Ringer was at the time a resident medical officer. The observations appear to have been conducted with great care and accuracy. No one who has not been engaged in similar investigations can fully appreciate the difficulties to be overcome in order to ensure success, or the great value of such complete records of even a single case as those now before us. For the minute details we must refer our readers to the original paper; we limit ourselves here to a simple statement of the chief results arrived at by the author.

The temperature began to rise previous to the cold stage as experienced by the patient, or before there was any feeling of cold or illness of any kind. The time before the cold stage at which the rise commenced varied. The temperature continued to rise during the entire cold stage, and the rise during this stage was greater than during any other. It reached its highest point during the hot stage, but fell again before the sweating stage, the fall being at first gradual, but during the sweating stage much more rapid. The rapidity of the fall was always in proportion to the slightness of the fit.

A close correspondence in every respect existed between the temperature and the frequency of the pulse.

The urea, chloride of sodium, and urinary water also began to increase in quantity before the commencement of the cold stage. They continued to rise rapidly, and became most abundant either at the termination of the cold, or at the commencement of the hot stage; they commenced to fall in amount before the temperature reached its highest point, and continued to fall, at first slowly, but during the sweating stage rapidly, the rapidity of the fall being proportionate to the slightness of the fit. These constituents always exhibited variations in amount corresponding to the variations in temperature. The variations in temperature often followed similar variations in the amount of urea, but never preceded them.

Quinine administered in a single dose of a scruple when the temperature commenced to rise, lowered the temperature and postponed the fit for an hour that day, but had no other effect on that fit, though it prevented its recurrence next day, another scruple having been taken in the meantime. It was found, however, that after the fit had been arrested by quinine, variations in the urea and chloride of sodium continued to occur at those periods when, had there been a regular fit, the temperature would have risen. The paper is illustrated by numerous tables and twelve charts, showing the relations between the temperature and the quantities of urea and chloride of sodium excreted.

The increase in the amount of urea aud chloride of sodium during the cold and hot stages of ague, has been already affirmed by several observers; but Mr. Ringer appears to be the first who has traced any comparison between this increase and the rise in the temperature.

XXII. Case of Paralysis as to Voluntary Power of the Limbs on one side of the Body, attended by Hyperesthesia as regards the impressions of Pinching and Pricking on the corresponding side of the Face; being the result of Compression of certain lateral parts of the Brain from

an Intra-cranial Aneurism; with Observations on "Induced" Cerebral Paralysis. By JOHN W. OGLE, M.D.-This was an exception to the very general rule of paralysis being on the side of the body opposite to that of the cerebral lesion. The patient was a female, aged forty-six, who had been the subject of epilepsy, and whose symptoms were complete loss of sight, impairment of the senses of smell and taste on the left side, with partial loss of muscular power on the left side of the body, and contractile hyperesthesia of the skin of the left side of the face and head. After death there was found an aneurism of the anterior cerebellar artery on the left side, compressing the left crus cerebelli, and the contiguous portions to a slight degree of the pons varolii, cerebellum, and efferent root of the fifth nerve. Fourteen cases have been collected by Dr. Brown-Séquard in which paralysis was observed on the same side of the body as that of the cerebral lesion, and it is a remarkable circumstance that in all these cases the lesion consisted in compression of precisely the same portion of the brain as in Dr. Ogle's case-namely, the inferior surface of the middle cerebellar peduncle. Dr. Brown-Séquard thinks that in such cases we must regard the paralysis as similar to what has been termed "reflex" paralysis, and due to the irritation of centripetal nerve fibres, rather than to any obstruction in the powers of transmission of the efferent nerve fibresthat, in short, the paralysis is due to an "excess" rather than to an "absence" of action. If this explanation be correct, we have an irritative action starting from the point of lesion, and so operating as in some manner or other to paralyse certain motor fibres in the opposite side of the brain, which, decussating at the anterior pyramids, affect the muscles on the side of the body corresponding with the original encephalic lesion.

XXIII. The Sequel of a Case of Lithotrity, in which a Communication existed between the Bladder and Intestine. By CHARLES HAWKINS, F.R.C.S.-This case was published in the preceding volume of the Society's Transactions.** On February 2nd, 1858, the patient was reported to be quite free from calculus in the bladder, and there were no symptoms of stone from this time to that of his death, which took place on April 19th, 1859; but the patient continued to pass fæces occasionally with his urine. A fistulous communication was found to exist between the lower part of the posterior wall of the bladder and the sigmoid flexure of the colon.

