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 THE EEGIMEN 
 
 TO BE ADOPTED 
 
 IN CASES OF GOUT 
 
THE REGIMEN 
 
 TO BE ADOPTED 
 
 IN CASES OF GOUT 
 
 Dr. WILHELM EBSTEIN 
 
 PROFESSOR OF CLINICAL MEDICINE IN GOTTINGEN 
 
 TRANSLATED BY 
 
 JOHN SCOTT, M.A., M.B. 
 
 HONORARY PHYSICIAN, MANCHESTER SOUTHERN HOSPITAL FOR DISEASES OF 
 WOMEN AND CHILDREN 
 
 LONDON 
 
 J. & A. CHUECHILL 
 
 11, NEW BURLINGTON STREET 
 1885 
 
PKEFACE. 
 
 The object of this treatise is almost entirely practical, It 
 gives a description of the mode of living which I consider 
 necessary not only for the actual victims of gout, but for 
 those who have inherited a disposition towards the disease. 
 Scientific questions are only entered on to the extent that 
 is necessary to secure a foundation for my propositions. In 
 the additions and explanations which are appended to the 
 text, I have expanded and completed, in the light of further 
 investigations, some questions which have been already dis- 
 cussed in my monograph on "The Nature and Treatment 
 of Gout." 
 
 WlLHELM EBSTEIN. 
 Gottingen, December 20th, 1884. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/regimentobeadoptOOebst 
 
TKANSLATOK'S PBEFACE. 
 
 I have translated this little work at the request of Professor 
 Ebstein, and while abridging it slightly in some places, have 
 striven to omit nothing that might interest English readers. 
 The decimal system, in which the weights and measures of 
 the original are given, has been retained in the translation 
 as being more suitable for comparisons of figures, but I trust 
 the day is not far distant when we shall see this system 
 universally adopted. 
 
 John Scott, 
 
 Manchester, April 9th, 1885. 
 
THE REGIMEN TO BE ADOPTED 
 IN CASES OF GOUT. 
 
 While the question whether, and to what extent, the use of 
 pharmaceutical remedies and the application of other methods 
 of cure are of service in gout,(i)* has been a subject of the 
 liveliest controversy for ages, and we are not yet in a position 
 to say the final word on the subject, there has been for an 
 equal period not the least doubt that a judicious method of 
 living has a very powerful influence both in preventing the 
 disease and in modifying its course. Knowledge of this fact 
 was based, in the first instance, neither on purely theoretical 
 hypotheses as to the causes and nature of gout, nor on the 
 analysis of detailed clinical observations, but on the universal 
 perception of the fact that gout, cceteris paribus (in the same 
 country and amongst the same race), has a greater number of 
 victims in proportion as strictness and simplicity of life have 
 been abandoned in favour of luxury and effeminacy. As 
 early as the first century after Christ, Seneca pointed out 
 that the surprising increase of gout in Eome was a conse- 
 quence of increased luxury in living, and adduced as sufficient 
 proof the frequent occurrence of gout in the female sex. 
 Women, in fact, who in his time were not behind men in 
 licentiousness of life, were attacked by gout themselves ; 
 whereas in the time of Hippocrates, when they lived a simple 
 and modest life, they were spared its onsets. Areteeus of 
 Cappadocia (60 or 90 a.d.), the greatest physician since the 
 
 * These figures relate to the additions and illustrations at the end of 
 the work, 
 
 B 
 
2 THE REGIMEN TO BE ADOPTED 
 
 time of Hippocrates, in his model description of the symptoms 
 and course of gout, still further developed the statements of 
 Seneca as to its causes. But both by Aretaeus and Ccelius 
 Aurelianus (in the third century after Christ) stress was laid 
 on the hereditary nature of gout, and the conviction gradually 
 made its way that luxuriousness of life was not the sole 
 factor in its production. The hereditary nature of gout 
 is duly insisted on in the writings of Sydenham, Boerhaave, 
 and Frederick Hoffmann. We read in Van Swieten's " Com- 
 mentaries on Boerhaave's Aphorisms," that the gouty subject 
 almost always begets gouty subjects ; that hereditariness has 
 actually a greater significance in the case of gout than in any 
 other disease ; and that he has observed boys afflicted with 
 the same disease as their parents. Apart from Cadogan, who 
 denied the hereditariness of gout, alleging that if this were 
 the case all the offspring of a gouty person should suffer 
 regularly and without exception from the disease, all other 
 observers have placed hereditariness in the front rank of 
 predisposing causes. There was really little need of Falconer's 
 refutation of Cadogan, for, long before the latter wrote, precise 
 ideas prevailed on the question of heredity. It was known 
 that the grandchild of a gouty subject might be the victim 
 of gout, the disease sparing the intermediate generation. J. 
 Hutchinson communicated a matter of fact which is of import- 
 ance in connection with the hereditariness of gout, namely, 
 that an individual runs a danger of contracting gout in 
 proportion as the gouty process is developed in the parent. 
 Thus, the elder members of a family may escape the disease, 
 whereas the younger, born at a time when the parent is more 
 and more under its influence, may show traces of it very 
 early. We may with confidence support the principle that 
 hereditariness is at least as important a factor in the produc- 
 tion of gout as is excess of eating and drinking combined with 
 inactivity of life ; for excesses we may avoid, but hereditary 
 influences we cannot escape. Sir William Temple is perfectly 
 right when, in his well-known work on " Health and Long Life," 
 he says that the first condition lies in the strength of our race 
 or the surroundings of our birth. The ancients have given 
 concise expression to the same idea in their proverb, " Gau- 
 
IN CASES OF GOUT. 6 
 
 deant bene nati," as quoted by Temple; while in our own 
 times we have a humorous appreciation of it in the saying, 
 " We cannot be too particular in the choice of our ancestors." 
 But in speaking of the hereditary transmission of gout, we 
 must remember that the disease does not show itself in all 
 the members of a family, nor is it propagated from father to 
 son, and thence to grandson, in a direct line. We must not, 
 then, expect to find the symptoms showing themselves soon 
 after birth, as we do in the case of syphilis. I have never 
 seen any cases of congenital gout, and we know that the 
 symptoms of gout, though somewhat more frequent than is 
 generally supposed, yet are comparatively infrequent in 
 youth. As a parallel example to those which I have men- 
 tioned in my book on gout, I may add one which I owe to 
 the kindness of my colleague, Eosenstein, of Leyclen. The 
 case was that of a boy ten years old. This is the only case 
 of gout at an early age that Eosenstein has observed in a very 
 extensive clinical experience of the disease. 
 
 Gout is not infectious ; still less is it contagious. For 
 all that, contagion has played a certain part in the history 
 of this disease. We read in Van Swieten's " Commen- 
 taries on the Aphorisms of Boerhaave," who was the first 
 to defend the view of the com m unicability of gout, " I have 
 observed that women of good family, who lead a regular life, 
 contract gout from gouty husbands." That women under 
 such circumstances do occasionally contract gout is certainly 
 correct, but such cases are far from establishing the conta- 
 giousness of gout. Cases of this nature are much more 
 easily explained from our modern standpoint, that even 
 good family and the most regular life cannot get the better 
 of an innate gouty disposition. Boerhaave's view, however, 
 found a number of supporters. Joseph Von Quarin (1734- 
 1814), body -physician to the Emperor, went so far as to 
 produce observations showing that even dogs which shared 
 the couch of a gouty master might contract the disease 
 through the emanations from his body. In the course of 
 time the belief in the contagiousness of gout gradually wore 
 out. In more recent times, Von Vering is the only one 
 whom I have found maintaining that gout may be com- 
 
 B 2 
 
4 THE REGIMEN TO BE ADOPTED 
 
 niunicated through perspiration, clothes, or the occupation 
 of a common bed. Yet in the Prussian Sanitary Eegulations 
 of 8th August, 1835, we find gout classified as a con- 
 tagious disease, along with bad forms of scab of the head, 
 cancer, and consumption. In the case of gout the beds 
 used by the patients had to be disinfected, and articles of 
 clothing, including stockings and boots, to be destroyed. As 
 this regulation is still in force, this short excursus may be of 
 service in reminding us of its existence, although from our 
 modern point of view it is a mere curiosity. 
 
 Still more recently a further etiological factor has been 
 adduced as giving an impetus to the origin and development 
 of gouty symptoms, viz., lead-poisoning. A satisfactory con- 
 clusion is still far from being attained on this point; for, 
 granting that in those lead-workers who suffer from uric 
 acid gout we cannot, as a rule, look to heredity, much less 
 to luxury of life, for the explanation of the gouty process, yet 
 the scientific material at our disposal will by no means prove 
 that lead-poisoning alone (i.e., without the presence of a 
 disposition to gout, (2) which we shall soon subject to closer 
 examination) can develop the gouty process. 
 
 We have accordingly, up to this point, learnt to recog- 
 nize only two factors as of importance, viz., heredity, and 
 luxurious riving combined with idleness. The first alone was 
 recognized as a determining cause by single observers such 
 as Cullen and Hamilton. But as we can have no prophylactic 
 measures against heredity, these must be confined to warning- 
 gouty patients against all excesses, and inculcating upon 
 them exceptional moderation and abstinence. This precept 
 we meet with in all directions, both old and new, as to the 
 mode of living to be adopted by the gouty. It came to be 
 seen that the ultimate cause of gout could not consist merely 
 in luxurious living, for it was found that people occasion- 
 ally suffered very severely from the disease, although they 
 were anything but luxurious in their living, and might even 
 be distinguished for activity and industry ; and in the second 
 place, numerous persons could be seen leading a life of luxury 
 without ever suffering from gout. Hence commenced a 
 search for the ultimate cause of gout. How long a search it 
 
IN CASES OF GOUT. O 
 
 has been ! and what is there that has not been blamed for the 
 gout ? (3) The outcome of these endeavours was a number 
 of special prescriptions on the mode and scheme of life, 
 by means of which the ultimate cause was supposed to be 
 conquered. These prescriptions underwent manifold modi- 
 fications and changes according as the views of individuals 
 changed about the ultimate cause. Xo real advances were 
 made in scientific knowledge. An exaggerated specialization 
 was in vogue, which, starting from unsound premises, never 
 hit the right path, and too often neglected the interest of the 
 patient in vain contests over the materies morbi. Along with 
 a special anti-gout diet, numerous pharmaceutical and other 
 remedies were employed to neutralize the gouty poison. It 
 does not lie within the compass of this essay to expound 
 these, or to follow their historical development ; but it may be 
 of interest to make a few remarks on the treatment of gout by 
 so called secret remedies, the more particularly as in a disease 
 like gout, which is characterized by a chronic course and 
 lengthened remissions, a wide door is opened for quackery 
 and unscrupulous puffing. A system of puffing may indeed 
 vindicate itself by producing cases where favourable results 
 have been obtained by the remedy employed; but it is 
 unfortunately too easy for it to plume itself with results that 
 are not to be ascribed to the remedy, and it is easy enough 
 to fool credulous patients. This charlatanism is not a pro- 
 duct of our time, but even centuries ago boldly raised its 
 head under the mask of science. In the middle of the 
 seventeenth century, when the tartarus of Paracelsus (1493- 
 1541) was still regarded as the final cause of many severe 
 illnesses — when this saline earthly entity, which Paracelsus 
 called tartarus, " because wherever it penetrates it burns 
 with hellish pains," was considered to be the product of 
 defective digestion, and more particularly to be the materia 
 peccccns of gout — J. Zipffell, of Leipzig, advertised his remedy 
 for gout. This he did in a book dedicated to John George, 
 second Duke of Saxony, Julich, Cleves, and Berg. His " Medi- 
 camentum Antipodagricum " was "a spirit warranted to seize, 
 resolve, and precipitate the Materia, Tarta/rea, to carry off and 
 out the disease bit by bit, and all for hard cash." A worthy 
 
6 THE REGIMEN TO BE ADOPTED 
 
 companion to this same gentleman was M. Le Febure, of 
 Bochelle, who asserted that, through the grace of God Him- 
 self, the remedy for gout had been revealed to him ; but he 
 was very anxious to dispose of the revelation for a pecuniary 
 consideration, as his book on the subject (1720) shows. 
 
 Coming nearer to our object, which is to establish rules for 
 the guidance of those who suffer from gout, or who are pre- 
 disposed to it, we shall best fulfil our task by looking at the 
 subject from two points of view. (1) We must sift entirely 
 the results of medical experience; and (2) we must bring 
 our scientific knowledge of the nature of gout to bear on its 
 therapeutics and prophylaxis. In this last respect we stand 
 upon firmer ground than our predecessors, and however many 
 gaps there may be in our knowledge, yet we have enough 
 of it to give us many a useful hint. Even although here, 
 as in so many other domains of medicine, our advances in 
 scientific knowledge are not accompanied by corresponding 
 advances in remedial measures, yet it would be a great mistake 
 to undervalue our knowledge. It is only by keeping our 
 eyes steadily fixed on the goal we wish to reach that we shall 
 ultimately find the means of attaining all that may be 
 possible ; for in gout, at any rate, we ought not to trust to any 
 lucky chance putting us in the way of discovering specific 
 remedies. 
 
