tained that large amounts of lead were removed in the form of iodide of lead, easily soluble in iodide of potassium, which is well known to pass off readily by the urine. At the present time, this belief still holds its ground among physicians. Yet, in the cases which have come under my notice, repeated analyses made at various periods after the use of iodide of potassium was commenced, and under large and small doses, have never detected more than a very small proportion of lead. Usually, it is more readily discovered after than before taking the iodide; but sometimes none at all can be found, when the symptoms of the case are well marked. As the processes used allow of the detection of exceedingly minute quantities of this metal, the conclusion cannot be avoided that, in cases of chronic lead-poisoning, the process of elimination is very slow, and a long time must be required to remove any considerable deposit from the tissues.

Some analyses lately made in a case at the Mass. Gen. Hospital will show this. The patient, an Irishman, forty years of age, entered the Hospital, March 9th, 1859. He has been employed in glass-works for thirteen years. For the last six or seven months has worked in the lead house at the East Cambridge Glass Works, as a sifter of red-lead. For two or three months, has suffered from lead colic, and been under treatment at East Cambridge-taking, among other things, a few small doses of iodide of potassium. Paralysis commenced about a month before his entrance, and is rather general, though more severe in the arms than in the legs. There is no distinct wrist-drop. The blue line about the gums is evident. On March 12th, the urine was analyzed, and no lead found. Iodide of potassium was then given, at first in doses of five grains three times daily. On March 17th, one and a half pints of the urine were tested by Kletzinsky's process. Lead was distinctly detected, but not in sufficient quantity to be collected and weighed. On March 26th, the patient now taking iodide of potassium in twelve-grain doses three times a day, three pints, being nearly the whole of a day's urine, were analyzed by the process which I usually employ. The lead was separated as sulphate, and weighed. Its amount corresponded to 5 of a grain of oxide of lead, a little less than of a grain to the pint. The patient has improved under treatment. In other cases, I have found the amount of lead eliminated to diminish in a few weeks under the use of iodide of potassium, until beyond the reach of chemical tests, although the paralysis has not been relieved until afterward.

In the patient above referred to, sulphide of ammonium, applied to the skin of the arın, produced a brown discoloration, from the formation of sulphide of lead. This effect is frequently seen in patients from white-lead works and similar manufactories, where the fine dust from lead preparations is gradually worked into the exposed parts of the skin, and is difficult of removal. The effect of baths of alkaline sulphides, however, proves that absorbed lead may be deposited in the skin, and that the metal in the tissues is, to a certain extent, in a soluble form. Such a bath discolors various parts of the body, but not uniformly. The color is sometimes nearly black. When the sulphide of lead formed on the skin has been removed by repeated washing with soap and water, the

brown color is stated to be again and again obtained by repeating the sulphuretted bath at intervals of a few days; showing that when the lead is removed from the skin, a new portion is brought out from the interior. I have not had an opportunity of observing the effect of a repeated use of the sulphuretted bath, but it would seem that an appreciable amount of lead can be thus eliminated.

I find, from the recently published book of Dr. Thudichum, on the Pathology of the Urine, that Kletzinsky has noticed the very minute amount of lead eliminated by the urine. In fourteen cases of distinct lead poisoning, in which the urine of a whole day was analyzed, Kletzinsky succeeded in two only in proving the presence of the metal. In the others, only a doubtful indication was obtained. In a well-marked case in London, under the use of ten grains of iodide of potassium three times a day, Dr. Bernays twice failed to find lead in the urine of twelve hours; but after administering iodide of potassium for ten days, it was present in sufficient quantity to give a copious precipitate with sulphuretted hydrogen, in the solution obtained by evaporating the urine nearly to dryness, and dissolving the residue in aqua regia.

It is evident that iodide of potassium, the most energetic agent known for removing absorbed lead from the system, is far less efficient in this respect than is generally believed. Boston Medical and Surgical

Journal.

PRACTICAL CLINICAL REMARKS ON PARTICULAR FORMS OF RENAL

DROPSY.

By W. R. BASHAM, M.D., Physician to Westminster Hospital.

GENTLEMEN :-Epidemic diseases scarcely differ more from each other than does the same epidemic disease differ in intensity and destructiveness at the various periods of its return.

