an unusual quantity of urine; that it has its proper smell; and that I have not suffered from thirst or a dry skin; but the moment I eat cereal food the urine increases in specific gravity. I ought to state that the warm bath is part of the treatment, and this I use daily. A little brandy is the only good thing I take. I have never yet met any medical man who

spoke of more than arresting a disease like mine: cures are said to have been performed, but there are none of a satisfactory kind.”

Such was the patient's account of his own case. Dr Kennedy then directed attention to the special points in it: 1st. The enormous doses of the liquor potassæ ; 2nd. The absence of thirst; 3rd. The small quantity of urine passed; and 4th. The active state of the skin. He also took occasion to state that there are numerous authentic cases of cure on record, and referred particularly to the seventh volume of the Edinburgh Medical and Surgical Journal in proof of this. He also alluded to the recent important discoveries of Bernard, who had clearly shown that sugar could be elaborated by the system itself; and hence, that the idea of cutting off the supply of articles containing sugar must in future be much modified. In conclusion, it was suggested that an entire change of climate might suit cases of this intractable disease.-Dublin Quarterly Journal, August, 1853, p. 212.

61.-ON GOUT AS IT AFFECTS THE BLADDER.

By DR. ROBERT B. TODD, F.R.S., &c.

[Preceding his observations by mentioning some cases in which pus is found in the bladder, Dr. Todd goes on to consider the subject of gout in the bladder. He says:]

Gout appears to me to manifest itself in the bladder in four different ways.

1st. It manifests itself as a distinct and very obvious inflammatory affection; so that I imagine, in these cases, the mucous membrane of the bladder would be found red and inflamed, presenting, indeed, the ordinary appearance of a mucous membrane in a state of inflanimation. This condition must, however, be distinguished from inflammation of the bladder, occurring from other causes, and unconnected with any specific inflammation. Gouty inflammation of the bladder is an analogous affection to gouty inflammation of the lungs, gouty bronchitis, or gouty pneumonia and gouty nflammation of the stomach. In cases of this kind there is a great tendency to the secretion of pus by the mucous membrane of the bladder. If there be any difficulty in the free evacuation of the pus, the urine becomes alkaline, from the retention of a small quantity of the secretion, and the subsequent decomposition of the urea; the highly alkaline urine, in its turn, keeps up the irritability of the bladder, and promotes the secretion of more pus. In this way, either a weak or paralytic state of bladder, or an enlarged prostate, or a stricture in the urethra may stand in the way of the complete restoration of this organ to its healthy functions.

2ndly. Gouty inflammation attacks the bladder in a different manner to that last described, so as to produce incontinence of urine. A gouty man becomes troubled with incontinence of urine, and we find that this incontinence depends upon a highly irritable state of the mucous membrane of the bladder, and a consequent inability of that organ to retain the urine, and not upon a paralytic state of the sphincter vesica muscle. In this form, the sensibility of the mucous membrane is very much exalted, and the bladder becomes intolerant of the presence of the smallest quantity of urine, so that the evacuation of its contents is constantly taking place at short intervals. The prominent symptom then, in such cases, is frequent micturition of small quantities of urine, the urine being pale, acid, devoid of mucus or pus; sometimes, it may be, albuminous, owing to the existence of gouty disease of the kidneys.

It is difficult to define the exact pathological condition of the mucous membrane of the bladder in this affection. It is an irritable rather than an inflammatory state,-a condition in which the sensibility of the mucous membrane of the bladder is greatly exalted, owing to the influence of the gouty poison, which seems capable of irritating the bladder as cantharidine does. The cases in which it is apt to occur are generally in elderly persons, whose systems seem thoroughly imbued with gout, and in whom deposits exist in the joints, or the tendinous sheaths, or in the arteries. It occurs in old persons, and often accompanies enlargement of the prostate gland. Sir Benjamin Brodie describes cases which, I suspect, are of this nature, the primary cause of the symptoms being gout. He says, "An elderly man complains of frequent attacks of giddiness. Sometimes, in walking, his head turns round, so that he is in danger of falling; and this symptom probably arises from altered structure of the

arteries of the brain, causing an imperfect state of the cerebral circulation. This state of things is sometimes attended with an irritable condition of the bladder, and, although the urine is of a healthy quality, and the bladder itself is free from disease, the patient is tormented with a constant micturition, voiding his urine without pain, but at short intervals, and in small quantity."