 We look nowadays for the materia peccans of gout in uric 
 acid. It was a long time, however, before this knowledge 
 became widely disseminated. After the investigations of 
 Wollaston, Tennant, and Fourcroy, towards the end of last 
 century, had already shown that gouty concretions contain 
 uric acid, and when the notion was not far off that there 
 might be a bond of union between gout and uric acid, C. 
 Scudamore, in his well-known and serviceable book, published 
 in the second decade of this century, maintained that gouty 
 concretions occurred so seldom and in so few individuals that 
 it was impossible to build a theory upon them, still less 
 to look for the ultimate cause of gout in them. The sure 
 natural basis was again abandoned, and vague unripe theories, 
 which would not ally with definite conceptions, took its place. 
 Thus we see S. A. Turck putting forth the view that gout 
 
IN CASES OF GOUT. 7 
 
 was founded on galvanic life, and had its origin in a morbid 
 electro-chemical process ; and Eeichel, a physician attached to 
 the baths at Steben, starting from analogous considerations of 
 the polarity of mineral waters, sought to bring into vogue his 
 galvano-electric chains of pure gold ore. Meanwhile even 
 investigators of repute could not reconcile themselves to the 
 uric acid theory. The want of actual data as to the influence of 
 uric acid upon gout, and the complete stagnation of pathological 
 investigation in this respect, explain to us how Henle, in 
 1847, regarded the deposition of uric acid as something acci- 
 dental, and sought for the origin of gouty inflammation in an 
 internal, perhaps central, affection of the nerves. Henle thus 
 championed views in his time which have again been revived 
 by Duckworth and others, even at the present day, when we 
 are in the possession of new and weighty facts pointing to 
 the influence of uric acid upon gout. The latter observer 
 regards gout as a tropho-neurosis, which is either primary and 
 congenital, or secondary and acquired through a blood-poison- 
 ing ; but, as a matter of fact, I maintain that all the nervous 
 symptoms which are observed in gout are to be regarded not 
 as causes, but as consequences of the uric acid. 
 
 It is incomprehensible to me how any one can ever again 
 fall back on such unsatisfying theories as these. 
 
 We owe an actual advance in our knowledge of this 
 subject to A. B. Garrocl, who, in his work on Gout, in 1859, 
 was the first to show that urate of soda is present in 
 abnormal quantity in the blood of gouty patients. Still, 
 highly as we must estimate the proof given by Garrocl, there 
 was not enough of material brought forward to satisfy the 
 demands which Henle, in his " Rational Pathology," had justly 
 required as a preliminary condition for a physiological history 
 of gout. From the facts adduced by Garrod, the conclusion 
 could not really be drawn that the symptoms of gout are 
 a necessary consequence of uric acid, i.e., really come into 
 existence under its influence. With the view, therefore, of 
 working out a physiological history of gout, I published my 
 monograph on " The Nature and Treatment of Gout," in 
 which I endeavoured to establish the proof that uric acid is a 
 chemical poison, which can cause not merely inflammatory 
 
8 THE REGIMEN TO BE ADOPTED 
 
 but also necrotizing and necrotic processes in animal tissues. 
 I succeeded in establishing, by anatomical investigation of 
 gouty organs, that the only typical appearance in gout was 
 that of elements undergoing necrosis or already necrosed. 
 These were found by me not merely in the hyaline joint- 
 cartilages of gouty subjects, and in the rest of the so-called 
 connective tissues (I examined the fibro-cartilages, the 
 tendons, and the loose tissue beneath the skin and between 
 the muscles), but also in the kidneys. Among the manifold 
 anatomical changes which may be induced in the kidneys by 
 gout, this was recognized as the only actual and characteristic 
 appearance. The formation of these foci of necrosing and 
 necrosed elements follows directly from the fluid parenchyma 
 being exceedingly rich in neutral urate of soda, and stagnating 
 in the affected parts. The separation of crystallized urates 
 in the affected tissues is the secondary process, and only 
 follows after the tissue has been completely destroyed by the 
 uric acid. This deposition of the crystallized acid combina- 
 tions of uric acid does not follow, in my opinion, from the 
 fluids undergoing an alteration of their reaction in gout, in 
 consequence of which the neutral urates would be changed 
 into acid — for in that case we should constantly see these 
 depositions in very many places of the gouty organism, — but 
 simply from the fact that through this local necrosis an acid 
 reaction ensues of the affected tissues, in which the neutral, 
 easily soluble uric acid combinations circulating in the blood are 
 changed into the less soluble acid salts of uric acid, or even 
 into uric acid itself. This change is an easy one, because the 
 combinations of uric acid with the alkalies are very unstable. 
 In the typical gouty foci that arise in this way — that is to say, 
 necrosed tissue with deposition of crystallized urates, or 
 ultimately of uric acid itself — calcareous salts may be subse- 
 quently deposited, just as in other dead tissues. In the 
 neighbourhood of the typical gouty foci there is generally 
 developed early a reactive inflammation of greater or less 
 extent. Matters may remain permanently in this condition — 
 that is to say, no urates are deposited — if the uric acid accu- 
 mulation is too insignificant to cause necrosis of the tissues. 
 In order to establish the deleterious effect of uric acid upon 
 
IN CASES OF GOUT. i* 
 
 the tissues, I found it necessary to have recourse to experi- 
 ment, for the foregoing results, though based on anatomical 
 investigations, were always open to the objection that the 
 deposition of uric acid was accidental and non-essential, while 
 the real cause of the disturbance of the tissues might be 
 some nervous cause, tropho-neurotic or otherwise. 
 
 Experiments were accordingly made upon birds, healthy 
 cocks being selected for the sake of convenience. The 
 principal object of the investigation was to ascertain the 
 results of ligature of the ureter in these animals. I may 
 expressly state that these experiments were not undertaken 
 with the intention of producing artificial gout, but merely 
 to show the extremely pernicious effect of accumulation of 
 uric acid upon animal tissues. By the ligature of the ureter, 
 retention of the urine — which in birds is composed almost 
 exclusively of uric acid — is produced, and we are enabled 
 to produce with certainty in different tissues and organs of 
 these animals, as in the liver and heart, tissue-changes which 
 are analogous to the gouty accumulations observed in human 
 organs. There are developed, for instance, as the result of 
 ligature, not merely depositions of uric acid salts in the 
 tissues and organs of animals experimented on, but necrosis 
 can be demonstrated everywhere that the crystallized deposits 
 are formed. Besides this, there is set up a more or less 
 extensive reactive inflammation in the neighbourhood of 
 these experimentally-produced tissue-changes. It did seem 
 surprising in these experiments that in the kidneys of these 
 animals, in which accumulation of uric acid was specially 
 marked after the ligature, these necrosed patches should be 
 wanting. If we look at this fact from the teleological point 
 of view, it is not unreasonable to suppose that healthy 
 kidneys have a greater power of resistance than other organs 
 to the deleterious influence of uric acid. A further series of 
 experiments seemed to show that this hypothesis borders upon 
 certainty. Instead of tying both ureters of the birds, I pro- 
 cured complete retention of the uric acid by destroying the 
 secreting epithelium in the tubuli uriniferi of the cortex, and 
 the result was that I was able to demonstrate extensive depo- 
 sitions of crystallized urates, and eventually of uric acid, even 
 
10 THE REGIMEN TO BE ADOPTED 
 
 in the kidneys of these animals. We possess such a means 
 for the destruction of the renal epithelium in the subcutaneous 
 introduction of chromic acid salts. These poisons penetrating 
 to the secreting structure of the kidney, destroy it ; and after 
 this is done we see, even in the kidneys of birds, the develop- 
 ment of patches such as were observed in the liver and other 
 organs when the ureters were tied. These experiments show 
 the correctness of the hypothesis that the healthy tissue of the 
 kidneys in birds has a greater power of resistance to the action 
 of uric acid than have, for example, the liver and muscular 
 structure of the heart. But as against the significance of 
 these experiments it might still be urged that, even although 
 uric acid is, as we have observed, the chief nitrogenous waste 
 product in birds, yet there may possibly be other substances 
 present in the urine, which, in spite of their insignificant 
 quantity, may interfere with the nutrition of the tissues. 
 Furthermore, it might be objected that in the organism of 
 these animals, damaged, as it was, by the ligature of the 
 ureters, or by the subcutaneous injection of chromic salts, 
 additional pathological processes might be at work causing 
 inflammation and necrosis. There was nothing for it but 
 to seek for the means of overcoming these objections. 
 The way was clearly indicated. I had to find out whether 
 even chemically pure uric acid and its combinations with 
 soda in the gouty foci displayed toxic qualities against 
 animal tissues. By using pure uric acid and its soda salt I 
 succeeded in constantly producing infiltration in the cornea 
 of a rabbit's eye. Similar experiments with urea, xanthine, 
 guanine, kreatine, kreatinine, and hippuric acid produced no 
 results, and there were equally no results in my control- 
 experiments with 5 per cent, solution of sodium phosphate. 
 It was thus proved that chemically pure uric acid and its 
 solution in sodium phosphate have a highly pernicious influence 
 on the nutrition of certain tissues. Supported by these facts, 
 we may therefore unhesitatingly assume that the gouty changes 
 in the body are a necessary consequence of the uric acid. 
 
 Unfortunately, however, the development of the whole 
 range of symptoms of gout in man cannot be pursued with 
 the same exactitude as will enable us to prove that the 
 
IN CASES OF GOUT. 11 
 
 influence of uric acid alone is enough to elucidate the 
 anatomical changes in the organs in uric acid gout. 
 
 I have in my work on Gout given my views on this 
 question; and this much I think I may say, that the 
 symptoms of gout can be easily, and indeed satisfactorily, 
 explained through the hypothesis which I have set up. 
 
 I can here enter upon those views only in so far as they 
 bear on the regimen and treatment of gout. An increased 
 formation of uric acid in the human organism, as ascertained 
 by the quantitative estimation of that secreted with the urine, 
 does not give rise of itself to any typical attack of gout. 
 Experience shows us this. We see in a series of cases of 
 sickness the secretion of uric acid increased, not merely 
 relatively, but also absolutely, especially as compared with 
 the urea, and yet no gout is developed. If, then, the mere 
 increased formation of uric acid is inadequate to elucidate the 
 development of the whole range of gouty symptoms, it has 
 been assumed that retention* of the uric acid takes place. This 
 can be brought about if the uric acid is not secreted in normal 
 quantity by the kidneys, and in this way there is developed 
 universal retention of uric acid — that is to say, an increased 
 collection of uric acid spread over the whole body. 
 
 The widely circulated view of Garrod, that the kidneys 
 are affected in this way, even in the milder forms and early 
 stages of gout, is about as little proved as is his view that an 
 attack of gout can be occasioned by the sudden remission of 
 the uric acid secreting power of the kidneys, occurring, as 
 this may, under the most diverse general disturbances, as, for 
 example, under traumatic influences, or even mental emotions. 
 Such a generalized retention of uric acid, caused by a 
 disturbance of the uric acid secreting power of the kidneys, 
 is not proved either by demonstration of increased uric acid 
 in the blood — for this might occur through increased form- 
 ation of uric acid — or by diminished secretion of the same 
 through the urine, as urged by Garrod ; for it is well known 
 that the quantity of uric. acid separated by the urine fluctu- 
 ates, even in healthy subjects, within tolerably wide bounds, 
 and may, as C. Neubauer's investigations show, sink as low 
 * Stauung — " a stowing away." 
 
12 THE REGIMEN TO BE ADOPTED 
 
 as '2 gramme in twenty-four hours. Boedeker found the 
 amount of secreted uric acid varying in eight healthy young 
 men, under similar conditions of life, between '3 and 1*4 
 gramme per diem. Apart from that, the mere fact of 
 increased production of uric acid, with diminished separa- 
 tion of it by the kidneys, would not be enough to prove the 
 retention of uric acid in the organism, for the total amount 
 of uric acid that is formed in the body need not be secreted 
 through the kidneys, but may undergo further changes in the 
 organism. Garrod has himself assumed that accumulations 
 of uric acid are occasionally destroyed in the bodies of gouty 
 patients. After he had found, for example, that the serum 
 from a blister over an inflamed gouty part contained no uric 
 acid, he assumed that gouty inflammation had the property 
 of destroying the uric acid in the blood of the inflamed part. 
 It may further be noted that the statements of very trust- 
 worthy observers vary much as to the secretion of uric acid 
 in gout. Scudamore was impressed with the excessive form- 
 ation of uric acid and urates in the urine of gouty patients. 
 Garrod, on the contrary, maintained that he observed the 
 secretion of uric acid to be under the normal in the 
 different periods of gouty derangement. He said that 
 such was the case during the acute attack, during chronic 
 ailments of the joints, and at last at a time when all gouty 
 symptoms were absent. Lehmann, Eanke, Bartels, and Von 
 Mering published analogous observations. Bouchard stated 
 that the subjects of gout passed an increased quantity of 
 uric acid (from *4 to 1*5 gramme in twenty-four hours) in 
 the intervals of remission. Bouchard observed a diminution 
 of the secretion in solitary cases of gout in which there was, 
 at the same time, interstitial inflammation of the kidneys ; 
 and he observed the same in cachectic gout. Even during 
 the acute attack Bouchard observed no diminution of the 
 secretion of uric acid. Lecorche, in his observations, came 
 to results agreeing with those of Bouchard, and differing 
 from those of Garrod. Lecorche admits, as a matter of fact, 
 that there is a certain diminution of the secretion of uric 
 acid in gout (on an average '2 gramme in twenty-four 
 hours), but he found, as against Garrod, that during the 
 
