The nature and treatment of gout and rheumatic gout

Front matter

TUFTS COLLEGE

GIFT OF DR. J. H. PliATT

Boston Medical Library in the Francis A. Countway Library of Medicine --Boston

Contents

CHAPTEE I.

I Introductory Remarks : — Knowledge of the ancient writers upon the subject of Gout — Views of Hippocrates — Celsus — Galen — Aretseus — C^lius Aurelianus — Alexander Trallianus — Aetius — Paulus ^glneta — Demetrius Pepagomenos — The Arabian Physicians— The principal Authors of the 17th and 18th centuries — Extracts fi-om Lucian's Poems — The Tragapodagra and Ocypus — Classification of Gout adopted by difi'erent Authors — Dr. Cullen — Dr. Mason Good — Author's Division ....

Chapter II

Acute Gout ; — Description of an early Attack — Premonitory Symptoms — Seat and Character of Gouty Inflammation — Part first affected— Pain — Edema — Desquamation — Not followed by Suppuration— Apparent exceptions — Febrile Disturbance — Progress of Gout — Less common forms— Acute general Gout — Sequelae of Acute Gout — Heberden's opinion of the desirability of the occurrence of Gout — Sydenham's description of Acute Gout 30

CHAPTEE III.

Chronic Gout : — Not a constant sequel to the Acute affection — Description of — Constitutional Symptoms — Alterations of structure produced by Chronic Gout — Nature of the so-called Chalkstones or Tophaceous deposits — Their microscopic and chemical characters — Their frequent occurrence — Situation of — Upon ears — Often useful in diagnosis — Around joints — Within bursse — causing much deformity — Illustrative cases — Gouty Abscesses — Mr. Moore's and Mr. Howship's description of — Circumstances leading to the formation of extensive Chalk-like deposits — Sydenham's description of Chronic Gout ..... 65 c

CONTENTS.

CHAPTEE lY.

Blood in Grout; — Altered condition of the Blood in Gout often assumed by the older Writers, not proved until very I'ecently — Composition of the Blood in Health — Its alteration in Grout — Globules — Fibrin — Albumen — Discovery of Urate of Soda in the Blood- — Mode of separating Uric Acid and Urate of Soda from it — Clinical Method for determining the presence of Uric Acid in the Blood — Details and Precautions — Delicacy of the Test — Ready Decomposition of Uric Acid in the Blood — Probable Changes which ensue — Table containing a short Summary of Cases of Gout in which Uric Acid was proved to exist in the Blood — Discovery of Uric Acid in Fluids artificially effused — Use in Diagnosis — Small amount of Urea in the Blood in Gout, also of Oxalic Acid — Traces of Uric Acid and Urea in healthy Blood — Perspiration in Gout — Oxalic Acid found in this Secretion 100

CHAPTER Y.

Urine in Gout : — Characters of healthy Urine — Table exhibiting the Composition of Urine and the daily Elimination of its different Constituents — Uric Aoid^The manner in which it exists in the Urine — Relation between the Acidity of Urine and the Uric Acid contained in it — Condition of the Urine in Acute Gout — No excessive Excretion of Uric Acid in many cases — Elimination of the Urea but little influenced — Urine in Chronic Gout — Deficient Excretion of Uric Acid — No marked Deficiency in the Excreted Urea- — Frequent Presence of small amounts of Albumen — Urine of Gouty Individuals in the intervals of the Fits — Probable Explanation of the frequent Returns of Gout — Microscopic Characters of the Urine in different Forms of Gout 146

CHAPTER YI.

The Morbid Anatomy of Gout : — Great Importance of the Subject — Changes in the Joints observed by Morgagni, Dr. Monro, and others — Sir B. Brodie's Dissection of a Gouty Subject — Cruveilhier's Observations — The Author's Investigations — 1. Of Cases of Chronic Gout with extensive Chalk Stones — 2. Of subjects exbibiting Points of Deposition on the Ears alone — 3. Where no Deposit or Deformity existed — 4. When only the Ball of one Great Toe had been affected with Gout . . . . .185

CONTENTS.

CHAPTER YII.

Morbid Anatomy of Grout 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 — Changes in the Kidneys of Gouty Subjects : 1. In the Chronic Forms of the Malady ; 2. In the Early Stages — Deposits in other Situations — Often unconnected with the Disease ........ 221

CHAPTER YIII. .

