On the 5th, the joint-symptoms were well.

The bicarbonate of potash was given in the first twelve hours of the day, so that, if possible, its effects might not extend into the following day's urine. It appeared on the first day to increase the urea considerably, the sulphuric acid in a less degree, and the phosphoric acid in an extraordinary degree. When it was afterwards given, the effect on the urea and sulphuric acid was very trifling; but the phosphoric acid, which had fallen, was again increased, and fell again the next day. The effect on the acidity of the urine was very interesting; although it produced alkaline urine for the time, yet on the following day the acidity was raised to almost double the amount it had been before the medicine was taken. On the day when the second quantity of alkali was taken, the urine was again alkaline; but, on the following day, the acidity was again very greatly increased. In fact, the acidity of the fourth and sixth days, when no medicine was taken, is so great as to give an average of acidity equal to 22.3 grains of oxalic acid for the four days, although, on two of the days, a large quantity of alkali permitted no acidity to be perceived. It is evident, therefore, that the alkali increased, in reality, very largely the excretion of acid.

1 The solids contained 65.52 grains of soluble salts.
The solids contained 187 grains of soluble salts.

In the former case, probably about two thirds only of the bicarbonate passed off in the twenty-four hours; but in this nearly the whole of it must have been eliminated in the thirteen hours during which it was taken. It increased the organic solids, the SO, and the substance containing unoxidized sulphur. The effect on the PO, was not determined.

To sum up our knowledge of the urine in gout, it may be said that, before the paroxysms, there is diminution of all the chief ingredients, especially of the uric acid, phosphates, and pigment and extractives; that during the paroxysm, there is also insufficient elimination of uric and phosphoric acids, and extractives, but that the urea and sulphuric acid are in good, though not in excessive, quantity; that, after the paroxysm, the elimination of the uric and phosphoric acids increases. As there is reason to think there is no deficient but rather an increased formation of uric acid in the blood, the want of excretion must be owing either to some affection of the kidney (which is unlikely), or to some peculiar and unnatural combination in the blood or organs, which hold back this and other substances. If this be the case, the deficient elimination is, as it were, only a consequence of more important antecedent aberrations in metamorphosis, of which impeded excretion is a natural sequence. What these are, however, is quite unknown; but an unnatural formation of uric acid, either from food or tissues, may possibly be part of them.

SECTION XX.

ACUTE DISEASES OF THE SKIN.

Acute Ecyema Impetiginodes.

In a man aged twenty-one, weighing 55 kilogrammes, whose body was almost entirely covered with the erup

tion, Dr. Benckel made the following interesting obscrvations:

On a mean of twenty-six days, the solid and fluid ingesta in each twenty-four hours amounted to

3660 grammes.

The egesta each in 24 hours amounted to-
Kidney excretion
Intestine

Skin and lungs,

دو

2023 grammes

121

The body, therefore, increased in weight.

With respect to the urine, the following table gives the mean of three periods.

In each twenty-four hours, there was excreted by the kidneys,

in grammes

In the first three days, there were numerous crystals of oxalic acid in the urine.

One kilogramme of body-weight excreted in twenty-four hours 0.654 of urea during the height of the disease, and 0.524 during the decline.

The urea was therefore in some excess during the period of severe disease; the uric acid was also a little over the amount of convalescence; the sulphuric acid was not augmented by the disease, though it was so by the potash. The phosphoric acid was a little increased during the use of the potash; but as it was in still greater quantity afterwards, it may have been merely rising

1 Archiv des Vereins, Band ii, p. 35.

2 These numbers are to each other, if the urine be taken as unity, as 1, 0.059, 0.73.

Grosse gives the numbers in health as 1, 0.09, 0.7. Beitrage zur Kenntniss der Grosse des menschlich Stoffwechsels. See Introduction, p. 33.

During the acute stage, it The free acidity was at scarcely altered by the

in amount as the disease went off.
was evidently diminished (retained ?).
first a little below the rule, and was
liquor potassæ.