IN CASES OF GOUT. 13 
 
 gouty onset the daily amount secreted with the urine is 
 increased to 1 gramme and more, and that it sinks again at the 
 end of the attack, and averages "57 gramme per diem. Obser- 
 vations of Michel also show that the secretion may increase 
 during the acute attack. From these facts and considerations 
 we may conclude that Garrod's theory of the retention of 
 uric acid in gout cannot be maintained, and that his 
 observations are contradicted by those of a number of 
 observers equally trustworthy with himself. At all events, 
 we may say that a derangement of the function of the 
 kidneys is not an absolutely indispensable condition for the 
 origin of the gouty attack. On the contrary, I am of 
 opinion that in by far the majority of cases the gouty process 
 may he developed, and continue for a long time vnthout the 
 parenchyma of the kidneys being materially injured or in any 
 way hindered in the exercise of its regular, healthy functions. 
 Still, I admit at once that there is a form of gout where 
 severe impairment of the kidneys is the starting-point of 
 the gouty process. I have distinguished this form of gout 
 as primary kidney gout. This form shows, along with 
 other grave tissue-changes, a greater or less degree of general 
 uric acid retention, in so far as the uric acid cannot be 
 secreted in sufficient quantity through the kidneys. Death 
 generally ensues much earlier here, before extensive gouty 
 changes take place in the cartilages of the joints. Hence it 
 follows that the post-mortem shows the most advanced forms 
 of gouty kidney, with greater or less deposition of crystallized 
 urates, while the joints are completely free from every gouty 
 change. In this severe form of gout, which I have described in 
 my book on Gout (p. 157 of the original), and to which possibly 
 individual dispositions co-operate, the kidney affection is so 
 prominent, that in treatment we fix our eyes not so much 
 on the gout as on the inflammatory process in the kidneys. 
 This variety need not detain us, the more especially as we 
 are only concerned with regimen. I content myself here 
 with the statement that even in this form the general dietary 
 given for primary articular gout would seem to be the most 
 suitable. Fortunately, too, the number of these cases is ap- 
 parently small, as contrasted with those which I denominate 
 
14 THE REGIMEN TO BE ADOPTED 
 
 primary articular gout, and which have therefore much 
 greater practical interest for us. 
 
 In primary articular gout matters are exactly the reverse 
 of what they are in the first variety. We have here to deal 
 with cases of gout in which we find the most violent gouty 
 impairments of the joints, skin, and subcutaneous connective 
 tissue in the form of gouty nodes, without the slightest renal 
 symptoms showing themselves during life, and in which even 
 the autopsy shows the kidneys to be occasionally perfectly 
 sound. In order, however, to elucidate these cases, we cer- 
 tainly do not require to assume, with Garrod, that the uric 
 acid secreting power of the kidneys is diminished. Such 
 cases may be explained by the assumption of a localized 
 retention of uric acid. This assumption fits the actual facts 
 of the case, and may be more correctly expressed as a limited 
 retention in definite 'parts of the body of the fluids overladen 
 with uric acid combinations. I am of opinion that this 
 localized uric acid retention (I shall, for the sake of shortness, 
 use this expression) is generally caused by the fact that the 
 uric acid built up in the affected parts themselves is detained 
 in the small vessels and lymphatics in its passage in a centri- 
 petal direction. It appears to me necessary to accept it as 
 true that the formation of uric acid goes on of itself in the 
 peripheral parts of the body (the muscles, and medulla of the 
 bones), and that it is the retention of this which causes the 
 attacks of gout. In this way we can explain the symptoms 
 and course of this primary articular gout, which is by far the 
 most frequently occurring variety. There is thus in gout, as 
 I take it, a formation of uric acid going on in all the muscles 
 and in the marrow of all the bones, which, proceeding from this 
 apparently reversed origin, reaches the capillaries and general 
 vascular system. I have attempted to demonstrate this in my 
 book on "The Nature and Treatment of Gout," (4) and I shall 
 here simply add some remarks elucidatory of the pathogenesis 
 of this primary articular gout. Let us assume that every- 
 where in the body of the gouty — that is to say, in all their 
 muscles and in the medulla of the bones — uric acid is formed; 
 then if any hindrances to the circulation of the fluids occur, 
 such hindrances will show themselves, cwteris paribus, soonest 
 
IN CASES OF GOUT. 15 
 
 and easiest in those parts of the body which are generally 
 distinguished by slowness of the circulation — and this means 
 chiefly in the most peripheral parts of the body. Seeing, 
 then, that the vis a tergo fails to exercise its due weight 
 sooner in the under than in the upper part of the body, the 
 reason is plain to us why the finger-joints, the lobe of the 
 ear, the point of the nose (the " copper-nose " of the gouty), 
 as a rule, are much later affected than the joints of the foot 
 and toes, especially the joint between the first and second 
 phalanges of the great toe, and the metatarso-phalangeal 
 joint of the same toe. If it is correct, and we may accept 
 it as proved, that these last joints are almost always first 
 and most frequently affected by gout, there can be no doubt 
 that there are mechanical influences at work which explain 
 the preference of gout for them. On this point I may say 
 that Henle, at my solicitation, again directed his attention to 
 the subject, but could not succeed in finding any specially 
 disposing cause in the construction of these joints. Nor can 
 badly made shoes be blamed for the phenomena, although 
 G-. H. Meyer certainly points out that the disfiguring and 
 painful inflammations and swellings of these joints, which 
 result from badly constructed shoes, certainly induce a locus 
 minoris resistcntice for the gouty process. Here we bring 
 into view the importance of a factor which in many ways 
 underlies the localization of gouty inflammations. Expe- 
 rience has taught us that everything which promotes the 
 circulation of the fluids of the body hinders the development 
 of gout ; while everything that restrains, disturbs, retards, or 
 arrests the circulation, gives an impetus to the gouty process. 
 One of the most convincing proofs of the justice of this 
 principle is an observation made by Charcot. In making a 
 post-mortem on the body of a woman forty years old, who 
 had suffered from hemiplegia, he found the majority of the 
 joints on the paralysed side of the body infiltrated with 
 uric acid salts. This fine observation is explained easily, 
 and in entire conformity with natural conditions, by the fact 
 that in the paralysed limbs, owing to the want of muscular 
 influence on the circulation, a localized retention of uric acid 
 took place on the principle explained above. The assumption 
 
16 THE REGIMEN TO BE ADOPTED 
 
 in this case, that somehow, owing to the withdrawal of nervous 
 influence, uric acid was formed only in the paralysed parts, 
 must be rejected for many reasons ; this, amongst others : 
 that in the kidneys also of the woman traces of urate of soda 
 were found. 
 
 These preliminary remarks enable us to find our bearings, 
 and construct for ourselves the development of an attack of 
 gout in the great toe. It may go on somewhat in the fol- 
 lowing way : — In a gouty individual, as uric acid is developed 
 in all the muscles and bones of the body, it is developed, as a 
 matter of course, in the muscles of the foot and in the medulla 
 of its bony framework. This anomalous tissue-change may 
 go on without any symptoms, or eventually may produce 
 slight discomfort. If, however, from any reason there is a 
 retardation of the circulation — and this might receive an 
 impetus, I think, from an increase of uric acid in the fluids — 
 then evidently all the consequences ensue of the retention of 
 fluids containing uric acid. If it were a question in gout of 
 the retention of merely normal fluids, we should simply have 
 ordinary oedema, constituting a painless, circumscribed, watery 
 swelling ; but as a material containing uric acid is accumu- 
 lated, the consequence is the typical gouty attack, i.e., an 
 aseptic inflammatory process. This runs its course with 
 severe pain in the affected parts, and redness, swelling, and 
 tightness of the surrounding soft parts. In these cases there 
 remain as signs of the oedema, especially in remitting inflam- 
 mations, pittings on pressure, which are characteristically long 
 in rising again, and the local inflammation ends with subse- 
 quent desquamation. The inflammation ceases as soon as the 
 deposition of uric acid relaxes and the disturbance in the 
 circulation is removed. Such an attack, however, leaves behind 
 it, in the majority of cases, lasting changes, chiefly in the carti- 
 lages of the joints, which result, in my opinion, is owing to 
 the great narrowness of the minute vessels, as a consequence 
 of which typical gouty foci are developed at a comparatively 
 early period. Still, this is not the place to treat this subject 
 exhaustively, or to go further into the matters which hang 
 upon these questions. I must content myself on this head 
 with a short exposition of some points in the clinical history 
 
IN CASES OF GOUT. 17 
 
 of gout. The process of gouty infiltration, after cases running 
 their course through a typical attack in the manner described, 
 will proceed more quickly in the affected individual in pro- 
 portion to the intensity of exciting causes which give an 
 impetus to the further development of gout. Amongst these 
 we may reckon the principal to be luxurious living with 
 slight bodily activity. More and more joints are attacked ; 
 more and more gouty deposits take place. This happens, 
 mutatis mutandis, always in the same way. Uric acid circu- 
 lating in increased quantity in the fluids produces affections 
 of the blood-vessels and heart, and of the most diverse mucous 
 membranes, organs, and tissues of the body. The kidneys, 
 being the chief eliminatories of uric acid, are principally 
 endangered ; they are affected sooner or later generally even 
 in the course of this primary articular gout, to which then 
 the kidney gout is superadded as a secondary affection ; and 
 in proportion as the power of the kidneys to excrete nitro- 
 genous waste products is thus injured, so do all the dangers 
 naturally increase which threaten the life of the gouty subject. 
 While I may, as occasion serves, return in the following 
 pages to individual points in the pathology of gout, I think 
 it is now possible upon the basis of what has been laid down 
 to get a nearer view of the task before us. This task is to 
 elucidate the treatment of gout, and more particularly to 
 bring under rules the mode of life that is most suitable for 
 gouty patients. In my opinion, much more attention must 
 be paid to the gouty disposition than is generally the case. 
 Persons who suffer from gout should, at an early period, 
 attend to the dietary and training of their children, and 
 medical men can by intelligent prophylaxis be of much 
 service in the instruction of people who are amenable to 
 advice ; for without predisposition we may say, as a rule, there 
 is no gout. We may assume this from the fact that there are 
 persons enough who, although they spend their days in the 
 greatest luxury and comfort, and live in the most refined 
 way, yet are never attacked by. gout, while, on the other 
 hand, moderate men, who are continually kept active by 
 strict hard work, may fall victims to the worst forms of 
 gout; and this is often observed in the case of men who 
 
 c 
 
18 THE REGIMEN TO BE ADOPTED 
 
 have to struggle constantly with need and poverty, and never 
 have the slightest taste of the enjoyments of life. This 
 plainly depends exclusively on the strength of the predispo- 
 sition to the disease, which of itself gives us the clue 
 why the same measures which, cceteris paribus, proved useful 
 with one patient are of little or no use with another, and 
 also explains why persons in whom the exciting causes of 
 gout have never become operative, are yet attacked by the 
 disease in so severe a fashion. That gout is hereditary is a 
 dogma dating back to a very early period in the history of 
 medicine, and has been taught as the result of irrefragable 
 experience. Whether, and how far, this power of hereditary 
 transmission can be weakened, cannot be settled with absolute 
 certainty ; but as Corradi, in particular, has tried to show from 
 a series of cases, the study of the history of culture among 
 nations leads us to the conclusion that through a series of 
 generations long-continued moderation exercises a favourable 
 influence on the frequency tmd course of gout in the later 
 generations. In this respect to co-operate in the weakening 
 of gout is the task and duty of every gouty person and every 
 one disposed to gout who has children. Whether in this 
 way gout may yet be completely exterminated, is a question 
 which naturally cannot be answered a priori. In any case it 
 follows from the facts already adduced, that the view pro- 
 pounded by Leube (in his work on the urine, published along 
 with Salkowski) on the relation of uric acid to gout is not 
 correct. 
 