Causes of Gout ; — Predisposing Causes : Hereditary Influence — Sex — Age— Temperament or Constitutional Peculiarity — Alcoholic Liquors — Differences in their Power of Inducing Gout — Indigestion—Animal Diet — Absence of Exercise - Severe Study — Mental Anxiety — Climate — Lead as a Predisposing Cause of Gout — Great Frequency of the Disease among Painters and Plumbei-s — Influence of the Absorption of Lead upon the Excretion of Uric Acid — Exciting Causes : Wines, &c. —Dyspepsia- Cold and Moisture — Mental and Bodily Excitement or Fatigue . 249

CHAPTER IX.

Pathology or Nature of Gout : — Evidence of a close Relation between Gout and CFric Acid — Characters and Composition of Uric Acid and its Salts — Products of its Metamorphosis under different Circumstances — Its Occurrence in different Classes of . Animals— Its Physiological and Pathological Relations — Opinions of the Ancients on the Nature of Gout — CuUen's Objections to the Doctrine of the Humoral Pathologists, and his own Views on the Subject — Murray Forbes' Theory — Opinions of Sir C. Scudamore, Dr. Barlow, Dr. Gairdner, and others — Reflections of Sir H. Holland — Author's own Views on the Nature of Gout — Explanation of the Gouty Diathesis and Premonitory Symptoms— Explanation of the Paroxysm and various Phenomena connected with the Disease ....... 304

CHAPTER X.

Treatment of Gout : — Short Review of the Treatment adopted by the Ancients — Is Gout a Cm-able Disease ? — Cullen's Opinion —Author's Views on the value of Remedies in the different

CONTENTS.

Stages of Gout— Treatment of Acute Gout— Diet and Regimen — The Value of Pursatives — Mercurials — Their injurious Effects in many Casc;s — Diuretics and Diaphoretics — Blood-Letting — Colchicum — Local Treatment— Leeches— Blisters — Warm Applications— Evaporating Lotions — Anodynes — Summary of the Treatment of the Gouty Paroxysm. 369

CHAPTER XI.

Treatment of Gout: — Colchicum — Importance of the Study of its Mode of Operation — The Hermodactylus of the Ancients probably a Species of Colchicum ^ — Chemical Composition of Colchicum • — Its Physiological Action — Curative Effects not Explainable by its Purgative Property — Its Influence on the Circulating System — On the Urine — Dr. Christison's Experiments— Observations of Professor Chelius — Author's Analyses exhibiting the Effect of Colchicum on the Urine — Deductions therefrom — Mode of employing Colchicum in the Treatment of Gout— The Question discussed as to its Liability to cause Mischief— Different Preparations of Colchicum — White Hellebore in Gout — Observations on its Action . . . . .386

CHAPTER XII.

Treatment of Gout : — Its Importance in the Chronic Stages of the Disorder — Medicinal Treatment of Chronic Gout — General Sketch of — Value of Special Remedies — Alkalies and Salines — Diluents — Lithia Salts proposed as Curative Agents — Their Special Action and Advantages— Ash Leaves in Gout — Tonics — Their Value in Gouty Cases — Portland Powder — Discussion of the Liability of Tonics to produce injurious Consequences — Treatment of the Local Affections — Edema — Stiffness of Joints — Chalk-stones — Gouty Abscesses — Diet and Regimen in Chronic Gout — The Prophylactic Management of Gout . . . .417

CHAPTER XIII.

Treatment of Gout : — Mineral Waters — General Remarks on their Employment — Alkaline Waters of Vichy — Mode of Action of — Report on their Value by a Commission of the French Academy — Author's Experience of their Value — Saline Waters of Wiesbaden— Their Nature, Action, and Value in Gout — Sulphuretted Saline Waters of Aix-la-Chapelle — Employment in Gouty Cases — Carlsbad Waters— Influence of Mineral Waters containing little Saline Matter, as of Wildbad, Teplitz, Buxton, etc. — Summary of the Treatment of Gout by Mineral Waters . . . . 475

CONTENTS.

CHAPTER XIY.

Irregular Forms of Grout : — Preliminary Observations — Difficulties in the Investigation of Irregular Forms of Grout — Mode of ascertaining the True Nature of Difficult and Anomalous Cases — Retrocedent or Metastatic Gout — Implicating the Stomach, Heart, and Head — Its Treatment — Gout Affecting the Digestive Organs — The Heart — The Respiratory Organs — Urinary Organs — The Eye — The Ear— The Skin— The Nervous and Muscular Systems — Treatment of the Different Forms of Irregular Gout 496

CHAPTER XY.

