of deposit, nor was any discovered in any other joint inspected.

The kidneys were congested, weighing 6 ounces each, and no white points or streaks observed.

Fig. 20. The metatarso-phalangeal joint of left great toe, from the same man from whom fig. 19 was drawn.

CHAPTER VII.

MORBID ANATOMY OF GOUT CONTINUED: DEDUCTIONS DRAWN FROM THE CASES RELATED IN THE LAST CHAPTER-PROOFS OF THE INVARIABLE DEPOSITION OF CHALKY MATTER IN THE INFLAMMATION OF TRUE GOUT-MICROSCOPIC AND CHEMICAL CHARACTERS OF GOUTY DEPOSITS IN DIFFERENT STRUCTURES-IN ARTICULAR CARTILAGE-SYNOVIAL MEMBRANE-FIBROUS TISSUE-ANCHYLOSIS OF GREAT TOE-CHANGES IN THE KIDNEYS OF GOUTY SUBJECTS: 1. IN THE CHRONIC FORMS OF THE MALADY; 2. IN THE EARLY STAGES-DEPOSITS IN OTHER SITUATIONS.

FROM an investigation of the phenomena brought to light in the last chapter, more especially with regard to cases of gout in which no appreciable deformity or rigidity of joints existed during life, some very important deductions may be drawn; deductions which cannot fail to exercise a strong influence upon our views of the intimate nature of the disease, and which we shall now endeavour to explain.

In the examination of the first class of casesnamely, subjects of chronic gout, with extensive chalkstones-the results of my observations, as far as the appearances to the naked eye are concerned, have already been sufficiently detailed: such, for instance, as the more or less complete incrustation of the surfaces of the bones with urate of soda, the infiltration of the surrounding ligaments, deposits within the tendons

and their sheaths, and occasionally along the tendinous expansions of the muscles. After a time, when the secretion of urate of soda into the tissues increases, neighbouring parts are pressed upon, atrophied, and absorbed, and the deposited matter slowly approaches the surface, usually in a semi-fluid form at first, but gradually becoming solid and chalk-like from the absorption of its more fluid portion. When there is only an integument covering the cartilage, as in the case of the helix of the ear, the deposit makes its appearance at the surface soon after its secretion, but when many other structures are interposed, a considerable time elapses before this occurs, and the deposited matter may undergo considerable hardening from absorption. The only point in which my observations differ from those of Cruveilhier has reference to the occurrence of the deposit within the substance of the bones and altogether disconnected with the cartilage. Cruveilhier found it in the astragalus, os calcis, and patella; I have frequently sought in these situations, but have never seen it except in direct connection with the cartilage, although in some of the phalanges it had penetrated to a considerable depth, and the osseous tissue had become much pressed upon and atrophied.

In the second class of cases, when no appreciable deformity was present during life, and no chalkstones except one or two on the cartilage of the ears, the examination brought to light the fact, I believe before unknown, that extensive deposits may

take place within the joints without corresponding external manifestation; it was also rendered probable that a close relation exists between the presence of the deposit and the occurrence of true gouty inflammation; for in Case 6 the joints less commonly implicated were free from deposit, as both hip and shoulder-joints, and one elbow, whereas the joints more frequently affected with gout were found incrusted. As the history of the case was unknown, there were no means of positively ascertaining which joints had been inflamed during life.

In the third class, when not a trace of external deposit was perceptible, it was likewise demonstrated that the cartilages and other structures of the joints may be infiltrated with urate of soda.

In Case 10 one great toe only was examined, and here the interesting fact was elicited, that the articular cartilages of the metatarso-phalangeal joint may be completely incrusted, the surrounding ligamentous tissues freely sprinkled, and still the articulating surface of the metatarsal bone with the tarsus, and likewise the phalangeal joint, remain free from disease; this I have seen in other instances, and it exemplifies the great tendency of gout to select one joint in preference to others.

In Case 9 many joints of the lower extremities were affected, but with complete freedom of the upper limbs and hip-joints; thus pointing to the same conclusions as Case 6, but in a still more marked degree.

By Case 11 we are enabled to confirm in a remarkable manner the conclusions to which the foregoing cases point. The history was well known; the patient had been a medical man, and could give the details with accuracy, and it was positively ascertained that he had experienced but eight fits of gout, and these had been spread over a period of thirteen years; once only was a finger affected, the remaining attacks being confined to the great toes, feet, and knees. In this case the examination showed an incrustation of all the joints known to have been implicated, and the freedom of the rest, and thus proved almost to demonstration that gouty inflammation is invariably accompanied with deposition of urate of soda.

In Case 15 this fact was proved beyond all reasonable doubt, for the patient had only experienced the disease in a single joint, the ball of one great toe, and even in this it had not been severe; still the surfaces of the metatarsal bone and phalanx were sprinkled over in a marked degree, and a spot was likewise observed on the ligament.

Cases 13 and 16, however, establish the fact absolutely. In Case 13 evidence was obtained during life that the left knee had been only once affected with gout, and then very slightly, the right knee having been always quite free from the disease; the postmortem examination demonstrated a slight deposit in the structures of the left knee, but none in the right. And, lastly, in Case 16, the result of a single fit of gout was characteristically revealed. After this