XXIV. A Case of Vesical Calculus of unusual size, removed by the Recto-vesical Operation. By GEORGE SOUTHAM, F.R.C.S., Manchester. -The stone in this case had been growing for sixteen years. After its removal it had an irregularly-oval form, measured eight inches in circumference in one direction, and seven in the other, its extreme length being three inches and a third. It consisted for the most part of earthy and triple phosphates, imbedded in which at one extremity Vol. xli. p. 441; and British and Foreign Medico-Chirurgical Review, April, 1859,

p. 446.

was a small round alternating calculus, made up of lithic acid and oxalate of lime. The patient was a male, aged twenty-one; the operation was successful, and after four months, all signs of the fistulous communication between the bladder and the rectum had disappeared.

XXV. On different Forms of Primary Syphilitic Inoculation. By HENRY LEE, F.R.C.S.-Mr. Lee in this paper mentions four cases in which patients labouring under primary syphilis were inoculated with matter taken either from their own sores or from those of another patient. The conclusion arrived at is, that suppurating syphilitic sores are readily inoculable with the point of the lancet upon the patients who bear them, but that the indurated sores-those affected with the specific adhesive inflammation, and which alone are capable of giving rise to secondary symptoms-are, as a rule, not capable of being thus inoculated. The author is inclined to believe that these suppurating and indurated sores have often been mistaken for each other, and in this way he accounts for the immunity from constitutional syphilis which has followed the ordinary practice of syphilization. Inoculation with pus from a suppurating sore would not be followed by constitutional syphilis under any circumstances, and although Dr. Sperino, the great advocate of syphilization, frequently asserts that the secretion was taken from an indurated chancre, yet Mr. Lee's experiments would show that the secretion from an indurated chancre is not inoculable upon the same individual. Hence it is inferred that what Dr. Sperino has designated indurated sores belonged in reality to the phlegmonoid or some other variety of suppurating syphilitic sores.

REVIEW VII.

The Nature and Treatment of Gout and Rheumatic Gout. By ALFRED BARING GARROD, M.D., F.R.S., Physician to University College Hospital, &c. &c.-London, 1859.

It must be known to most of the readers of this Journal, that during a considerable period of time Dr. Garrod has been engaged in conducting a series of laborious investigations into the chemical pathology of gout and rheumatism. Some of the results of these labours have been published in the Medico-Chirurgical Transactions," and they are all embodied in the handsomely-printed and illustrated volume whose title appears at the head of this article. In this treatise Dr. Garrod has given a complete history of gout, commencing with an introductory chapter, in which reference is made to the opinions of some of the chief amongst the ancient writers on this interesting disease.

To attempt a full analysis of the volume is not consistent with our present design; our purpose is rather to direct attention to the chief facts which Dr. Garrod has succeeded in establishing, and to the doctrines, pathological and therapeutical, which he endeavours to build * Medico-Chirurgical Trans., vol. xxxi. p. 88; vol. xxxvii. pp. 49, 181; vol. xli. p. 325.

upon those facts. Passing over the second and third chapters, in which the well-known outward phenomena of acute and chronic gout are described, we come to the fourth chapter, which treats of the "Blood in Gout."

The normal constituents of the blood in gouty patients are not necessarily changed, but when the disease has been of long duration, and especially when, as frequently happens, the kidneys are degenerated, the density of the serum appears to be somewhat lower than in health, the average density in cases of chronic gout being from 1027 to 1028.

urea.