Rheumatic Gout : — Remarks on the Use of the Name — Confusion arising from the Employment of the Term — Different Diseases included under the head of Rheumatic Gout — Cases of True Gout to which the Title is given — Cases of Sub-acute Rheumatism — Diagnosis of Goiit and Rheumatism— Capsular Rheumatism — Rheumatoid Arthritis — The Chronic Rheumatic Arthritis of Adams — Nodosity of the Joints of Haygarth — Symptoms of — Anatomical Characters — Causes — Pathology — Diagnosis — Table Exhibiting the Differential Diagnosis of Gout, Rheumatism, and Rheumatoid Arthritis — Treatment of Rheumatic Gout — Diseases in Connection with the Gouty Diathesis — Prognosis of Gout and Rheumatic Gout 526

Index . 597

EXPLANATION OF THE PLATES.

Plate I. (To face page 64.) Fig. 1. — The ear of a gouty subject, exhibiting one small nodule of urate of soda upon the edge of the helix, the only external evidence of chalk-stones visible throughout the body.

Fig. 2. — The ear of another gouty subject, -with several deposits on the helix.

Fig. 3. — The great toe of a gouty patient, considerable deposits of urate of soda seen approaching the surface, the veins in their neighbourhood enlarged, and the whole toe inflamed.

Plate II. (To face page 96.) — The arm of a gouty man, in which chalk-stones had become developed to an extreme degree ; the bursa over the olecranon enormously distended with chalk-like matter.

Plate III. (To face page 220.) Fig. 1. — The knee-joint of a gouty man, recently opened, and . exhibiting the white plaster-like layer of urate of soda in the articular cartilage on the heads of the femur, tibia, and patella.

Fig. 2. — The section of a thumb, showing the thin layer of deposit on the articular cartilages, also on the ligaments, causing anchylosis, and extending towards the surface.

Fig. 3. — The section of a finger, exhibiting the same phenomena as Fig. 2, in addition to which the urate of soda has pressed upon the phalangeal bones and caused partial absorption ; some of the same matter is seen penetrating the bone itself.

EXPLANATION OF THE PLATES. xv

Plate IV. (To face p. 248.) Fig. 1.— The hand of a -woman in the early stage of rheumatoid arthritis, or rheumatic gout.

Fig. 2. — The contracted kidney of a gouty subject.

a. External surface, showing the wasting of the cortical

portion. 6. Section of the kidney, exhibiting white streaks of urate of soda in the direction of the tubuli uriniferi, and points of the same matter at the end of the pyramids.

Plate V. (To face page 304.) Fig. 1. — A thin vertical section of articular cartilage affected with gouty deposit, exhibiting the crystalline character of the urate of soda, dense towards the free edges of the cartilage, and gradually becoming thinner ; external to this deposit a thin layer of organic matter is seen. Linear magnifying power, 220.

Fig. 2. — A thin horizontal section of the same cartilage, taken from a specimen obtained from a limb amputated by Mr. Listen, in 1847. The arrangement of the crystals in stellar groups is well shown. Linear power, 220.

Fig. 3. — Crystals of urate of soda from a semi-fluid chalky concretion. Linear power, 220.

Fig. 4. — Crystallised urate of soda, obtained by evaporating the watery solution of the blood in gout. Linear power, 220.

Fig. 5. — Uric acid, crystallised on fibres from the blood in gout, by the uric acid thread experiment. Linear power, 100 and

Fig. 6. — Oxalate of lime, crystallised on a fibre obtained from the perspiration of a gouty subject. Linear power, 220.

Plate VI. (To face page 358.) Fig. 1. — Different forms of crystals of uric acid obtained from urine. Linear power, 80.

Fig. 2. — Urates of soda and ammonia.

a. Amorphous form.

b. Urate of ammonia from urine of birds and reptiles. c and d. Urates occurring in urine.

Linear power, 220.

n EXPLANATION OF THE PLATES.

Fig. 3. Different forms of oxalate of lime from urine. a. The octohedral form. 6, Dodecahedra.

c. The ovoid, or dumb-bell, variety. Linear power, 220.

Fig. 4. — Phosphates of magnesia, ammonia, and lime.

a. Prismatic form of triple phosphate, from neutral or

slightly alkaline urine.

b. Stellar variety.

c. Feathery form of phosphates from effloresced blood

serum.

d. Phosphate of lime.

Linear power, 220.

Fig. 5. — a. .Blood discs.

b. Pus corpuscles.

c. Pus corpuscles treated with acetic acid.