 Leube attributes the production of uric acid in gout solely 
 to the greater ingestion of nitrogenous food; he denies the 
 existence in gout of an actual uric acid diathesis, on which 
 in general he throws doubt, except perhaps in the case of 
 leukaemia. But in the case of leukaemia we cannot speak 
 of a definite diathesis or disposition of the individual 
 towards increased production of uric acid. The individual 
 only produces more uric acid because the organism is 
 leukaemia So far also as the views can be explained which 
 are held as to the causes of the increased secretion of uric 
 acid seen in many cases of leukaemia, all observers are 
 agreed on this, that this increased secretion is due simply 
 
IN CASES OF GOUT. 19 
 
 to the leukaemia affection. TJie increased secretion of uric 
 acid in leukaemia is a 'product of this disease.^) The reverse 
 is the case in gout. Here uric acid is not the consequence 
 but the cause of the disease. Increased formation of uric 
 acid, in so far as tins is evidenced by its increased secretion 
 through the urine, does not of and by itself alone constitute 
 uric acid gout. This fact shows us at once that the abnor- 
 malities in the production of uric acid winch happen in the 
 case of gout must be special and peculiar. I look for these 
 abnormalities in the circumstance that the gouty patient, in 
 consequence of a congenital and generally hereditary pre- 
 disposition, produces uric acid in his muscles and in the 
 medulla of his bones. As it has not been proved that the 
 healthy individual produces uric acid in these tissues, I 
 regard this phenomenon in gout as the production of uric 
 acid in an anomalous* situation. This congenital disposition 
 is peculiar to the gouty and to all who suffer from the uric 
 acid diathesis. Tins anomaly is hereditary; it is not the 
 product of a definite organic or systemic affection, but it 
 consists of a peculiar disposition of tissue-change, and this 
 we denominate a diathesis. This diathesis may be aggravated 
 by certain exciting causes, but so far as we know cannot be 
 produced by these alone. It would be possible indeed that 
 in the case of leukaemia the impairment of the medulla 
 of bone might also have a part in the increased uric acid 
 production ; but at all events the part would not be a great 
 one, otherwise this disease would associate itself with 
 articular gout. At any rate, in those cases of leukaemia 
 where the affected medulla of the bones produces uric acid, 
 there is this difference from gout, that in the latter disease 
 the medulla does not show a leukaemic affection, and only 
 in rare cases a gouty one. In the case of gout we have 
 thus to deal with an increased formation of uric acid, as 
 we have this formation occurring both in its usual position 
 and in anomalous sites. I thus define the uric acid dia- 
 thesis in gout as an increased uric acid production in con- 
 sequence of a perhaps invariably inherited predisposition 
 which seems actually to consist of a reproduction of uric 
 * Perversem. 
 
 c 2 
 
20 THE REGIMEN TO BE ADOPTED 
 
 acid in anomalous sites, — in the muscular tissue and in the 
 medulla of the bones. If we grant that there is a peripheral 
 formation of uric acid, the only point is to localize it in the 
 proper tissues — the muscles and medulla of the bones, — for I 
 think it is quite inadmissible to admit Cantani's view that 
 the uric acid is partially deposited in the connective tissue. 
 I regard the cartilaginous and other connective tissues as 
 entirely, or almost entirely, paths for the fluids and supports 
 of the tissues, but not as self-acting laboratories of tissue- 
 change. (6) 
 
 The considerations laid down in the foregoing pages give 
 us not merely a better understanding of the development of 
 the gouty process, but show us also how important it is to 
 direct our energies against the local retention of uric acid (as 
 explained on p. 14), and to combat the other factors which 
 help the development and advances of the gouty process. 
 This is all the more necessary as we are not in a position to 
 obviate thoroughly the disposition or diathesis that lies at 
 the basis of uric acid gout. 
 
 How then shall we get nearer to the problems of the 
 treatment of gout which present themselves to medical 
 practice ? 
 
 We have come to this conclusion, that in primary articular 
 gout we have not to deal with any retention of uric acid 
 referable to its deficient elimination through the kidneys, but 
 that we must accept the idea of an increased production of 
 uric acid through its formation in anomalous positions, i.e., in. 
 the muscles and medulla of the bones. The very first point, 
 then, which we must aim at is to seek to procure a reduction 
 of uric acid formation in general, for in this way we can affect 
 the particular obnoxious production in anomalous sites. 
 
 As in so many things, here also practice has long outstripped 
 theory. Before any definite idea had been formed as to the 
 relation between uric acid and gout, the assumption was held 
 that uric acid was responsible for the disease, and the efforts 
 of physicians were directed to counteracting the supposed 
 increased formation of uric acid. As it was supposed that 
 this latter depended entirely on a defective method of nourish- 
 ment, an attempt was made to settle the kind of subsistence 
 
IN CASES OF GOUT. 21 
 
 under the influence of which the least possible quantity of 
 uric acid is formed. 
 
 This task is by no means a simple one. The first principle 
 that must be laid down is, that no methods should be selected 
 which produce bodily weakness and diminish the resisting 
 power of the individual. 
 
 Naturally we have to deal here not merely with the nature 
 but also with the quantity of the food to be allowed to the 
 patients. As regards the nature of the food which will best 
 combat the formation of uric acid, there has never prevailed 
 amongst observers that unity of opinion which is desirable. 
 Still, the researches of Lehmann, Bence Jones, and H. Eanke 
 agree in this, that with an exclusive flesh diet, ceteris paribus, 
 more uric acid is secreted than with a purely or almost purely 
 vegetable diet. Although H. Eanke considered the influence 
 of diet to be but slight, yet it exists, and on the principle that 
 small things accumulate to great in course of time, we ought 
 to hesitate before contributing in the slightest degree to giving 
 an impetus to the formation of uric acid in the case of a 
 person who has any disposition towards this increased form- 
 ation. It is plain that different individuals comport them- 
 selves in different ways as regards this point, as is shown 
 by the various results attained by observers. According to 
 Haughton's researches, the daily amount of uric acid secreted 
 by flesh-eaters as contrasted with vegetarians is on an average 
 4*5 to 1*5. From Eanke's experiments we have, at the same 
 time, the important fact that the nature of the diet has less 
 influence on the elimination of uric acid than it has on that of 
 urea. We must conclude from the experiments of H. Eanke 
 that the secretion of uric acid is increased by the ingestion of 
 food, apart from the nature of that food. Nevertheless, with- 
 out reference to the fact that exclusive flesh diet increases the 
 uric acid secretion, this diet has so many other inconveniences 
 and dangers for the human organism, that it must be specially 
 renounced when there is a disposition to gout independent of it. 
 On the other hand, purely vegetable foods, even though less 
 uric acid may be secreted by their use, are unsuitable for 
 many reasons as an exclusive means of support for persons in 
 general, not to speak of gouty subjects in particular. Both 
 
22 THE REGIMEN TO BE ADOPTED 
 
 animal and vegetable foods after all contain the same 
 materials, although in different proportions, and experience 
 shows us that it requires a perfectly healthy condition of the 
 intestine to digest purely vegetable diet. For this reason 
 vegetarians themselves, who should on principle reject any 
 food of animal origin, do not, as a rule, reject the use of milk, 
 cheese, and butter. The intestinal canal in gouty patients is 
 very susceptible to functional disturbances, and if we select a 
 purely vegetable diet, the actual quantity of nourishment to 
 be taken will be so great as to overpower the efforts of the 
 bowel to manage it. (7) 
 
 The gouty patient then, as well as the healthy individual, 
 ought to have a mixed diet composed of animal and 
 vegetable foods. How is this diet to be arranged ? On 
 this point we have commands and prohibitions of the most 
 diverse nature. It would take us too far to enumerate and 
 criticise these ; but in the case of the regimen recommended 
 by Cantani it would be easy to show the defects which such 
 dietetic prescriptions contain, in so far as they are founded on 
 one-sided principles. I select Cantani's system because it has 
 a great number of followers both in Italy and in Germany. 
 None of these, however, so far as I have been able to see, 
 have followed out Cantani's prescriptions for any length 
 of time in their entirety. Cantani limits, as far as possible, 
 the food of gouty patients to flesh meat, soup, eggs, fish in 
 moderate, and vegetables in greater quantity. Of the last he 
 allows simply salad plants, such as lettuce (garden salad), 
 borage {Borago officinalis), dandelion (Leontodon taraxacum), 
 chicory, cress {Lepidium sativum). Of these things, Cantani 
 says, the patient must take just exactly as much as will 
 satisfy his hunger. In another place he goes so far as to say 
 that the patient should, as a rule, never fully satisfy himself. 
 It is pretty certain that so distinguished a physician as 
 Cantani saw some objections to this scheme, for he says him- 
 self, " It is clear that if we look at the human constitution in 
 general, and the various tissues of omnivorous man, a one- 
 sided regimen of diet, to the exclusion of so many known 
 foods, however theoretically beneficial it may be, cannot be 
 carried out in its entirety, for the patient would have difficulty 
 
IN CASES OF GOUT. 23 
 
 in enduring it." In practice we must be content with follow- 
 ing without interruption these prescriptions in their full 
 strength for some months. The exact time he gives in one 
 part of Iris book as from six to twelve months. For the rest 
 of the patient's life Cantani orders him to refrain, as far as 
 possible, from using those articles of diet which do not suit the 
 gouty tendency, but which man in general, as an omnivorous 
 animal, cannot entirely do without. But on no account is the 
 patient ever to indulge in any of those articles of food which 
 are recognized as absolutely prejudicial in gout. So far 
 Cantani. Amongst those things which Cantani recognizes as 
 absolutely prejudicial in gout are the carbo-hydrates and fats. 
 I agree with Cantani in restricting the use of the carbo- 
 hydrates as far as possible. Under certain circumstances I 
 forbid some of them entirely. To begin with, I may say that 
 such restriction is necessary, for experience shows us that it 
 is precisely under the influence of the carbo-hydrates that 
 most severe forms of dyspepsia arise. Be then the bond 
 between gout and dyspepsia what it may — let gout be the 
 cause or the consequence of dyspepsia (I believe that in by 
 far the majority of cases we have to deal with the latter state 
 of affairs), — be these things as they may, the limitation of 
 the carbo-hydrates in general forms a very important part of 
 the treatment of one of the most important symptoms of 
 gout ; a symptom which as often as not will disappear under 
 an alteration of the regimen in this direction. The articles 
 which it is of most importance to limit temporarily, or better 
 still permanently, are those which are distinguished by excess 
 of starch, which is ultimately converted into sugar. 
 
 As regards fats the case is quite different. But before I 
 enter upon this point, I must come back again to Cantani's 
 prescriptions as given above. These would make the diet of 
 gouty patients very offensive to them, by forbidding ingredi- 
 ents which are perhaps universally used in Germany and 
 also elsewhere. Certain vegetables could not be used in the 
 form of salads, for Cantani forbids his patients acids in 
 general, and thus acid salads are excluded. Besides, as he 
 holds milk, fat, and sweets in abomination, his patients 
 cannot eat salads prepared with cream or bacon. No veget- 
 
24 THE REGIMEN TO BE ADOPTED 
 
 ables must be cooked with fat or olive oil. The wretched 
 gouty patient who does not care for green salads or vegetables 
 such as spinach, savoys, and white cabbage cooked with 
 nothing but salt to make them palatable, is shut up for six 
 months or a year to a diet consisting exclusively of moderate 
 quantities of flesh, fish, soup, and eggs. He could certainly 
 exist upon it ; but there is a contradiction in allowing eggs 
 and forbidding fat. Cantani drives a hole in his own 
 principles. If fat is forbidden, egg-albumen, which contains 
 only 5 per cent, of fat, may indeed be allowed, but not the 
 yolk of eggs, which contains albumen, but principally fat to 
 the extent of nearly 30 per cent. Accordingly it is precisely 
 on account of its containing fat that yolk of egg has often 
 been entirely excluded from the diet of gouty patients. 
 
 If we come back now to the question of the use of fat in 
 gout, we shall find a firm principle prevailing up to now, 
 that fat is not good for gouty patients. Eemarkably 
 enough we find in the older writers no special directions 
 as to the use of fat, however detailed their injunctions as 
 to diet may be. So far as I know, Scudamore is the first 
 to speak out against fat. Pork, which he regards in general 
 as indigestible, must be taken, if taken at all, without the 
 skin and fat. Salmon, under all circumstances, he regards 
 as unsuitable. Garrod is the most tolerant of fat, for he 
 says, " Some small slices of fried bacon may be beneficial 
 in many cases, if the lean part is put aside as too difficult 
 to digest on account of its hard fibres." 
 
 Garrocl quotes (cf. Literary Index, No. 22) a statement 
 made by Boecker, who found that 85 to 90 grammes of 
 butter taken daily had no influence on the secretion of 
 water, urea, uric acid, or any of the urinary constituents. 
 To justify the prohibition of fat reliance was placed on a 
 series of experiments carried out by G. Meissner and E. 
 Koch. From these it appears that when fat is taken, more 
 uric acid is secreted than is normally the case. What really 
 happens is that when fat is taken, under certain circum- 
 stances, succinic acid, and, along with it, greater quantities 
 of uric acid in combination appear in the urine. These 
 observers gave patients the ordinary diet, and then for two 
 
IN CASES OF GOUT. 
 
 25 
 
 successive afternoons gave half a pound of butter, and no 
 results followed; but on the third day, the butter being 
 still continued, the succinic acid, in combination with a base, 
 showed itself in the urine. 
 
 I thought it would be useful to make some experiments 
 myself as to how the secretion of uric acid was affected by 
 moderate quantities of fat. A trustworthy healthy man, thirty 
 years of age, was put under a diet containing fat in exactly 
 known proportions. The urine was carefully collected and 
 examined by Herr Jahns, apothecary to the university here. 
 The determination of the uric acid was done in the usual way 
 by treating the urine with muriatic acid, in the proportion 
 of "0048 to every 100 c.c. of the mixture of urine and 
 muriatic acid. The quantity of uric acid dissolved by the 
 water used to wash the filtrate was put against the colouring- 
 matter deposited, and not reckoned. The urea was deter- 
 mined by Liebig's method, as modified by Pfluger. 
 
 The diet used during the experiments was as follows : — 
 
 Morning : 400 c.c. coffee, 100 grms. white bread. 
 
 Mid-day : 300 c.c. soup, 125 grms. meat, 100 grms. potatoes, 
 100 grms. fruit, 100 c.c. wine, followed by 200 grms. coffee. 
 
 Evening : 300 c.c. beer, 100 grms. rye bread, 50 grms. meat. 
 
 In the course of the day 350 c.c. water. 
 
 The way the experiment was carried out, and its results, 
 are given in the following table : — 
 
 No. of 
 
 Date of 
 
 Conditions of 
 
 Quantity of 
 Urine in 
 24 Hours. 
 
 Uric Acid in 
 
 Urea in 
 
 Experiment. 
 
 Experiment. 
 
 Experiment. 
 
 24 Hours. 
 
 24 Hours. 
 
 1st Series. 
 
 
 
 
 
 
 
 No. 1 
 
 13th. June 
 
 Diet as ahove 
 
 1,380 c.c. 
 
