on gout, adopts a division somewhat similar to though simpler than that of Cullen, namely, regular gout, which affects the joints alone, and is either acute or chronic, and irregular gout, affecting non-articular tissues, or disturbing the functions of various organs. It is often stated that the attack of gout comes on with out any previous warning ; but, while this is true in many instances, the reverse is probably as frequently the case, and the premonitory symptoms, especially in those who have previously suffered from the disease, may be sufficiently precise to indicate the impending seizure. Among the more common of these may be mentioned marked disorders of the digestive organs, with a feeble and capricious appetite, flatulence and pain after eating, and uneasiness in the right side in the region of the liver. A remarkable tendency to gnashing of the teeth is sometimes observed. This symp tom was first noticed by Dr Graves, who connected it with irritation in the urinary organs, which also is present as one of the premonitory indications of the gouty attack. Various forms of nervous disturbance also present themselves in the form of general discomfort, extreme irritability of temper, and various perverted sensations, such as that of numbness and coldness in the limbs. These symptoms may persist for many days and then undergo amelioration immediately before the impending paroxysm. On the night of the attack the patient retires to rest apparently well, but about two or three o clock in the morning is awoke with a painful feeling in the foot, most commonly in the ball of the great toe, but it may be in the instep or heel, or in the thumb. With the pain there often occurs a distinct shivering followed by feverishness. The pain soon becomes of the most agonizing character : in the words of Sydenham, "now it is a violent stretching and tearing of the ligaments, now it is a gnawing pain, and now a pressure and tightening; so exquisite and lively meanwhile is the part affected that it cannot bear the weight of the bedclothes, nor the jar of a person walking in the room." When the affected part is examined it is found to be swollen and of a deep red hue. The superjacent skin is tense and glistening, and the surrounding veins are more or less distended. After a few hours there is a remission of the pain, slight perspiration takes place, and the patient may fall asleep. The pain may continue moderate during the day but returns as night advances, and the patient goes through a similar experience of suffering to that of the previous night, followed with a like abatement towards morning. These nocturnal exacerbations occur with greater or less severity during the continuance of the attack, which generally lasts for a week or ten days. As the symptoms decline the swelling and tenderness of the affected joint abate, but the skin over it pits on pressure for a time, and with this there is often associated slight desquamation of the cuticle. During the attacks there is much constitu tional disturbance. The patient is restless and extremely irritable, and suffers from cramp in the limbs and from dyspepsia, thirst, and constipation. The urine is scanty and high-coloured, with a copious deposit, consisting chiefly of urates. During the continuance of the symptoms the inflammation may leave the one foot and affect the other, or both may suffer at the same time. After the attack is over the patient feels quite well and fancies himself better than he had been for a long time before ; hence the once popular notion that a fit of the gout was capable of remov ing all other ailments. Any such idea, however, is sadly belied in the experience of most sufferers from this disease. It is rare that the first is the only attack of gout, and another is apt to occur within a year, although by care and treatment it may be warded off. The disease, however, undoubtedly tends to take a firmer hold on the constitution and to return. In the earlier recurrences the same joints as were formerly the seat of the gouty inflammation suffer again, but in course of time others become implicated, until in advanced cases scarcely any articulation escapes, and the disease thus becomes chronic. It is to be noticed that when gout assumes this form the frequently recurring attacks are usually attended with less pain than the earlier ones, but their disastrous effects are evidenced alike by the disturb ance of various important organs, especially the stomach, liver, kidneys, and heart, and by the remarkable changes which take place in the joints from the formation of the so- called chalk-stones or tophi. These deposits, which are highly characteristic of gout, appear at first to take place in the form of a semifluid material, consisting for the most part of urate of soda, which gradually becomes more dense, and ultimately quite hard. When any quantity of this is deposited in the structures of a joint the effect is to produce stiffening, and, as deposits appear to take place to a greater or less amount in connexion with every attack, permanent thickening and deformity of the parts is apt to be the con sequence. The extent of this depends of course on the amount of the deposits, which, however, would seem to be in no necessary relation to the severity of the attack, being in some cases even of chronic gout so slight as to be barely appreciable externally, but on the other hand occasionally causing great enlargement of the joints, and fixing them in a flexed or extended position which renders them entirely useless. Dr Garrod describes the appearance of a hand in an extreme case of this kind, and likens its shape to a bundle of French carrots with their heads forward, the nails corresponding to the stalks. Any of the joints may be thus affected, but most commonly those of the hands and feet. The deposits take place in other structures besides those of joints, such as along the course of tendons, underneath the skin and periosteum, in the sclerotic coat of the eye, and especially on the cartilages of the external ear. When largely deposited in joints an abscess sometimes forms, the skin gives way, and the concretion is exposed. Sir Thomas Watson quotes a case of this kind where the patient when playing at cards was accustomed to chalk the score of the game upon the table with his gouty knuckles. The recognition of what is termed irregular gout is less easy than that form above described, where the disease gives abundant external evidence of its presence ; but that other parts than joints suffer from gouty attacks is beyond question. The diagnosis may often be made in cases where in an attack of ordinary gout the disease suddenly leaves the affected joints and some new series of symptoms arises. It has been often observed when cold has been applied to an inflamed joint that the pain and inflammation in the part ceased, but that some sudden and alarming seizure re ferable to the stomach, brain, heart, or lungs supervened. Such attacks, which correspond to what is termed by Cullen retrocedent gout, often terminate favourably, more especi ally if the disease again returns to the joints. Further, the gouty nature of some long-continued internal or cutane ous disorder may be rendered apparent by its disappearance on the outbreak of the paroxysm in the joints. Gout, when of long standing, is often found associated with degenerative changes in the heart and large arteries, the liver, and especi ally the kidneys, which are apt to assume the contracted granular condition already alluded to as one of the forms of Bright s disease (see BRIGHT S DISEASE). A variety of urinary calculus the uric acid formed by concretions of this substance in the kidneys is a not unfrequent occurrence in connexion with gout ; hence the well-known association of this disease and gravel. As regards the pathology of gout, all inquiry agrees in connecting it closely with an altered state of the blood, more particularly with the presence in that fluid in excessive
amount of uric acid, and its subsequent deposition in the