Fig. 6. — a. Granular cysts of urinary tubes.

b. Organic globules.

c. Epithelial scales.

Linear power, 220.

ON GOUT,

NATURE AND TREATMENT.

CHAPTER L

Introductory Remarks : — knowledge of the ancient writers

UPON THE subject OF GOUT — VIEWS OP HIPPOCRATES — CELSUS

GALEN — ARET^CS — C^LIUS AURELIANUS ALEXANDER TRAL-

LIANUS AiiTIUS — PAULUS ,EGINET A— DEMETRIUS PEPAGOMENOS

THE ARABIAN PHYSICIANS — THE PRINCIPAL AUTHORS OF THE

17tH and 18tH centuries — extracts from LUCIAn's POEMS — THE TRA6AP0DAGRA AND OCYPUS — CLASSIFICATION OF GOUT ADOPTED BY DIFFERENT AUTHORS — OF DR. CULLEN — DR. MASON GOOD — author's DIVISION.

Gout is a malady faMy entitled to boast of its great antiquity, for it was probably one of the earliest diseases to wliich flesh, became heir when man began to participate in the luxuries of civilised life. It is a disease, also, which can lay claim to having had among its victims some of the most renowned of the human race, from their position, opulence, and intellect. The great Sydenham, often styled the English Hippocrates, himself a martyr to gout, thus

2 HISTORICAL INTEODUCTION.

alludes to the subjects most liable to be affected by it:

" For humble individuals like myself there is one poor comfort, which is this, viz. that gout, unKke any other disease, kills more rich men than poor, more wise than simple. Great kings, emperors, generals, admirals, and philosophers, have all died of gout. Hereby IsTature shows her impartiahty, since those whom she favours in one way she afflicts in another — a mixture of good and evil pre-eminently adapted to our frail mortality :

Among nations in an uncivilised state, living chiefly on the produce of the chase obtained by personal exertion, or subsisting at least on the simplest fare, gout, according to the reports of eminent travellers, is entirely unknown even at the present day; but in our own country, and in many other parts of the civilised world, the case is far otherwise ; for not only is gout even in its most marked and typical forms exceedingly prevalent, but in its lurking and undeveloped condition it is probably still more so, and exercises a considerable influence over the character and progress of many other disorders.

These considerations alone render it an object of the highest importance that the disease should be clearly understood in all its bearings.

Another reason for the necessity of a further and

IMPORTANCE OF THE STUDY OF GOUT. 3

accurate study of gout, arises from tlie fact, that errors in distinguishing it very frequently occur, not only with regard to the more marked forms of the affection, but even with its most common manifestations. It is by no means rare, to hear of inflammation of a joint by one practitioner, called gout, by another rheumatism, and by a third, rheumatic gout ; and such discrepancies of opinion, of the highest importance in treatment, often arise from the difiiculty of clearly distinguishing its true character on account of our imperfect knowledge of the malady. As we proceed, Ave shall be able to demonstrate beyond all doubt, that gout is a disease sui f/enen's, having a pathology of its own, and producing alterations in the various tissues which it attacks, difl"ering from all other changes, — alterations which are, indeed, completely pathognomonic. If diflicultics arise in distinguishing the more regular forms of gout, they are greatly increased when its irregular manifestations require to be discriminated. Although in a highly gouty state of the system, functional disturbance of various organs, and even imflammatory affections may and do arise, depending upon such morbid state, — conditions whose real nature it is most important to determine accurately, — still in practice, even at the present day, the term is not unfrequently applied, more to quiet the patient and satisfy the mind of the physician, than from any evidence that the disease under consideration is strictly connected with gout ; for it must be remembered

B 2 that tlie occurrence of gout does not ensure exemption from other maladies, and the latter, when they arise, have no necessary relation to the former. A careful j^erusal of the writings of some of the authors of the last and commencement of the present century, must convince every thinking mind that many of the forms of gout so elaborately described, especially by Continental physicians, have no real existence in nature.

It will be one object of the present treatise, to endeavour more clearly to point out and separate those affections which are distinctly traceable to the gouty diathesis, to found their diagnosis on a more philosophical basis, and thus to pave the way for a scientific and successful treatment.