This remark is specially applicable to scarlet fever. In some years, all, or the majority of cases, exhibit mild and favorable symptoms. A slight febrile disturbance, with sore throat, is followed by a diffuse scarlet rash, which gradually pervades the whole body; and, fading on the sixth or seventh day, leaves the cuticle to desquamate, and the patient to a rapid convalescence. Of this simple form of the epidemic, Sydenham has truly said that it deserves little more than the name of a disease, and that the patient is in little danger but through the officious zeal of the physician. But the characteristics of other epidemics of the malady are very different, and the present visitation, now of more than three months' duration, has been particularly illustrative of the prefatory remark; for the majority of the cases have presented unfavorable, not to say fatal symptoms, the mortality, according to the Registrar-General's Reports, having been greater than for some years. In the more malignant form of the disease, sore throat is a very prominent symptom; and it may be

doubted whether a great number of the fatal cases recorded as diphtheria have not been scarlatina anginosa, or scarlatina maligna. In the scarlatina anginosa, the sore throat is the symptom which alone attracts attention; and if the peculiarities of the inflammation be not closely noted, an inattentive observer might view the throat disease as a simple tonsillitis, or be ready, when unfavorable symptoms followed, to classify it under the title of diphtheria.

In the true scarlatinal sore throat, the tonsils, soft palate, uvula, and back of pharynx, are involved in a diffuse inflammatory redness of a brilliant hue-the tongue partaking of this elevated color, and oftentimes being furred, and the enlarged papillæ appearing through and their color being also elevated, the similitude to a strawberry has been imagined; and hence "strawberry tongue" has been accepted as the characteristic of this stage of scarlet fever. The throat, however, not only presents an inflammatory redness, but there is considerable tumefaction, sufficient to impede deglutition and speech, and, extending to the external parts, produces swelling of the submaxillary glands, and stiffness and painful distension of the integuments about the throat. Specks or points of ulceration make their appearance on the tonsils, and a viscid, tenacious mucus is formed, which adheres to the parts, and sensibly increases the difficulty of deglutition. This viscid secretion may be mistaken for the croupous pellicle which is formed in diphtheria the specks of ulceration discoverable beneath this viscid mucus will, however, distinguish the scarlatinal from the diphtheritic inflammation. The eruption comes on late and imperfectly, and may be, and is, often overlooked. Within ten days or a fortnight, the urine becomes scanty, dark-colored, and albuminous. In many, the presence of blood is unmistakable; in others, the urine acquires but a dirty or sooty appearance. This condition of the urine will, I believe, if any doubt remains, distinguish the scarlatinal from the diphtheritic disease. By some writers in the weekly medical journals the urine in diphtheria has been described as albuminous. But, with every respect for these communications, I should venture to classify the disease as scarlatina rather than diphtheria. It is this evidence of the disordered state of the renal organs which constitutes the element of danger in these cases, and which eventually leads to the development of the most unmanageable of all the forms of albuminuria-acute morbus Brightii.

It is a singular fact that the activity of the renal disorder bears no proportion to the apparent intensity of the original febrile poison. For it may be said that inversely as the manifestation of the symptoms of scarlet fever is the susceptibility to the renal disorder; for the more highly developed the scarlet rash, the more complete will be the proof of the elimination from the blood of the febrile poison; and the less characteristic the rash, the more certain that the poison lurks in the system, unheeded and undestroyed, and eventually to implicate the kidneys in a disorder fatal in proportion to the tardiness with which it is recognized. In this type of cases, the eruption is slow to show itself; and in place of a diffuse efflorescence, it occurs in patches, far less intense in color than in the simpler and milder form of the disease. The constitutional dis

turbance is oftentimes great; but cases are frequently met with, where ultimately a fatal termination by renal disease takes place, in which the primary disorder was not marked by any symptoms of urgency. The patient appears to convalesce favorably, but, slowly and insidiously, evidence of lurking mischief becomes apparent. In some cases there may be symptoms of a secondary fever about the fourteenth day from the date of the sore throat, some restlessness, loss of appetite, and chilliness. But these symptoms are sometimes wanting, or so feebly pronounced as to be unnoticed. Frequency of micturition, scanty, dark-colored urine, and a puffiness of the face, may be, and often are, the first symptoms noticed by the patient. General anasarca of the surface follows, with a pallor so peculiar, of such alabaster whiteness and purity, as to become almost a specific feature of the disease.