The decrease in the urea and the uric acid must be ascribed to the gradual improvement in the disease, and not of course to the influence of the liquor potassæ.

Acute Urticaria.

Dr. D. Maclagan,1 in examining the urine in a case of acute urticaria, believed the urea and uric acid to be in very small amount; but the per-centage amounts only were determined, and the urine may have been merely dilute. No such deficiency has been noticed in other cases.

SECTION XXI.

GENERAL CONCLUSIONS ON THE CONDITION OF THE URINE IN FEBRILE DISEASES.

The urine in almost all febrile diseases has certain characters, sufficiently common and constant to have at all times attracted attention. These are a deficiency of water, a deepening of colour which arises from absolute increase of pigment, as well as from concentration, and a heightened relative acidity produced only by the deficiency of water (Vogel). These characters are not, however, peculiar to fever; for they will occur in certain chronic apyrectic affections, especially of the liver.

In addition to these obvious and well-known characters, the so-called "febrile urine" presents other more recondite but not less important phenomena. If no incidental circumstances come into play, the urine gives evidence in most cases of a remarkable increase of the urea and the uric acid, the representatives of the nitrogenous tissues. As very little food is taken, and as the amount of these substances is often much more than in health, the inference is unavoidable, that the patient is, so to speak, feeding on his own nitrogenous tissues, which rapidly waste and disappear. So far the urine resembles that which is produced by excessive flesh-feeding; but, in addition, hippuric acid would appear to be present in many cases in large quantities—a peculiarity of metamorphosis which finds no parallel when the urea

1 Monthly Journal of Med. Science, August, 1846, p. 157.

and uric acid are heightened artificially by increase of nitrogenous food. As already said, the pigment, derived, it is supposed, from metamorphosis of the red blood-cells, is also increased; and so is the SO, the amount of which is, to a certain extent, an indication of the metamorphosis of the sulphur-holding (i. e. nitrogenous) tissues.

The chlorides and the phosphates, on the other hand, are, except in exceptional cases, not increased, or are decreased. Allowing full weight to the deprivation of food, and to the increased action of the skin or bowels, I think we are justified in saying that, as a rule, there is retention of chlorine,1 and deficient metamorphosis of the structures furnishing phosphoric acid, except possibly in the acute inflammations of nervous and muscular tissues.

This increased excretion certainly commences very early in febrile diseases, and it is probable, from the experiments in ague, that it begins at the very onset, and is, with the alteration of temperature, one of the earliest, perhaps the earliest sign of the morbid condition; throughout it runs more or less parallel with the heightened temperature, and, with occasional exceptions and deviations, which are generally easily accounted for, it may be laid down as a rule, that the presence of the one condition implies that of the other.

Yet this is not the case always; for (apart from incidental circumstances) in some fevers there is occasionally, first, a very high temperature with no great amount of metamorphosis, and second, there are chronic diseases without increase, or even with decrease, of temperature, in which there is augmented urinary elimination. In the first case, the exception is accounted for sometimes by the fever being of short duration, being followed by a pyrectic period, in which metamorphosis is below the normal, so that if the pyrectic and apyrectic periods are put together, the deficiency in the one more than counterbalances the excess in the other. Or the excretion of the urine is, as it were, supplemented or compensated by the augmented action of other organs, especially of the skin or bowels; or is diminished by previous inanition, and by the want of material from which urea and uric acid can be derived. In the latter case (of an a-febrile disease, and increased urinary elimination) it is possible that there may have been, in some cases, a previous retention followed by increased elimination; but it would be hazardous at present to affirm that this will explain all cases.2

1 I believe this was pointed out first by Schonlein, but I have not been able to find the reference. I had observed the fact, without knowing this.

The cause of the increased elimination in febrile disease is extremely obscure. It can scarcely be considered as arising altogether or simply from the increased