That the ancients were fully cognisant of the phenomena of gout, and in fact that it was one of the disorders the nature and treatment of which were best known to them, is at once evident from a perusal of their writings. It is true that an undue stress was frequently laid upon the mere seat of the affection, and that different names were not uncommonly applied to the same disease in its different local manifestations, and also that the same name was often given to maladies of a very diverse character ; but this should not surprise us, considering their total ignorance of even the rudiments of some of those sciences which are essential to a clear understanding and separation of different pathological conditions of the body. Gout and rheumatism were doubtless often

CLASSIFICATION BY THE ANCIENTS. 5

confounded with each other by the Greek physicians ; and this remark is also appHcable to some pathologists of the present day. However, although the same general term was often appHed to both diseases, still it Avill be at once manifest, from the many quotations from their more important works which we shall have occasion to bring before our readers, that true gout was mostly separated from other joint affections, its peculiar phenomena and progress clearly defined, its various causes ascertained, and its treatment, dietetic and medicinal, carefully laid down.

In general the Greek physicians gave different names to the affection, according to the situation in which it occurred: for example, when the foot was attacked, it was named Podagra {irobdypr], or irobdypay from 7T0VS, the foot, and aypa, a seizure, — t(ov Troowr aypa, Lucian) ; when the hand, Chiragra (x^tpdypa, from x^'^Pj t^^G hand, and dypa) ; when in the Imec, Gonagra {yovdypa, from yovv, the knee) ; and Omagra, Cleisagra, Pechyagra, Dentagra, &c., when either the shoulder, clavicle, elbow, teeth, &c., became the special seat of the disease ; when, however, many joints were simultaneously affected, the term Arthritis (ap6pov, a joint) was more commonly applied. The word gout appears to have been introduced into medicine about the end of the thirteenth century, by Radulfe, and it probably owes its origin to the idea which has been very prevalent in all ages, that the disease w^as caused by the presence of some peculiar humom' in the blood, which v^as thrown out, or, as it were, distilled into the joints drop by drop; and hence in different modern languages terms expressing the same notion are employed, terms in fact corresponding to our word gout ; thus, by the French the disease is called " Goutte," by the Grermans '^ Gicht", by the Italians " Gotta," and by the Spaniards " Gota," and so forth.

The writings of Hippocrates, who lived about 350 years before the Christian era, show that he was by no means unacquainted with the disease under consideration, and many of his aphorisms indicate the possession of a considerable knowledge of the laws and nature of gout. We find it stated, for example, that gouty afi'ections occur or trouble most in spring and autumn ; that women do not have gout until the catamenia have stopped; that young men are free from the disease till venery is indulged in, and that eunuchs are also exempt from gouty afi'ections ; and it is likewise stated that gouty patients who have tophi, or chalk-stones in their joints, who have led a hard life, and whose bowels are constipated, are beyond the power of medicine ; that the best remedy for them is an attack of dysentery or other determination to the bowels, but that under other circumstances the disease may be cured by a skilful physician. He considered the disorder as dependent on the retention of concocted humours, and advised purgmg, and the appHcation of cooling agents, even going so far as to pour cold water on the inflamed foot. Although at the present day we cannot perhaps subscribe to all the

OPINIONS OF HIPPOCRATES. 7

opinions above expressed, still we must agree in their general truthfulness ; for gout usually occurs in spring and autumn, although it often attacks patients at other seasons of the year. Women, again, seldom suffer, at least from the regular forms of gout, until they have arrived at the age when the catamenia disappear ; very young men, unless strongly inheriting the disease, seldom have gout, and few who have had much experience in its treatment vdll entertain very sanguine hopes of a radical cure, when the joatient is suffering from chalk-stones and the other deformities so often the sequelee of the chronic forms of this affection. Some of the aphorisms of Hippocrates were even more correct at the time they were enunciated than at subsequent periods, or at the present day, for luxurious living had not yet been so freely indulged in ; probably gout was then unknown among eunuchs, and women were seldom martyrs to it.

The treatment of Hippocrates consisted in administering pm-gatives either by the mouth or by injection ; the drinking of asses' milk and whey, and the affusion of cold water to the affected parts, considering that the pain would be alleviated by any application which induced a moderate torpor of the limb.

Celsus, who lived about the beginning of the Christian era, in speaking of the treatment of gout, remarked that bleeding at the commencement of the attack had the effect of causing some patients to be free from the disease for a year, some even for life ;

he also recommends either cold or warm applications, depending on the presence or absence of inflammatory action. He, however, enjoins some caution with regard to the appliance of cold, and recommends a regulated manner of living and the avoidance of corpulence ; with regard to the value of exercise, he remarks, " it is very necessary that those who are troubled with nervous pains, such as happen either in the gout of the feet or hands, should give the parts affected as much exercise as possible, and should expose them on all occasions both to fatigue and cold.''