Frances G, aged nineteen, was admitted into Queen Adelaide ward, on the 10th of November, suffering from general dropsy of the surface of the body. There was oedema of the face, arms, wrists, and back of the hands, as well as of the trunk and lower extremities. The swollen state of the face usually subsided as the day advanced. There was the usual pallor of the skin. There was some dyspnoea, with occasional cough and trifling expectoration of catarrhal mucus. The urine had been very scanty, and micturition distressingly frequent: during the night, the desire to pass urine occurred every hour, and the rest was consequently much disturbed. The urine had a cloudy, dirty, soot-like appearance, was highly albuminous, threw down a copious, coarse deposit, and exhibited under the microscope blood-corpuscles, coarse, granular, fibrinous flakes, containing blood-disks, large, fibrinous blood-casts, many large granule cells, and some scattered renal epithelial cells. She complained of a sense of fulness and aching across the lumbar region, and pain was excited by pressure over the region of each kidney. The chest was resonant some catarrhal wheezing was heard in the large tubes. The sounds of the heart were natural. She stated that four weeks since she suffered from sore throat, at a time when scarlet fever prevailed in the house in which she lived; that her voice and power of swallowing were affected; but that she had no distinct eruption on the skin; but was told she had, and was treated for, scarlet fever. As near as she can remember, a fortnight after the sore throat, she noticed that her urine became very scanty, and of a dark red color, as if it contained blood. The catamenia had not appeared for the last six months. In a few days she became conscious of a swelling in her face after sleep, and subsequently the hands, arms, feet, and ankles became anasarcous. She was ordered a warm bath daily, the compound jalap powder every morning, a diaphoretic mixture every four hours, and to be clothed in flannel. On the following day, she was dry-cupped across the loins, which, with the above treatment, diminished the sooty appearance of the urine; and in two days, the quantity of urine had considerably increased.

A week after admission, the dropsy had completely disappeared. The urine was clear, specific gravity 1018, and albuminous. The deposit, examined by the microscope, consisted of dense fibrinous casts, some blood-casts, a few scattered blood-corpuscles; very little epithelium was

She was ordered the

visible, and no epithelial casts could be seen. sequichloride of iron, and an improved diet. But this treatment appeared to have been commenced too early, for on the 25th of November there was a return of hæmaturia, which, however, disappeared by the loss of a few ounces of blood from the loins by cupping.

On November 30, she again began to improve: there was no return of oedema, although the urine continued highly albuminous.

On December 4, the urinary sediment first gave warning of the unfavorable change which was commencing in the cell structure of the tubes, notwithstanding the disappearance for a time of the dropsy, and the apparent improvement in the general condition of the patient. The urinary sediment had been examined every two or three days since admission, and up to this date it consisted of fibrinous casts, large, coarse granular casts, containing a few blood-corpuscles and a few scattered epithelial cells; but no epithelial casts, or free shedding of the epithelium, which is often observed in the dropsy after scarlet fever. But now the casts were becoming transparent, containing large compound granule cells, some exudation corpuscles approaching in character to the pus cell, and a few epithelial cells; and some of the casts contained numerous resplendent granules-the disengaged nuclei of disintegrated epithelial cells. Two days later the casts became still more transparent or hyaline, with an increased number of exudative corpuscles with reniform and trefoiled nuclei. The epithelial cells did not present any characteristics of fatty or abortive development. On the 11th of December, the anasarea of the surface again made its appearance. The urine became less abundant. Purgatives were again beneficially employed. The sesquichloride of iron was again taken, and for a few days another interval of improvement, so far as the diminution of the anasarca was accepted as a sign, was apparent. But the urinary sediment became more abundant. Large, solid moulds of fibrin, the greater part containing no cell structure, many hyaline moulds, containing large, compound granule cells, and many free nuclei, indicated that the disease was progressing most unfavorably. On the evening of the 27th of December, she became very restless; and on the morning of the 28th, suddenly calling for assistance, she almost instantly became insensible. The jaws became locked; there was some rigidity of the extremities; the pupils were dilated; but there was neither convulsive movement, nor stertor, nor foaming at the mouth. The respiratory movements gradually became slower and less apparent, and she ceased to breathe, without any movement or spasm, at eleven o'clock A. M.

Post-mortem examination twenty-eight hours after.-The external surface of the body was but slightly anasarcous. The pleural and abdominal cavities contained a small quantity of orange-colored serum. The lungs were free from pleuritic adhesions, but were slightly odematous. The heart was large; it weighed thirteen ounces and a half; there were several maculæ albida both on its anterior and posterior surfaces; the cavities of the heart, as well as the valves, were natural. The liver was healthy. The left kidney was the larger of the two: it weighed seven ounces and a half: it was irregular in shape, considerably lobulated above