 •545 g 
 
 rms. 
 
 26-3 grins, 
 
 6 
 
 „ 2 
 
 14th „ 
 
 Thesame+100 
 
 
 
 
 
 
 
 grms. butter 
 
 1,360 ,, 
 
 ■412 
 
 
 25-3 „ 
 
 2nd Series. 
 
 
 
 
 
 
 
 No. 3 
 
 22nd „ 
 
 Diet as ahove 
 
 1,990 „ 
 
 •417 
 
 
 24-8 „ 
 
 „ 4 
 
 23rd „ 
 
 The same+120 
 
 
 
 
 
 
 
 grms. butter 
 
 2,170 „ 
 
 •401 
 
 )> 
 
 26 „ 
 
 ,, 5 
 
 24th „ 
 
 Diet as above 
 
 1,710 „ 
 
 •393 
 
 
 25-1 „ 
 
 3rd Series. 
 
 
 
 
 
 
 
 No. 6 
 
 3rd July 
 
 Diet as above 
 
 2,180 „ 
 
 •425 
 
 
 25-6 „ 
 
 >, 7 
 
 4th „ 
 
 Thesame+150 
 
 
 
 
 
 
 
 grms. butter 
 
 1,480 „ 
 
 •518 
 
 
 26-1 „ 
 
 >, § 
 
 5th „ 
 
 Diet as above 
 
 1,380 „ 
 
 •690 
 
 >) 
 
 24-7 
 
26 THE EEGIMEX to be adopted 
 
 From these experiments this much may be gathered, that 
 in a daily consumption of butter up to 120 grins, no increase 
 of the secretion of uric acid takes place. If the prohibition of 
 butter and fat in the regimen for gouty patients is based on 
 the assumption that fat increases the production of uric acid, 
 the statement cannot be justified as far as the secretion of 
 the acid by the urine is concerned. 
 
 The butter was exceedingly well tolerated by the individual 
 experimented on. 
 
 There is, then, no other ground for excluding fats from 
 the mixed diet which we recommend in gout. All reasons 
 which can be adduced against its allowance prove themselves 
 weak ; and weighty indeed must be the reasons which would 
 justify us in rejecting so important an article of diet as 
 fat. But there are a number of circumstances which 
 show us that fat is a very valuable food in gout, always 
 within necessary bounds, and with adaptation to individual 
 circumstances. 
 
 This follows at once, if we consider the quantity of food 
 that should be regarded as reasonable for a gouty patient. 
 Sydenham expressed his views on this point as follows : — 
 "Therefore moderation in eating and drinking is to be 
 observed, so as on the one hand to avoid taking in more 
 aliment than the stomach can conveniently digest, and of 
 course increasing the disease thereby, and on the other hand 
 defrauding the parts by immoderate abstinence of the degree 
 of nourishment requisite to keep up the strength, which will 
 weaken them still more ; either of these extremes being 
 equally prejudicial, as I have often experienced, both in 
 myself and others." Sir William Temple says, in his treatise 
 on the " Cure of the Gout by Moxa," — " But that which I 
 call temperance, and reckon so necessary in all attempts and 
 methods of curing the gout, is a regular and simple diet, 
 limited by every man's experience of his own easy digestion, 
 and thereby proportioning, as near as well can be, the daily 
 repairs to the daily decays of our bodies." 
 
 As regards Temple's recommendation that the individual 
 experience of the patient should be taken into account, I 
 grant at once that a certain amount of latitude should be 
 
IN CASES OF GOUT. 27 
 
 allowed to him in the quantity and choice of different articles 
 of diet. We can do this all the easier, inasmuch as amongst 
 gouty patients we find a very great number of them to be 
 highly intelligent, and — the two things are unfortunately not 
 identical, as experienced physicians can ratify — relatively a 
 goodly number of men who are both intelligent and amenable 
 to scientific instruction. But a system of directions is not 
 merely desirable, but also necessary, in order to keep the 
 patient, for example, from lasting injury inflicted by a course 
 of diet which an apparent success might delude him into 
 thinking was a useful one. The essential point of these 
 directions is to secure the due nourishment of the patient 
 without overloading his highly sensitive stomach. In this 
 respect fat is excellent. Its power of checking hunger, known 
 to Hippocrates, plays an important part. In my book on 
 "Corpulence and its Treatment" I have gone more fully 
 into this point. In any case the use of fat does not allay the 
 feeling of hunger by spoiling the patient's appetite, and caus- 
 ing nausea or other dyspeptic symptoms ; but, on the contrary, 
 those forms of dyspepsia winch are due to a diet over-rich in 
 starchy foods are alleviated when part of the starch is re- 
 placed by fat. I have frequently, by this simple change in 
 the bill of fare, seen obstinate dyspepsia, that had resisted 
 every form of treatment, give way in the shortest time, and 
 this, too, in gouty people. I grant that idiosyncrasies exist 
 here as everywhere else, and that occasionally people are 
 found who do not care for fat, or even good butter, to begin 
 with, and who assert that they cannot bear these sub- 
 stances. In my experience such cases are very rare. I do 
 not remember any such patient who for any length of time 
 objected to good butter. But I may say that those persons 
 who object to good fat as unbearable or unpleasant are very 
 few compared with the great number of those who, in spite 
 of their representations to the contrary, are forbidden fat by 
 their medical attendants. Besides this, I have observed that 
 where an idiosyncrasy against fat does exist, it is generally 
 easily conquered in by far the majority of cases, especially if 
 the patients observe that their prejudice was ill founded, and 
 that their troubles get better under a diet in which fat has 
 
28 THE EEGIMEN TO BE ADOPTED 
 
 a place. I consider that fats are only really contra-indicated 
 in those cases which are developed in consequence of 
 mechanical insufficiency of the stomach — that is, where the 
 muscular elements of the stomach are insufficient to empty 
 its contents into the bowel in the normal fashion. That 
 fat is advantageous in diseases of the stomach is asserted 
 by earlier unprejudiced observers. I may state that so 
 prominent a clinical teacher as C. Bartels, of Kiel, refused 
 to eliminate fat from the diet of patients suffering from 
 dilatation of the stomach, an affection which certainly forms 
 a fruitful soil for the development of dyspeptic symptoms. 
 That fats of the best quality — and it is only such we should 
 use both for the healthy and the sick — do not injure digestion 
 is proved by physiological observations. The experiments of 
 Frerichs in his classical work on digestion could only confirm 
 the experiences of earlier observers, such as Tiedemann and 
 Gmelin, Boucharclat and Sandras, Blondlot, Bernard and 
 Barreswil, to the effect that fats suffer no actual change in the 
 stomach, except that they are melted by the heat. C. A. Ewald 
 has expressed himself in a like sense. Even though we accept 
 as correct the statement of Ph. Cash, that the neutral fats are 
 split up in the stomach into glycerine and fatty acids, 
 yet physiological and pathological experience proves that 
 no particular embarrassment arises from accepting the 
 proposition. 
 
 In determining what fats are to be employed, regard must 
 be had to individual circumstances. Furthermore, I may here 
 remark that I have never seen disturbances of the alimentary 
 canal arise from the introduction of an adequate quantity 
 of fat into the diet of gouty patients ; on the contrary, fat 
 suits them very well : and I may say this much, that the 
 gouty process seems to be anything but unfavourable to the 
 absorption of fat. The carbo-hydrates, although playing, 
 according to Voit, a similar important part in keeping up the 
 condition of the body as regards albumen, ought to be reduced 
 to a relatively small quantity, on account of their greater 
 indigestibility, in all cases where the gouty patient is inclined 
 to dyspepsia. As a matter of fact, they may be unhesi- 
 tatingly set aside in favour of that quantity of fat which is 
 
IN CASES OF GOUT. 29 
 
 suitable to individual circumstances. Another point to 
 notice is this : — We know that when hard work is required, a 
 dietary into which fat enters is absolutely necessary. We 
 shall see that we can give no better advice even to the gouty, 
 and all of the gouty disposition, than to exercise their natural 
 strength. A suitable ingestion of fat is by far the most 
 appropriate and convenient method of enabling the patient to 
 do that. The consumption, then, of a suitable quantity of fat 
 being a point which was known, even in antiquity, to have a 
 beneficial effect in satisfying the appetite of gouty patients, 
 and in counteracting the tendency to excess, the next thing 
 that is worthy of observation is, that there should be but scant 
 choice in the details of the dietary. (8) The danger which 
 the variatio delected brings with it is a specially great one in 
 the case of the gouty, for if they take in any degree too much 
 even of the kind of food which is allowed them, they run 
 against the principle of limitation which is of such importance 
 in the treatment. The gouty individual stands in the first 
 rank of those who must eat merely to live. If ever he found 
 any pleasure in living to eat he must wean himself from it as 
 soon as possible. Sweets apart, our gouty friend may be as 
 ticklish as he likes, but he must never be a glutton. He 
 must cease to eat as soon as the first feeling of satisfaction 
 comes on ; nor must he give way to the false appetite which 
 comes on after this, and which if gratified brings lrim to the 
 non possumus stage. Gouty people who lead a quiet life must 
 have no second breakfast, and their dinner or principal meal 
 should be taken between twelve o'clock and two. Supper 
 should be moderate in quantity. (9) 
 
 The reader will see that these principles agree in general 
 with those which I have prescribed for the corpulent ; and as 
 corpulence and gout go very often hand and hand, there is no 
 difficulty in carrying out the treatment, but the same regimen 
 will meet both indications. As a matter of course, gouty 
 persons with a tendency to corpulence must be refused many 
 things which a healthy fat man would be allowed to take. 
 Amongst these things we may reckon many sorts of vegetables, 
 such as cabbages and so forth. Whatever diet is used, it 
 must be so adjusted and prepared as to give as little trouble 
 
30 THE KEGIMEN TO BE ADOPTED 
 
 to the stomach as possible, and so be best adapted to the 
 nutrition of the individual. Potatoes, in so far as they are 
 allowed in general, and leguminous vegetables had better be 
 prepared as purees; and meat must be scraped or grated, and 
 lightly fried in butter, for those who have bad teeth. Patients 
 must be strictly enjoined to eat slowly and chew well, and 
 if their teeth are defective should provide themselves with 
 artificial sets. By acting on these principles and prescribing 
 certain changes, both quantitative and qualitative, adapted to 
 individual cases, we shall be able to limit corpulence in those 
 patients who are inclined to it. We shall also find this to be 
 the best means of supporting gouty patients who are not- 
 corpulent, and of keeping up their bodily condition so far as 
 the gout will allow. Unfortunately, gout often enough causes 
 severe derangements of nutrition, and it is specially incumbent 
 on the medical attendant to limit and avert such derangements 
 by means of dietetic prescriptions, never, however, allowing 
 himself to give any impetus to the gout by denying the patient 
 what is absolutely necessary. I consider it to be a thing not 
 at all permissible, and very bad practice, to attempt to subdue 
 gout by starvation cures and such like methods of treatment, 
 which simply lower the strength of a patient, who has dangers 
 enough to combat without this. Every case must be treated 
 according to its own individual merits, within the framework 
 of the principles laid down here, and no attempt must be 
 made to cut the treatment to a uniform pattern throughout. 
 Where corpulence has to be reduced it must be done slowly. 
 Those cures for corpulence which act quickly are particularly 
 unsuitable in the case of gout. 
 
 As regards relishes, such as condiments in general, vinegar, 
 &c., only that quantity should be taken which is absolutely 
 necessary to make the food palatable. Dishes which require 
 much condiment to make them acceptable ought, as a rule, 
 to be entirely avoided. Apart from many other disad- 
 vantages which the unrestricted use of condiments entails, 
 they produce direct irritation of the mucous membrane of the 
 intestinal canal if they are taken in any quantity ; and it is a 
 primary indication with us to irritate the intestines as little 
 as possible in cases of gout.(io) 
 
IN CASES OF GOUT. 31 
 
 Fruit, on the contrary, we may freely recommend to the 
 gouty and those who have a tendency to gout. 
 
 Wohler, relying on facts observed by himself, has taught 
 us that the vegetable acids with alkaline bases become 
 changed into .carbonates in the animal economy, and in 
 view of the disadvantages which are entailed by a prolonged 
 use of the alkaline carbonates, he recommends as a substi- 
 tute the vegetable acids. The use of these is justified by the 
 fact that they are not only pleasant, but can be continued for 
 a long time without injury to digestion. Such fruits, there- 
 fore, as cherries and strawberries, which contain an organic 
 acid; can be taken with good results, and are less injurious to 
 digestion than the alkaline carbonates. Wohler mentions the 
 so-called cherry cure, which enjoyed a special reputation in 
 gout. He also takes notice of the strawberry cure, which 
 was the means by which Linnaeus cured himself of a long- 
 standing gout. Similarly, other fruits may be employed with 
 advantage. I recommend them as far as possible as an 
 integral portion of the diet. But when the cure is confined 
 exclusively to the use of fruits, as, for example, in the grape 
 cure, we must be very cautious. Dyspeptic troubles are 
 easily induced by such means, and the mischief thus wrought 
 counterbalances any good that may be derived from the fruit. 
 
 As regards the question of drink, pure water is in general 
 the best drink for any one, and gouty people are no excep- 
 tion. Sydenham is, perhaps, the only observer of note who 
 regards the exclusive use of water as injurious, unless the 
 patient has been accustomed to take nothing else from his 
 youth. He forbids wine in gout, as being actually detrimental, 
 and in this he runs counter to the proverb — " You may drink 
 wine or leave it, but the plaguy gout sticks all the same."*- 
 Instead of it he recommends a thin hopped or unhopped 
 London small beer. 
 