Galen, who flourished about the latter half of the second century, was of opinion, that gout was caused by some unnatural accumulation of matters in the part affected ; these matters were supposed to consist of phlegm, bile, blood, or a mixture of these fluids, and tophi, or chalk-stones, were considered to be formed by such becoming concrete or soKdified. In his comments on the aphorisms of Hippocrates, he remarks, that " though in the time of Hippocrates, eunuchs were not afflicted with gout, yet they are now, in consequence of too much sloth and intemperance. Truly in the time of Hippocrates, on account of their temperance and extreme moderation, on the whole, few suffered from gout ; but in our times, luxury and indulgence being so much increased, that it is impossible they can be more so, the number of those who have the gout is infinite.'' Galen's method of treatment consisted in bleeding and purging, and the appHcation of repellents and

OPINIONS OF GALEN AND ARET.EUS. 0

discutients ; but lie remarks tliat " you cannot give mucli relief to those wlio are incontinent, drunkards or gluttons, either by purgatives, or by bleeding ; but if they follow your directions, you will benefit them most by bleeding early in the spring, and then paying attention to exercise and diet.''

Seneca also, in his epistles, makes a similar remark on the influence of change of manners and habits, as exempHfied during the Eoman Empii^e, on the liability to certain diseases, for he says, " the nature of women is not altered, but their manner of living ; for while they come up to the men in every kind of Hcentiousness, they equal them too in their very bodily disorders." ^' AVhy need we then be surprised at seeing so many of the female sex afflicted with gout, and also with baldness, contrary to the maxims of Hippocrates, the greatest of physicians, and the best acquainted with nature ? Seeing they have by their vices thrown away the natural advantage of their own sex, and by putting off the woman are doomed to suffer all the diseases peculiar to the other."

Aretaeus, the Cappadocian, who probably was a contemporary of Galen, and flourished about the middle of the second century, although, Hke Hippocrates, he classified all joint affections under the term Arthritis, yet subdivided them, according to the parts attacked, into Podagra, Chiragra, and so forth. That he had a very clear conception, and was familiar with many of the phenomena of true gout, is evident from his account of the manner in which it makes its invasion. He states, for example, that " the joints begin to be affected in this way : pain seizes the great toe, then the forepart of the heel on which we lean, next it comes into the hollow of the foot, but the ankle swells last; and they blame a wrong cause; some, the friction of a new shoe ; others, a long walk ; another, again, a stroke, or being trod upon ; but no one will, of his own accord, tell the true one ; and the true one appears incredible to the patients when they hear of it. On this account the disease gets to an incurable state, because at the commencement, when it is feeble, the physician is not at hand to contend with it ; but if it has acquired strength from time, all treatment is useless. In some, then, it remains in the joints of the feet until death ; but in others it spreads over the compass of the whole body. For the most part it passes from the feet to the hands. For to the disease there is no great interval between the hands and the feet, both being of a similar nature, slender, devoid of flesh, and very near the external cold, but very far from the internal heat : next, the elbow and the knee, and after these the hip-joint, which is the transition to the muscles of the back and chest. It is incredible how far the mischief spreads. The vertebrae of the spine and neck are affected with the pain, and it extends to the extremity of the OS sacrum : there is a general pain of all the parts of the groin, and a pain peculiar to each part thereof. But likewise the tendons and muscles are

YIE^YS OF ARET^US, 11

intensely pained ; tlie muscles of tlie jaw and temples, tlie kidneys and bladder next in succession. And, what a wonder ! at last tlie nose, tlie ears, and tlie lips sujffer ; for everywhere there are nerves and muscles. Callosities, also, form in the joints : at first they resemble abscesses, but afterwards they get more condensed, and the humour being condensed is difficult to dissolve ; at last they are converted into hard white tophi, and over the whole there are small tumours, like vari, and larger, but the humour is thick, white, and like hailstones."*

We shall find, as we proceed, that the description above given, is indeed very correct of the progress which gout not unfrcqucntly makes in its more chronic and inveterate forms ; and the production of tophi, or chalk-stones, is most accui'ately described ; it is also noted by this writer, that men are more frequently aff'ected than women, and at the same time more slightly (this last statement as far as real gout is concerned, is certainly erroneous) ; that the most common age is thii^ty-five, but that it may be sooner or later according to the temperament of the individual. As to the nature of the disease Areta)us says, none but the gods can truly understand, but men may know the probable cause ; the explanation, however, which he ofi'ers is not such as would be satisfactory at the present day. With regard to his treatment of gout, the following summary