often the system is not yet sufficiently relieved, and the symptoms of dyspepsia continue nearly as

is just in the latter case that the unwonted presence of accumulated uric acid ought to excite the liveliest reactive struggles. Just as little can it be assumed that the exudations free the blood from the materies morbi ; for the alleviation occurs most distinctly in those cases in which reabsorption takes place. These secretions appear secondarily, as we have just seen; and when the blood is rich in uric acid, they and their organizations are also rich in it. Apart from this, the commencement of the gouty attack offers no analogy with that type of disease where there is a pre-existent excretion from the blood, as in suppurative fever, milk fever, and the premonitory outbreak of the exanthemata. Still it is always conceivable that another and less palpable material, which hitherto, like that of miasmata and most contagions, eludes our research, may be present in the blood as the immediate cause of gout, and occasion these periodic reactions, as well as all the derangements of the nervous system and of the chemistry of the organism, by a specific irritation of the nervous centres of the ganglia and the spinal cord. This substance is possibly excreted-whether by the skin or kidneys-in that febrile reaction which follows the acute local pain of the paroxysm. This much may be generally asserted, that the improvement which succeeds the attack is, as a rule, proportionate to the degree of febrile reaction, and this again to the degree of local pain. The materies morbi would thus be removed by the febrile reaction, just as we see other chronic dyscrasiæ disappear through fever, without therefore implying any necessary causal relation between the dyscrasia and the fever. It is, in fact, a well-known observation, that gouty patients often remain for a long time free from paroxysms after a febrile malady of however foreign a nature. Or, perhaps the general excitement of the vascular and nervous system produced by the fever is alone sufficient to restore a freer circulation, to liberate the nervous system from pressure, to excite its functions to new activity, and thus bring about a general improvement, without going so far as to imply material excretions. Julius Vogel thinks that, just as every acute febrile affection limits the

before. In such cases, when the patient has recovered the use of the affected limb, the other leg, or perhaps a hand, begins to ache. This pain gradually increases, and terminates in another acute and feverish attack, attended with a similar train of symptoms, in which may be perceived this difference only, that they are all less painful and more lingering than on the former occasion.

It has been admitted by most practical writers, that a certain outward conformation of the body marks a predisposition to gout. Persons with

large heads, of a sanguine habit of body, and who perspire very freely, have been stated to be in a particular manner prone to the disease. I cannot say that my own experience proves the truth of these observations; but I have certainly seen that people of a heavy muscular form, with a natural tendency to fatness, and those who have a large and protuberant abdomen, are singularly liable to gout.

Notwithstanding the severity of the symptoms

development of blood, so here also a degree of anæmia is produced for a longer or shorter time opposing the gouty disposition. In explaining this general improvement, it must also be borne in mind that the patient, who has often hitherto allowed himself every excess, changes his whole mode of life, during and after the attack, uses purgatives, &c.; treatment which would have produced a similar improvement before the attack, and would probably have warded it off altogether. Subsequently he returns to his old mode of life; for no patient forgets his sufferings more easily and more gladly than the gouty. The scene then begins anew." (Braun's Translation.)

I have described, this disease is often extended to a long period of three months; but such is by no means its most ordinary duration. A fit of the gout runs its course in ten days; and it is very common to see it attended with sufferings of far less gravity than those I have described. One or two painful nights, with a few days' swelling and weakness of the part, and but little constitutional disturbance, will finish the matter, and restore the patient to health. It is sometimes observed in this simple form, the part having a smooth and glossy appearance, without redness, pain, or other uneasiness. In cases of this kind, the parts most commonly assailed are those most liable to pressure, such as the ball of the great toe or the heel, and those parts most stretched and strained, as the plantar muscle, the fascia covering the instep of the foot, the thumb, the fascia of the wrist, or the metatarsal and metacarpal ligaments. These gouty pains at times yield to rest, and are sometimes driven off by violent exertion.

When the patient has suffered repeated attacks of the disease, the effused fluids are imperfectly absorbed. The solid and earthy matters remain behind, to form knotty excrescences on and around the extremities of the bones, limiting the action of the joints. These tumours, called chalk-stones, are not painful, unless at the time of the paroxysm.

When once formed, each successive attack of gout adds a layer of solid matter to that already deposited; and I have frequently observed these concretions grow much in size, though the patient may not have been conscious of the accession of any painful symptom. By the increase of the tumour, it invests the joint more and more, but it also approaches nearer and nearer the surface, till at last the thin film of skin covering the chalkstone gives way, and the earthy deposit is exposed. Fistulous openings are then formed, and a fluid, containing much of the same earthy matter, mixed with a sanious discharge, is effused. This matter is often of a very foul and offensive quality, especially when it proceeds from the neighbourhood of the larger joints.

Nor are these deposits confined to the neighbourhood of the articulations. The muscular and tendinous structures are much molested by them, their fibres becoming friable and obnoxious to sprains and rupture. Mr. H. J. Johnson, treating of the common accident, rupture of the tendo Achillis, writes, "Almost all the cases that have occurred to me were in persons of a gouty habit." ('Lancet,' 22d Nov., 1851.) Dr. Hamilton, of Lynn Regis, mentions the case of Mr. Andrew. Pigge, an apothecary of that town, in whom the whole cellular membrane, from the knees to the

toes, was filled with chalky matter, as if liquid mortar had been poured into the cells, and there left to harden after the evaporation of the water suspending it.

Renewed and oft-repeated attacks of gout do not fail to make sad havoc with the health and strength of the patient. It is matter of great interest to observe the mode in which his powers are undermined, the gradual inroad made on his digestive, secreting, and excreting powers, on his vital functions, and on his nervous and circulating systems. The first complaint is generally of the great loss of muscular power. Not the fibrous structure alone, where the disease had taken up its abode, but the whole muscular system of the body loses activity and strength; this, conspiring with the indolence so natural to the gouty, yields them up more ready victims to the disease. The process of nutrition in the muscles is less perfect than before. They lose bulk and perish; and this decline goes on, till, in the last stages of the complaint, they may be felt, as it were, dissected beneath the skin, and rolling under the finger like so many separate ropes.

The most remarkable change is in the functions of the stomach. The appetite becomes more capricious; it is greatly impaired for all the simpler kinds of food, and seeks the stimulus of condiments