 As matters stand at present, not only do different observers 
 differ in their views as to the use of alcoholic drinks, but 
 even the best authors contradict themselves on the point. 
 
 * Man mag den Wein trinken oder meiden, so bleibt doch die Plage des 
 Podagra. Compare the English. — "If yon drink wine yon have the 
 gont ; if you don't drink wine the gout will have you." 
 
32 THE REGIMEN TO BE ADOPTED 
 
 It would be easy to show this by a series of examples, and 
 thus point out the utter looseness of grip of such prescrip- 
 tions. As Cantani makes no mention of the use of alcoholic 
 drinks, he may be taken as regarding their exclusion as self- 
 evident. I agree with him to this extent, that I would reject 
 the use of alcohol in cases of gout, or of disposition towards 
 gout, because experience shows us that alcohol aids the 
 development of gout ; but I must add this, that in gout, as in all 
 other diseases, the prescription of alcohol may become a necessity, 
 and that we may eventually have, in spite of ourselves, to resort 
 to it, evil though it be, in order to save our patient from greater 
 evils. Alcohol is a means of stimulation which no physician 
 can afford to do without, even in gout. But I utterly forbid 
 its use in the cure of robust patients suffering from gout. 
 If they can do without it, however heavy the task to re- 
 nounce it, it will be an unmitigated benefit to them. It is an 
 absolute necessity for people with a strong tendency towards 
 gout to do without alcohol. I grant that patients who are 
 accustomed to good living, though they may willingly follow 
 out other points of the treatment, yet may not at a 
 bound give up their alcohol. Gradually, however, we shall 
 succeed in attaining our aim in at least a fraction of these cases. 
 Put it merely at 10 per cent., and we shall have done more 
 good by our universal prohibition than if we had spoiled even 
 these cases by half -measures. Alcohol is to be avoided not 
 merely because of itself and by itself it produces gout, 
 but because in the case of those who are disposed to gout, 
 or who already suffer from it, it gives an impetus to the 
 origination or the further development of the gouty process. 
 This is proved to us infallibly by the results of medical 
 experience. How much alcohol can be taken, or how long it 
 can be enjoyed, with impunity, cannot be even approximately 
 estimated by any one.(n) 
 
 If we are to regard water as the legitimate drink for gouty 
 patients, the question naturally arises, should the patient 
 drink much or little water? Cantani has specially recom- 
 mended the ingestion of large quantities of water. The diet 
 which I recommend discourages the ingestion of more water 
 than is necessary to keep the body in its natural condition as 
 
IN CASES OF GOUT. 33 
 
 regards fluids. The more we adhere to the principles of diet 
 laid down, the less necessity is there to call in the aid of water 
 to wash out the disease. By a strict attention to this dietary 
 the feelings both of hunger and thirst are appeased — a point on 
 which I have laid stress in my pamphlet on " Corpulence and 
 its Treatment." 
 
 A further reason that may have contributed to the recom- 
 mendation of the abundant use of water in the treatment of 
 gout, is the circumstance that it has been supposed to have a 
 restrictive influence on the formation of uric acid. It would 
 appear, from a series of careful experiments made by Genth, 
 that increased imbibition of water not merely diminishes the 
 secretion of uric acid, but even brings the secretion to the 
 vanishing point. Beneke, too, although he considers Genth's 
 method of estimating the uric acid to be defective, yet held 
 that it was very probable that drinking great quantities of 
 water reduced the uric acid in the urine. At the very least, 
 however, this is not a constant result. At my instigation 
 Herr Jahns instituted a series of investigations on this point, 
 the result being that the imbibition of great quantities of 
 water, up to 4,000 c.c. in the twenty-four hours, caused no 
 diminution in the uric acid secretion. It is plain that there 
 are here individual circumstances which are not at all easy 
 to be seen through ; and before proposing measures of this 
 sort, which must have some effect on the system, we ought 
 to be perfectly convinced that they will secure the desired 
 effect. Quite apart from this, however, we must be certain 
 that the object to be attained is of such value as to outweigh 
 the concomitant disadvantages, for I consider it very un- 
 desirable to flood the vascular system for any length of time. 
 Even if it were correct that drinking a deal of water reduced 
 the elimination of uric acid, still we should have no proof 
 that there was a diminished formation of the same in the 
 system. As a matter of practice I have always found that 
 my patients are much better when they do not interfere 
 with that lessened feeling of thirst which is induced by the 
 diet I have recommended. It is only when uric acid con- 
 cretions are present that I consider a freer ingestion of 
 fluids to be necessary, as I have shown more fully in my 
 
 D 
 
34 THE REGIMEN TO BE ADOPTED 
 
 book on " Urinary Concretions." In such a case I recommend 
 that the patient should, instead of taking his usual coffee 
 of a morning, have a weak infusion of black tea, taking the 
 same at night also as usual.(i2) 
 
 If the question is asked, from what date and for how 
 long this regimen must be persevered in, I think we ought to 
 recommend that those persons who have a strong hereditary 
 predisposition to gout should commence the treatment early, 
 following out its general principles, but having it adjusted 
 to their individual circumstances. As regards the quantity 
 of nutriment to be allowed, it must not be forgotten that 
 in the case of a growing body it is not enough to give merely 
 an equivalent for the daily waste. Still the greatest modera- 
 tion must be inculcated in such cases, and the stomach 
 should never be overladen. I allow weakly persons that 
 are disposed to gout one or two glasses of good wine, in 
 such cases as a stimulant seems useful or desirable. If an 
 attack of gout or premonitory symptoms of the same 
 supervene, and it is manifest that the development of the 
 disease has taken place, it is easier to induce these patients 
 to give up even this concession. After the symptoms of 
 gout have once clearly appeared, the patient should continue 
 for all his life to live as I have recommended. Such a 
 scheme of life may, in skilful hands, be modified in many 
 ways, but its primary principles must be always adhered 
 to. These are, moderation even in the things that are 
 permitted, no preponderatingly animal diet, and due regard 
 to be had to the use of fats and carbo-hydrates. This is 
 the way to keep the body in general, and the stomach in 
 particular, in the best possible condition. Such a dietary, 
 aiming, as it does, at conserving the body and keeping it 
 from corpulence, will fulfil two other conditions for which 
 the organism disposed to gout must be suited, and the 
 strictest possible adherence to which is essential to it, even 
 after the development of the gouty symptoms. The diet in 
 question will adapt the frame to all sorts of muscular 
 exercises, which in the widest sense of the word should be 
 practised by all who are disposed to gout, and by all gouty 
 patients who find themselves still in possession of bodily 
 
IN CASES OF GOUT. 35 
 
 strength. Riding, gymnastic exercises, mountain-climbing, 
 quick walking, hunting, skittles, billiards, velocipeding, and, 
 in short, everything that will harden the muscles must, as 
 I have explained (p. 19) in my remarks on the develop- 
 ment of primary articular gout, be diligently practised, for 
 the reason that they promote the movement of the vital 
 fluids, and counteract the tendency to local retentions of the 
 fluids when these are too rich in uric acid.(i3) Special 
 directions as to which of these exercises is best for practising 
 the muscles are not necessary, the question being one that 
 depends on such considerations as individual inclination and 
 capacity, differences of occupation, and the actual strength 
 of the affected individual. One restriction must, however, 
 go along with all these exercises — namely, that they must 
 not be pushed to the point of exhaustion. Our patients 
 must not be weakened in condition and constitution, and 
 here, as elsewhere, we have to find the proper medium.(i4) 
 I think it not unimportant, as far as this point goes, to add 
 that, according to H. Eanke's observations, a slight degree 
 of bodily activity seems to diminish the quantity of ' uric 
 acid secreted ; while if the activity is great, or carried to the 
 point of great exhaustion, it seems to increase the secretion. 
 But absolute unity of opinion has not been attained by 
 different observers on this point of the influence of move- 
 ment on the secretion of uric acid.(i5) As regards mental 
 activity, the training of the mental capacity, I think the 
 same rule holds good as in the case of bodily activity. 
 Exhaustion should be avoided. Due activity of the mental 
 powers up to the level of the capacity of the individual has 
 an enlivening and stimulating effect on the body, provided 
 that physical exercise is not entirely replaced by mental 
 work. If the one accompanies the other, a favourable 
 influence is exerted. Exclusive mental activity, especially 
 if associated with much sitting or exhausting night-work, 
 which weakens the resisting power of the individual, has 
 a prejudicial effect on the course of gout, if not directly, at 
 any rate indirectly, as the indispensable exercise of the 
 bodily powers is neglected. I think it is a faulty method 
 of treatment to set aside at the very beginning muscular 
 
 d 2 
 
36 THE REGIMEN TO BE ADOPTED 
 
 activity in favour of passive manipulation, favourable though 
 the influence of the latter is to the muscular system and 
 the circulation of the fluids. To this category belong 
 rubbing, friction of the body, and massage.(i6) Useful and 
 necessary as these things are within certain limits to be 
 defined, still, in the case of gouty patients, active bodily 
 activity must be practised and sought as long as possible. 
 These patients may have their bodily activity assisted by 
 friction, massage, etc., but must never carry this activity to 
 excess. Let " ne nimis " be their motto. To keep up the 
 physical capacity of our patients by judicious exercise of 
 the voluntary muscles is one of the leading indications in 
 the treatment of gout. Gouty patients, especially such as 
 like to take life very easily, often think that they can endure 
 much less than they actually can do. It is of great importance 
 to us to make a judicious estimate of this for every separate 
 case, to tear the patient ultimately from his passive con- 
 dition, and to let him clearly understand that mere ab- 
 stinence as regards eating and drinking will not always 
 lead to the desired goal. 
 
 In conclusion, some remarks must be made on the subject 
 of baths, clotliing, and residence. 
 
 It is unfortunate that, so far as Germany is concerned, 
 baths are generally employed only for medical purposes. 
 The gouty patient, whose means will in any way allow it, 
 pays a painful visit once or perhaps twice a year to some 
 spa, and thinks he has done enough. In the best case he 
 may occasionally use a bath for purposes of cleanliness ; but 
 even tins, on account of the difficulty that exists in many 
 places of getting it done, he does not employ to the extent 
 that is necessary or even desirable. Baths and other 
 methods of employing water belong, like proper diet and 
 muscular exercise, to the category of measures which the 
 gouty subject must constantly and diligently adopt. Hydro- 
 pathy has done much that is valuable in this respect, 
 more especially since it has come to be recognized that 
 the employment of water at low temperature is by no 
 means necessary in all cases, and at all events is not always 
 useful. As soon as we besfin to estimate the indications of 
 
IN CASES OF GOUT. 37 
 
 the very many different methods in which water may be 
 used as a remedial measure, a whole series of factors must be 
 taken into account, just as in every other question that 
 concerns the treatment of gout. I may mention here the 
 consideration of the individuality, the residence, the capacity 
 for resistance of the affected individual, and the stage of 
 the disease. The experience of the ancients, which has 
 been supplemented as occasion serves by that of the latest 
 observers, teaches us that even cold baths (17) and other cold- 
 water measures are not excluded from the treatment of gout. 
 The less the resisting capacity of the individual is, the further 
 the disease is advanced, the less must be our employment of 
 cold. In a case of primary articular gout, if the kidneys or 
 heart, or both, are affected, the employment of cold must be 
 at once desisted from. In all such cases warm baths must 
 be preferred.(i8) Whether any specially favourable influence 
 is exerted by baths and other measures of water-treatment in 
 the case of gout, through the influence that they have on the 
 secretion of uric acid remains still to be shown. E. Pfeiffer 
 (compare my work on " Urinary Concretions, " p. 252) has 
 advanced the statement that the secretion of uric acid is 
 diminished by the repeated use of warm baths. A test 
 experiment which I instituted gave, in the case of a healthy 
 man, no diminution of the uric acid eliminated during the 
 course of seven days (op. cit., p. 256). Granting, then, 
 that we were in a position to diminish even constantly by 
 the use of baths the secretion of uric acid, it would still 
 have to be proved that this diminished secretion exercised a 
 favourable influence in the disease, since (as explained on 
 p. 33) the mere diminution of the excretion without 
 further data is not enough to prove diminished formation of 
 the acid. 
 
 The clothing of gouty patients must be adapted to the 
 individual circumstances of the patient. Special attention 
 must be paid to the point that the most scrupulous care 
 must be taken to keep the body warm in all weakly cases 
 where increased forbearance is necessary. "We should, how- 
 ever, aim in general, as far as the arrangement of the clothes 
 goes, at a carefully graduated hardening. Woollen under- 
 
38 THE EEGIMEN TO BE ADOPTED 
 
 clothes(ig) are necessary, even in the warmest weather, and 
 should, be frequently changed, the more especially as they 
 do not show soiling so quickly as others. Special attention 
 must be given to the boots and shoes to be worn. We 
 have already spoken (p. 15) of the prejudicial influences 
 which these may have on the disease. Bad shoes favour 
 inflammatory affections of the feet ; and these again, like 
 everything that impedes the circulation, develop or aggra- 
 vate gout. Besides having well-fitting shoes, gouty people 
 should keep their feet warm, and wear woollen stockings 
 all the year through. 
 