But the great and the characteristic feature of the blood in gout is an excess of uric acid. We say an excess of uric acid, for Dr. Garrod has shown that the blood in health contains a trace of both uric acid and The process for the determination of the actual quantity of uric acid in the blood is one which requires a considerable amount of time, care, and skill in practical chemistry. To obviate this difficulty, Dr. Garrod has devised a simple method of ascertaining the presence of an abnormal amount of uric acid, which is readily applicable for clinical purposes, and which requires the abstraction of only a small quantity of blood. This process, which he names the "Uric-acid thread Experiment," is thus performed:

"Take from one to two fluid drachms of the serum of the blood, and put it into a flattened glass dish or capsule; those I prefer are about three inches in diameter and one-third of an inch in depth, which can be readily procured at any glasshouse. To this add ordinary strong acetic acid, in the proportion of six minims to each fluid drachm of serum, which usually causes the evolution of a few bubbles of gas. When the fluids are well mixed, introduce a very fine thread, consisting of from one to three ultimate fibres about an inch in length, from a piece of unwashed huckaback or other linen fabric, which should be depressed by means of a small rod, as a probe or the point of a pencil. The glass should then be put aside in a moderately warm place until the serum is quite set and almost dry. The mantelpiece in a room of ordinary temperature, or a bookcase, answers very well, the time varying from twenty-four to forty-eight hours, depending on the warmth and dryness of the atmosphere." (p. 110.)

In explanation of this process, it should be premised that the uric acid as it exists in the blood is combined with soda, and when it is present in quantities above a certain small amount to be presently noticed, the urate of soda being decomposed by the acetic acid, the uric acid thus set free crystallizes and collects on the thread, like sugar-candy upon a string. To detect the crystals, the glass containing the dried serum should be placed under a linear magnifying power of about fifty or sixty. The uric acid is seen in the well-known form of rhombs having a brownish tinge, the size of the crystals varying with the rapidity with which the drying of the serum has been effected, and the quantity of uric acid in the blood. To ensure the perfect success of this process, several precautions relating to the form of the glasses, the strength of the acetic acid, the quality of the thread, &c., are necessary, for the details of which we must refer to Dr. Garrod's book, p.111, et seq.

Degree of delicacy of the above test for uric acid.-The serum of

healthy blood, as also that of patients suffering from most diseases, although generally containing a trace of uric acid, gives no indication of its presence by the "uric-acid thread experiment," and this absence of extreme delicacy is practically a valuable quality. By a series of experiments, Dr. Garrod has determined the proportion of uric acid which must exist in the blood before its presence can be thus demonstrated. For this purpose he added urate of soda in definite proportions to the serum of blood taken from a healthy subject, and in which the most careful chemical analysis could scarcely detect the existence of a trace. The result was, that an amount of uric acid equal to at least 0.025 grains in 1000 grains of serum, in addition to the trace existing in health, was required before the thread experiment gave any indication of its presence. Hence, the appearance of uric acid on the thread is complete evidence of an abnormal amount in the blood. Our author, after entering into all the needful details relating to the above test for uric acid, gives in a tabular form a brief report of forty-seven cases of gout, in all of which, by the process in question, the serum of the blood was found to be "rich in uric acid."

He then proceeds to show that by means of the same test, when the blood serum contains an excess of uric acid, this material may also be discovered in the fluid which is effused under the influence of blistering agents applied to the skin. There is an obvious advantage in this means of testing the composition of the blood without the necessity for the performance of venesection. In conducting the thread experiment on blister serum the same precautions are necessary as when examining the blood serum, and this additional circumstance requires attention, namely, that the existence of inflammation of a gouty character has the power of destroying the uric acid in the blood of the inflamed part; so that the serum drawn by a blister over an inflamed gouty joint will give no indication of the presence of the uric acid which is abundant in the blood serum of the same patient.

Another material which the blood of gouty patients often contains in abnormal quantities is urea. This fact was communicated by Dr. Garrod, in the year 1848,* and the observation has been confirmed by his own later observations, as well as by those of Dr. Wm. Budd.† In many cases, doubtless, this excess of urea in the blood is a consequence of the renal degeneration which is so frequent a result of chronic gout, but in other instances this explanation appears not to be admissible. Thus, Dr. Budd gives the particulars of two cases, and refers to nine others, in which he detected urea in the blood, or blister serum, or both, of persons suffering from acute gout, there being at the same time no albumen in the urine, no casts of the uriniferous tubes, nor any other indication of renal disease or obstruction.

The urine in gout.-The clinical examinations of the urine of gouty patients are divided by Dr. Garrod into three classes. The first includes analyses of the urine in cases of acute gout: the second, the results obtained in the chronic forms of the disease: and in the third

• Medico-Chirurgical Transactions, vol. xxxi.

+ Ibid., vol. xxxviii.