The first patient whom I shall have the pleasure of presenting to you to-day may be said to be a walking pathological collection, on account of the number of different affections which are associated in his case. In the first place there are distinct evidences of chronic renal disease, the uriue containing albumen and hyaline and granular casts ; and from the small amount of cedema, the large quantity of urine, and the symptoms of ureemia that have been observed, we are justified in inferring

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... at he has the granular contracted kidney. In the second place we find that this man has hypertrophy of the heart, and as there does not seem to be any valvular disease whatever there can be but little doubt that it is connected with the affection of the kidneys. In the next place we find that the patient is suffering from lead poisoning, and as he is a painter by occupation there is no difficulty in tracing the source of the trouble. He has, as you notice, the characteristic form of lead paralysis which is ordinarily known as wrist-drop, and with which many of you are doubtless familiar. In lead palsy there is a more or less complete paralysis of the extensor muscles of the forearm, while the flexors generally retain their normal power. Some years ago I reported a remarkable case, observed in this hospital, in which immense strength was exhibited by the wrists of a patient suffering from this affection. In confirmation of the diagnosis of lead poisoning the history of our present patient shows that he has had attacks of lead colic. The question may, perhaps, now arise, Is there any connection between the lead poisoning and the disease of the kidneys? I do not think there is any reasou to suppose that there is a direct connection between the two, but it is certainly possible that there may be an indirect connection, as we shall see. In further investigating this case we find that, in addition to his other troubles, the patient has gout. It is not very often that we have cases of this affection in the hospital ; but from time to time they are met with, and those suffering from it are more apt to be addicted to the use of malt liquors rather than any others. Sometimes, however, we find it here in individuals who, as far as can be ascertained, are strictly temperate. In the present instance the seat of trouble is now the ankle, and not the great toe, where we naturally look first for the evidence of gout. It is not always easy, I would remind you, to make a diagnosis between gout and rheumatism. Of course, if the disease is well marked in its manifestations, there is no difficulty, but this is by no means always the case. Some physicians, when they are hard pushed about 1 Specially reported for the Journal. the matter, take refuge in the statement that the patient has " a little touch of both." It is no doubt in this way that the term " rheumatic gout " has arisen ; but this is a complete misnomer, because the variety of disease which is thus sometimes characterized is an entirely distinct affection. In this case, although the ankle is the present seat of trouble, and several of the other larger joints have been implicated, the history shows that the great toe has also been affected ; and this is a point in favor of gout. In addition, we have here a certain diagnostic sign of the disease in the presence of some little white spots in the helix of the ear, which a microscopic examination has shown to consist of concretions of urate of soda. We are, therefore, fully warranted in saying that this man has gout. But notwithstanding the fact that the patient has had and is still suffering from so many troubles, it is astonishing how comparatively well be looks, and how good his condition really is. Yet he has still another affection, of which I have not spoken, but wliich is mentioned in the history of the case, which I will now read you. The history is as follows : John S., a native of Germany, thirty-two years of age, and a painter by occupation. He says he has followed this trade for nearly twenty years. He was admitted to the hospital about a fortnight ago. There has been no gout in his family, and the family history is otherwise negative. He drinks a good deal of ale, but not much spirits. When asked as to the quantity of ale which he has been accustomed to drinking, he tells me three or four glasses of new ale a day. Four years ago he had a severe attack of lead colic, and nine months later a similar one, but has had none since. Some time after that he was suddenly attacked with lead palsy. He recovered from this, but the affection afterwards returned. After he recovered from the second attack he was free from the trouble until quite recently. Three years ago the left ankle became swollen and inflamed, and one year ago was similarly affected. About the same time he also bad an attack of typhus fever. He has not suffered much with headache, but has had dizziness and spots before the eyes. He has also been somewhat troubled lately with dyspnoea, but this may possibly be due to the condition of the heart. When he was admitted he complained of pains in several of the joints, and especially the right great toe. The urine was of a specific gravity of 1017, and contained albumen as well as large and small hyaline and granular casts. Some days he has passed as much as one hundred and fifty ounces of urine in the twenty-four hours. Four days ago he began to be troubled with intercostal neuralgia, and this is the fifth and last affection from which he has been suffering. He is being treated mainly with tonics, with the application of electricity to the wrists, and I believe he is improving. Now as to the possible connection between the lead poisoning and the disease of the kidneys. Garrod, who is the classic authority on gout, has shown that lead can produce this affection ; and it is well known that the granular contracted kidney has a special connection with gout. To such an extent is this the case that the late Dr. Parr distinguished the contracted kidney with the title of gouty kidney. It is a fact, however, that in a large number of gouty patients there is no such disease of the kidneys, while many cases of contracted kidney occur in those in whom there is no evidence of gout.