 The residence of gouty patients must answer all the ex- 
 pectations that are formed of a healthy residence in general. 
 Most gouty people, belonging as they do to the higher 
 strata of society, either have such a residence or have the 
 means of procuring it. As climatic conditions have, ap- 
 parently, no direct influence upon the development of gout, 
 seeing that this disease comes under observation in districts 
 of great diversity in this respect, no one need expect to 
 escape it and its ravages by going to a warmer climate, unless 
 at the same time he make the requisite alterations in diet and 
 general conduct of life. Yet a weak, sickly subject, requiring 
 indulgence, one who suffers from severe complications attack- 
 ing important organs, will find benefit by a residence in a 
 warmer or more uniformly temperate climate, which saves 
 him the horrors of a northern winter, and allows him to 
 move about even during winter in the open air. In any case we 
 should advise even our stronger patients to escape from the 
 turmoil of town life in summer, and go, according as indi- 
 vidual circumstances or those of the case dictate, to the 
 country, the seaside, the mountain, or the forest. (20) This 
 is particularly advantageous if such patients are unable 
 during the rest of the year to give that attention to their 
 physical condition which the necessities of the case demand. 
 Sleep (21) often returns, and the functions of the bowels(22) 
 become regular — two points of considerable importance to the 
 gouty individual, who gets along badly when these two 
 functions are not in good working order. Sleeplessness 
 weakens his resisting power, and under the influence of 
 
IN CASES OF GOUT. 39 
 
 constipation his digestive powers suffer, not to speak of other 
 inconveniences. 
 
 _ Here I close this work. Its object is simply to give 
 those who suffer from gout, and those who are disposed 
 to it, some advice as to how to live. The nearer they 
 determine to live up to all the rules here given, the more 
 benefit will they derive. It is a matter of common sense that 
 the gouty patient can pick out of these rules just what suits 
 him ; but he must stick to the proverb, " to do the one thing 
 and not leave the other undone." That as he regulates his 
 life in the way indicated, so will he be able to do without 
 those attacking* cures, which used to be recommended as 
 prophylactic measures against gout, and are still so employed, 
 though in a somewhat milder form. (23)* 
 
 It does not lie within the compass of this little treatise to 
 give the medical treatment or to describe the use of baths 
 in the disease. The beneficial effects of each, however, are 
 far behind those that are consequent on perseverance in an 
 intelligent manner of life. More than two hundred years ago 
 the renowned Sydenham, in his treatise on the gout, expressed 
 his belief that a specific remedy might be found against the 
 disease. Such a possibility may be held by him that is of 
 blissful confidence, but the probability of it is woefully slight 
 (cf. p. 6). Sydenham based his hope on the fact that in the 
 Peruvian bark a specific had been found against intermittent 
 fever. Nowadays we know that in the case of gout we have 
 not to deal with a specific infection or contagion, but with 
 a morbid process conditioned by defective tissue-change, and 
 this process depends on a disposition that is perhaps always 
 congenital and inherited. In many cases we may obviate 
 gout and we may assuage it, not, however, through a specific 
 to be devised, but simply on the basis of a mode of life 
 intelligent in every respect. 
 
 * Eingreifende. 
 
40 THE REGIMEN TO BE ADOPTED 
 
 ADDITIONS AND ILLUSTKATIONS. 
 
 (i)* The etymology of the word gout is by no means clear, 
 I myself had simply followed Garrod, who, according to the 
 German translation of his work, regards the word Gicht as 
 corresponding to the English gout, the French goutte, etc. 
 •Virchow has recently derived the word Gicht from the 
 Latin gutta, but although goutte is undoubtedly derived from 
 that source, and although this derivation agrees with the 
 old ideas that were held as to the origin of gout, yet I cannot 
 allow that Gicht comes from the same stem. According 
 to my colleague, Professor Moritz Heyne, who is editing 
 " Grimm's Dictionary of the German Language," Gicht is 
 the same as the Anglo-Saxon masculine gihcla (the d in the 
 pronunciation being the same as the English th), and the 
 meaning is " bodily pain in general." Gicht is thus, properly 
 speaking, a general term, and may be compared to the word 
 weh = woe, pain. 
 
 (2) The question as to the causal relations between lead- 
 poisoning and uric-acid gout is still far from settled. The 
 joint-affections present in lead-poisoning were denoted, at 
 an early period, arthritis and podagra. If we go back to 
 Cullen we find that he gives three species of his genus 
 podagra regularis, to wit, arthritis podagra, arthritis restiva, 
 and arthritis rachialgica, which last is the same thing 
 as Devonshire or lead-colic, or as arthritis a colica. By 
 this we see that Cullen differentiates the forms of podagra 
 according to their etiological relations. His definition 
 of normal podagra corresponds entirely to the descrip- 
 tion of podagra in uric-acid gout. He says, in fact, that 
 normal podagra is associated with a rather severe in- 
 flammation of the joints, which lasts some days, and dis- 
 appears gradually, with swelling, itching, and desquamation 
 of the painful part. We see from this, that, apart from the 
 localization of the disease that is expressed by the word 
 podagra, a special kind of joint-inflammation is indicated by 
 
 * Note by the Translator: This is a discussion as to the derivation 
 and history of the German word Gicht, meaning gout. Professor 
 Ebstein has abridged it for me. 
 
IN CASES OF GOUT. 41 
 
 the word. The difference between arthritis and podagra had 
 been already clearly defined by Van Swieten in the fol- 
 lowing terms : — " Inter arthritidem et podagram hoc interest, 
 quod haec, etsi, cum inveteravit, plures simul aliosque ex 
 aliis articulos occupet, principio tamen pedes solum petat ; 
 quod nil tale opinantibus ingruat, nee diuturni esse primi 
 ejus impetus soleant. Arthritis vera febri continua inchoat, 
 torquetque diutius, at plerumque non redit, complures enim, 
 qui gravius hoc morbo laboravere, per omnem deinceps vitam 
 immunes ab eo fuerunt." 
 
 Eeturning from this short digression to lead-gout, we 
 gather from the vivid description which Stoll has given of 
 joint-affections in lead-sickness, that he has had before him 
 in single cases of lead-intoxication a real podagra or chiragra. 
 " In some," says Stoll, " the pain is more in the joints of 
 the fingers, hands, and feet, than in the muscles of the same 
 parts." Still all this does not give us any justification for 
 assuming that in these cases we have really to deal with 
 uric-acid gout. Even Garrocl, who first called attention to the 
 concomitance of lead-poisoning and uric-acid gout, expressed 
 himself with such reserve as to the causal relations of both 
 affections, that he may be looked upon equally well either as 
 an opponent or as a supporter of the view that lead-poisoning 
 can cause gout. He says, in fact, " a circumstance which 
 appears to point to the conclusion that lead of itself cannot 
 dispose to gout, is that female lead- workers often suffer from 
 lead-colic, but seldom from gout." Those observers who 
 maintain the connection between gout and lead-poisoning 
 almost all assume as the connecting link between the two 
 an inflammatory affection of the kidneys ; in fact, the form 
 that is known as contracted kidney. If this be true, we have to 
 deal with a primary kidney-gout (cf. p. 13). There remains, 
 however, the possibility that the affections of the extremities, 
 of the muscles as well as the joints, which occasionally occur 
 in lead-poisoning give an impetus to the development of gout, 
 and in such cases we should have to deal accordingly with 
 primary joint-gout. 
 
 As I have already said in my book on Gout (loc. cit., p. 158), 
 I have too few data at my command to settle this question. 
 
42 
 
 THE REGIMEN TO BE ADOPTED 
 
 In my former investigations I depended on information 
 given me by Dr. Jacob, of Lautenthal, in the Hartz. I 
 have collected further materials from Dr. Freymuth, of 
 Grund, and Plliinecke, of Zellerfield, in the Hartz district. 
 Dr. Jacob has quite recently made some observations having 
 special reference to the relations between lead-poisoning 
 and nephritis. 
 
 I think it best to put the observations of these three gentle- 
 men in a tabular form, and append to this the remarks which 
 they attach to their communications. I had put down a 
 series of questions to be answered with reference to the 
 points that interested me. 
 
 
 Answers by Dr. 
 
 Dr. Freymuth, 
 
 Dr. Jacob, 
 
 Questions put by lie. 
 
 Zellerfield. 
 a. 
 
 of Grund. 
 5. 
 
 of Lautenthal. 
 c. 
 
 (1.) How many of their 
 
 12 
 
 15 
 
 3 
 
 patients amongst the miners 
 
 
 
 
 suffer from gout {arthritis 
 
 
 
 
 uratica)? 
 
 
 
 
 (2.) How many of these 
 
 7 
 
 3 
 
 2 
 
 workers are engaged in the 
 
 
 
 
 lead mines ? 
 
 
 
 
 (3.) Have they seengouty 
 
 5 
 
 11 
 
 2 
 
 affections in their practice 
 
 
 
 
 in persons who had nothing 
 
 
 
 
 to do with the mines ? 
 
 
 
 
 (4.) How many of their 
 
 
 
 
 
 7 had nephri- 
 
 lead patients suffer from 
 
 
 
 tis(contract- 
 
 nephritis or coincident 
 
 
 
 ed kidney). 
 
 gout? 
 
 
 
 None of them 
 had ever 
 shown a 
 gouty symp- 
 tom. 
 
 (5.) Do their gouty pa- 
 
 1 
 
 With the at- 
 
 
 
 tients suffer at the same 
 
 
 tacks of gout, 
 
 
 time from uric-acid gravel ? 
 
 
 uric - acid 
 gravel almost 
 always ob- 
 served. 
 
 
 (6.) Have they in general 
 
 4 
 
 
 
 4 
 
 amongst their patients any 
 
 Of these one 
 
 
 
 suffering from uric - acid 
 
 had gout at 
 
 
 
 gravel ? 
 
 the same 
 time. 
 
 
 
IN CASES OF GOUT. 43 
 
 As regards 2a, note that the seven lead-workers suffering 
 from gout had repeatedly had lead-colics, and some of them 
 had also saturnine arthralgias and paralyses. Of the three 
 gouty lead- workers in 2b, one suffered from paralysis of the ex- 
 tensors of the forearm, and very violent attacks of colic ; the 
 second suffered only from attacks of colic ; the third had no 
 symptoms of lead-poisoning. As regards 2c, they have occa- 
 sionally attacks of gout, but in the intervals are quite healthy ; 
 they have had no attack of lead-poisoning for six and a half 
 years, previous to which they had certainly lead-colics, and 
 one of them had also paralysis of the extensors, which he 
 still retains. 
 
 As regards 3a, the subjects are three women of better 
 position, one teacher, and one civil functionary. 
 
 Of the eleven patients mentioned under 3b, nine belonged 
 to the Hartz ; two of these were women of the miner class. 
 Of the seven native Hartz people, none belonged to the better 
 class ; five were forest workers, who were never a winter free 
 from gout, and suffered proportionately more than the miners. 
 The two cases under 3c are those of a tradesman and a civil 
 functionary, both of whom were drinkers and stout. Dr. 
 Jacob has seen in Lautenthal eight cases of uric-acid gout in 
 six years, three of which have died. 
 
 Under 4c, note that of eight nephritic patients six had suf- 
 fered frequently from lead-colics, and after the cessation of 
 the colics contracted nephritis. The seventh had frequently 
 suffered from lead-colic at a more distant period, and had for 
 this reason been discharged from the lead mines. Only one 
 miner, who likewise had nephritis, had never had any tiring to 
 do with lead. Dr. Jacob's diagnosis in all eight cases was con- 
 tracted kidney. None of them had ever suffered from gouty 
 symptoms (attacks of gout, gouty deposits, and so on). Four 
 of them are dead ; two died with uremia, Autopsies unfor- 
 tunately could not be made. The youngest was 39 years 
 old, the oldest 59 ; one was 41, one was 43, the rest were 50. 
 The one who was aged 43 came to be treated in the medical 
 clinic of our university, and Dr. Jacob's diagnosis was veri- 
 fied. There was chronic interstitial nephritis, hypertrophy of 
 the left ventricle, with commencing compensation mischief, 
 
44 THE REGIMEN TO BE ADOPTED 
 
 paresis of the extensors of the right hand. At an earlier 
 period he had frequently suffered from lead-colics. 
 
 As regards, then, the connection between chronic lead- 
 poisoning, uric-acid gout, and contraction of the kidneys, I 
 might formulate my conclusions from these gentlemen's 
 observations thus : — 
 
 1. Within the area of observation of these three medical 
 men in the Hartz, gout is a relatively not infrequent disease, 
 and occurs more frequently amongst the lower classes, the 
 miners, etc. 
 
 2. At Zellerfield, the number of workers in the lead 
 mines who are affected with gout is exceptionally great. 
 Symptoms of kidney-affection could not be proved by any 
 of the three observers in the case of those gouty patients 
 who suffered from lead-sickness. 
 
 3. We may note the frequent occurrence of chronic 
 nephritis (contracted kidney) in lead-workers who had re- 
 peatedly suffered from symptoms of severe lead-poisoning. 
 A relation between the kidney mischief and uric-acid gout 
 could not be recognized. 
 