3rdly. A third class of cases exhibits a condition opposite to that which I have just described, in which, instead of the patient's being unable to retain even a small quantity of urine in his bladder, he is suddenly or rapidly affected with an inability to pass water, and the bladder becomes distended in consequence, causing great pain and suffering. The essential difference between these two conditions consists in this, that in the former case the mucous membrane is rendered highly irritable by the gouty poison, and kept so by some irritating quality of the urine, but in the latter case the muscular coat is the seat of the affection. There is ample evidence to show, that muscles may be attacked by the rheumatic or by the gouty poison. Thus, in subjects of gouty diathesis, it is not uncommon to meet with sudden and severe affections of external muscles, accompanied with constitutional disturbance similar to that of acute gout. I am just now attending a nobleman in whom very decided constitutional disturbance, accompanied by distressing intermission of the heart's action, preceded for some time the sudden appearance of a very painful inflammatory affection of the same portion of the gastrocnemius muscle on each side, which came on in the sudden way in which gout is apt to do. Lumbago is an instance of gouty affection of muscles. The intercostal muscles are often similarly attacked, giving rise to a most painful affection, which occasionally ends in pleurisy, or even pleuropneumony. Just in the same way gout may attack the muscular fibres of the bladder, stomach or colon; and in the cases of retention of urine such as I am describing, it affects the muscular coat of the bladder so as to paralyse it, in a manner analogous to that in which the active principle of belladonna may affect the muscular fibres of the iris, and cause a dilated, immovable pupil.

I will relate to you a case in illustration of this form of gout in the bladder. A barrister of great eminence in his profession was obliged to return to town from his circuit, where he was largely employed, and, indeed, overworked. He had been seized with severe muscular pains in the thighs and loins, which I regarded as gouty. The patient was of a gouty family, generated lithic acid freely, and had passed a considerable quantity of lithic acid gravel. On a former occasion I had attended him for one of those attacks of sudden affection of the intercostal muscles (gouty pleurodyne, as I would call it), passing on to dry pleurisy. For these reasons, I was justified, I think, in regarding and treating these pains as gouty in their character. After he had been three or four days under treatment for this affection, he found, one morning, on attempting to empty his bladder, that it refused to discharge its contents. A complete paralysis of the bladder had taken place, and evidently not from too great distension, as the patient did not suffer much inconvenience, and the quantity of water which had acccumulated was not considerable. Under a soothing treatment, with slight counter-irritation over the region of the bladder, this paralytic state gave way within four-and-twenty hours, but it was several days before the full power and tone of the bladder was restored.

4thly. Gout attacks the bladder, in some cases, as follows (and I take my remarks on this head from a case which actually came under my notice):-A gouty man indulges more freely in the delicacies of the table than he is usually wont to do; perhaps he is guilty of some indiscretion in what he partakes, eating cheese or some other indigestible matter which disagrees with him, and, before he goes to bed, he is suddenly seized with violent pains in the region of the bladder, which in some cases lasts an hour, but in others continues to torment the patient for two or three hours, preventing him from sleeping, and often producing great distress. This condition is usually relieved by free counter-irritation, and the administration of alkalies.

If, then, you find a man labouring under any of the four conditions that I have described, and at the same time you are able to discover from his history symptoms characteristic of a gouty diathesis, and you are convinced of the absence of calculus, you may feel satisfied that the symptoms are dependent upon a gouty inflammation of the bladder, and your treatment will be influenced accordingly. It must, however, be borne in mind, that a stone will cause the development of very similar symptoms, aud it will therefore be necessary to sound the patient carefully, in order to deter