 The reader must not think that I wish to draw any further 
 conclusions from these few figures than that there is in these 
 known parts of the Hartz a surprisingly great frequency of 
 gout. It is perhaps worth while to call attention to the 
 specially great liability of the lead- workers of Zellerfield to 
 gout. As far as can be concluded from the symptoms present, 
 there is no causal connection here between gout and an 
 affection of the kidneys. I am certainly very near thinking 
 that uric-acid gout occurs oftener amongst lead-workers in 
 the Hartz only because it is found there more frequently 
 amongst the workers in general. I think that we must stick 
 to this principle, that for the development of uric-acid gout 
 in general, as well as in lead-workers in particular, an indi- 
 vidual predisposition must be postulated, even though we 
 should grant that lead-sickness, like many other predisposing 
 causes, can give an impetus to the development of primary 
 articular gout. Such an individual predisposition must be 
 postulated, for, cmteris paribus, only an apparently insignifi- 
 cant fraction of lead-patients suffer from the symptoms of true 
 
IN CASES OF GOUT. 45 
 
 uric-acid primary articular gout. In relation to this disposition 
 I have to thank Dr. Andreae for an interesting communication. 
 He practised in Grossalmerode twenty-five years. He noticed 
 that the small number of potters in that place who worked 
 with lead gave him at least as many gouty patients as the 
 rest of the population did. He considered it worthy of note 
 that of eight patients suffering from uric-acid gout, and whom 
 he remembers to be lead-working potters, three (father, 
 mother, and son) belonged to one family. We may certainly 
 talk of a family predisposition to gout in this last case. 
 
 As regards the kidney-affection in lead-poisoning, it must 
 at any rate be considered very surprising that Dr. Jacob, 
 within six years, observed seven patients with contracted 
 kidney, and these, with one exception, had frequently suffered 
 from symptoms of lead-poisoning up to the onset of the 
 kidney-disease. As out of the 170 smelters who are under 
 Dr. Jacob's observation only about one-half have the chance 
 of getting lead-poisoning, we can hardly get over the idea 
 that there is a causal relation here, the nature of which, 
 however, it is impossible to state. 
 
 It is interesting that none of these nephritic patients have 
 ever had any typical attack of gout, or any other symptom 
 from which it might be concluded with certainty that they 
 had suffered from uric-acid gout. I confess that we cannot 
 say there was no primary kidney-gout in these cases, for 
 urate deposits are often found in the joints at the autopsy, 
 when during life there are neither typical attacks nor any 
 other symptoms of uric-acid gout. This is said to be 
 specially the case with the uric-acid gout of the poor. As 
 regards the etiological element of these cases, it is very easy 
 to think of the influence of the lead. Still, as only a certain 
 number of the patients treated by Dr. Jacob for lead- 
 poisoning were attacked with nephritis, an individual dis- 
 position must exist here also, and this may often consist 
 of a uric-acid diathesis. 
 
 The non-presence of urate deposits in contracted kidney 
 gives no justification for excluding the development of this 
 form of disease on a gouty basis, for such deposits may be 
 wanting even in the worst forms of gouty kidney. It would 
 
46 THE REGIMEN TO BE ADOPTED 
 
 be equally incorrect to conclude, from the non-presence of 
 gouty joint-changes in the dead body, that true attacks of 
 gout have never been present in the affected individual. 
 There could be no more striking proof of this than the 
 affection that led to the death of Professor Cohnheim. He 
 had suffered so far back as 1872 from what were certainly 
 attacks of gout, and in a communication which he sent me, 
 5th February, 1883, he reckoned he had had about fifteen of 
 these. At the post-mortem were discovered granular kidneys 
 with urate deposits, and an enormously hypertrophied heart, 
 but even the joints that had been most frequently attacked 
 were quite normal in their condition, and showed no deposi- 
 tion of urates (c/. Weigert, "Berl. Klin. Woch.," 1884, No. 35, 
 p. 564). From the facts as stated above, it will be seen 
 that the final decision as to the relations between gout, 
 contracted kidney, and lead-poisoning is associated with 
 enormous difficulties. Further experiences are required, and 
 the solution of the problem must be gradually worked up 
 to. My standpoint in the question is, that we cannot 
 entirely dispense with the assumption of an individual dis- 
 position, even though we grant a predisposing influence to 
 lead. Leyden has quite recently attempted to establish 
 definite criteria, especially anatomical ones, for the recognition 
 of contracted kidney in lead-disease. Praiseworthy as these 
 investigations are, I think they can scarcely enable us, under 
 all circumstances, to refer to lead-poisoning cases of granular 
 atrophy of the kidney which perfectly resemble those 
 depicted by Leyden. I have found, as a consequence of gout, 
 similar anatomical changes of the aortic system and the 
 kidneys in an individual still young, who certainly never had 
 anything to do with lead. Having shown in my work on 
 Gout that gouty inflammation runs its course without 
 deposition of urates, the death of the affected parts being 
 necessary in order that this may follow, I think that the 
 mere absence of these deposits is not enough to warrant us 
 in rejecting uric acid as a factor in these cases. 
 
 (3) Amongst the peculiar views which have prevailed as 
 to the nature of gout, and which have been defended in many 
 circles with the greatest tenacity, I may mention the fact 
 
IN CASES OF GOUT. 47 
 
 that even the sexual organs of the individual have been 
 supposed to play a part in the development of gout. More 
 particularly is this the case with regard to the male, for, so 
 far as I know, no one has assigned to the female organs of 
 generation any share in the production of gout. The original 
 propounder of these views was, I think, Van Helmont. He 
 placed the seat of gout in the materia seminalis. According 
 to his view, the gouty germ sleeps there till its awakening, 
 " like the nightingale in its nest." Pietsch considered the 
 universal cause of gout to be a degenerate, ill-formed semen, 
 which is re-absorbed from its vesicle and finds its way back 
 into the blood. Washings of the penis and scrotum accord- 
 ingly played a part in the treatment of gout. The pre- 
 scriptions as to the frequency of sexual connection, which 
 were given to the gouty patient, were very rigorous. Coste 
 says in his " Traite pratique de la Goiitte" (1768), " Every time 
 that a young man with the gout looks at a woman, he adds 
 a new root to his ailment, and if he is old the same thine: 
 will hasten his death." If we give gouty people the advice 
 to be careful and moderate in their sexual relations, and to 
 avoid all forced and artificial excitement, it is simply from 
 the general principle that all weakening influences must be 
 carefully kept from them. The fact that gout is hereditary 
 would seem to show that the number of gouty patients is in 
 some way not normal — a state of things which, however, is 
 not the cause, but a consequence, of gout. From these con- 
 siderations the gouty individual should learn to have some 
 regard for his descendants, who are not, in the language 
 of Temple, " bene nati," and should therefore be as careful 
 with his regimen in sexual respects as in others. 
 
 (4) With regard to the clinical appearances which indicate 
 a participation of the muscles in the gouty process, I shall 
 quote the following communication from Cohnheim in a letter 
 to me of 5th February, 1883 : — " Perhaps in view of your 
 hypotheses you may be interested to know that my experience, 
 gathered from my own body, is that the most troublesome 
 and longest-lasting sensation, enduring as it does even after 
 the attacks, is that of a high degree of muscular weakness. 
 This is a view which you have given more decided expression 
 
48 
 
 THE REGIMEN TO BE ADOPTED 
 
 to than any other authority." Sydenham too says, apparently 
 on the ground of his own personal experience, that the sinews 
 of the calf are so drawn with agonizing cramp, that the pain 
 would simply be past human endurance if continued without 
 remission. 
 
 (5) We have recently put together a series of figures as to 
 the absolute and relative quantity of uric acid (as compared 
 with urea) which is secreted in the urine of leuksemic 
 subjects. The quantitative estimations were made by Dr. 
 Deichmiiller, senior clinical assistant. 
 
 1. Frau Areus, 58 years old, taken in 14th December, 
 1883, discharged 1st January, 1884. Leukaemia lienalis.* 
 Weight, 40*5 kilo. Daily quantity of urine about 1,000 c.c, 
 sp. gr. 1005 to 1010. Urea secreted in 24 hours 13 - 9 grm. ; uric 
 acid, in 24 hours, 1*28 grm. Proportion of uric acid to urea, 
 1:10. 
 
 2. August Heidelberg, 21 years, a mason, admitted 13th 
 May, discharged 14th August, 1884. Weight, 58 kilo. 
 Leukaemia lienalis et lymphatica. Urine non-albuminous ; 
 daily quantity between 700 and 1,500 c.c. Sp. gr. between 
 1,016 and 1,020. 
 
 Secretion on — 
 
 + 
 u. 
 
 Total. 
 
 U. 
 
 Total. 
 
 - + 
 u. u. 
 
 Proportion. 
 
 Remarks. 
 
 May 16, 1884 
 
 20-5 
 
 1-98 
 
 1:10 
 
 Escape on the sediment, 0-87 U. 
 
 June 1, 1884 
 
 21 
 
 3-75 
 
 1: 5-6 
 
 Escape on the sediment, 0-45 U. 
 
 June 2, 1884 
 
 18-97 
 
 5-102 
 
 1: 3-7 
 
 Escape on the sediment, 0-238 U. 
 
 Average 
 
 20-15 
 
 3-467 
 
 1: 6-4 
 
 
 A secretion in one day of more than 5 grm. of uric acid, which 
 was observed once in the case of this patient, is the largest 
 quantity known to me in any case of leukaemia. Next to it 
 stands the observation of Bartels, who once noted 4'2 in a 
 leukemic patient (" Deutsches Arch. f. Klin. Medicin," I., 
 p. 23, 1866). 
 
 3. Friedrich Bertram, 36 years, gardener, weight 74'5 
 kilo. Leukaemia lienalis, enlarged lymphatic glands in 
 * Lienalis = splenic. 
 
IN CASES OF GOUT. 
 
 49 
 
 various parts. Daily quantity of urine at first from 1,000 
 to 1,700 c.c. ; later on as niuch as 2,000 c.c, sp. gr. 1014 
 to 1018. 
 
 Secretion on — 
 
 + 
 XT. 
 
 Total. 
 
 u. 
 
 Total. 
 
 - + 
 
 TJ. TJ. Remarks. 
 Proportion.] 
 
 May 18, 1884 
 May 27, 1884 
 June 5, 1884 
 
 18-5 
 16-3 
 15-5 
 
 3-2 
 2-7 
 1-9 
 
 1 : 5-2 Escape on the sediment, 1 -25 U. 
 1:6 Escape on the sediment, 1*1 — . 
 1 : 8-1 Escape on the sediment, 0-5 — . 
 
 Average . . 
 
 16-7 
 
 2-9 
 
 1:6-4 
 
 4. Conrad Grube, 48 years. Leukaemia lienalis. Admitted 
 19th July, 1884; discharged improved, 9th August, 1884. 
 Weight, 71 '5 kilo. Daily quantity of urine at first varied 
 very much, between 750 and 1,750 c.c. ; later on was con- 
 stant, between 1,500 and 1,750 c.c. Sp. gr. between 1017 
 and 1020. 
 
 Secretion on— 
 
 + 
 
 TJ. 
 Total. 
 
 TJ. 
 
 Total. 
 
 - + 
 
 TJ. TJ. 
 
 Proportion. 
 
 Remarks. 
 
 June 22, 1884 
 June 25, 1884 
 
 30-5 
 
 28-22 
 
 1-232 
 0-923 
 
 1:24-7 
 1:30 
 
 Escape on the sediment, -523 U. 
 0. Urate sediments copious at 
 
 first, but disappeared entirely 
 
 from July. 
 
 Average . . 
 
 29-36 
 
 1-077 
 
 1:27-3 
 
 
 The following table may be constructed from the figures 
 in these four cases. 
 
 
 + 
 TJ. 
 
 Total. 
 
 TJ. 
 
 Total. 
 
 - + 
 TJ. TJ. 
 
 Proportion. 
 
 Case 1 
 Case 2 
 Case 3 
 Case 4 
 
 13-0 
 20-15 
 16-7 
 29-36 
 
 1-28 
 3-467 
 2-9 
 1-077 
 
 1:10 
 
 1: 6-4] 
 
 1: 6-4 > Averages. 
 
 1:27-3 ) 
 
 In none of these patients could clinical symptoms be demon- 
 strated, from which implication of the medulla of bones could 
 be inferred ; but, for all that, this is by no means excluded. 
 
 E 
 
50 THE REGIMEN TO BE ADOPTED 
 
 In our cases the amount of uric-acid secretion was in inverse 
 proportion to the general bodily strength. 
 
 (6) As lymphatics arise everywhere in the connective 
 tissue, the sap-canals of this being simply the radicles of 
 the lymphatic vessels, we can easily understand why in 
 the case of uric-acid gout we have here blockage of the 
 fluids overladen with uric acid. "We have no need, in order 
 to elucidate these processes, to locate the formation of uric 
 acid in the connective tissue. In consequence of such 
 blockage in the lymphatics, extensive lymphangioitis with 
 rosary-shaped extensions of the lymphatics in the extremities 
 may be developed. This fact a gouty colleague of mine had 
 repeatedly occasion to observe in his own person. I mention 
 this because the right explanation of these things might cause 
 great difficulties. In the patient in question the processes 
 in course of time underwent a retrograde transformation. 
 From the implication of the lymphatics in the gouty 
 process, we can also understand that in gouty inflammation 
 of the kidneys the deposits of uric acid do not appear 
 exclusively in the tubuli uriniferi, but also frequently 
 in the interstitial tissue of the kidneys after causing the 
 death of the tissue. Pedell has recently added another case to 
 those mentioned in my book on Gout. The close aggrega- 
 tion of the cellular tissue and of the lymphatic vessels in the 
 papilla? of the kidneys explains how it is precisely in this 
 part of the kidneys that the gouty foci — really small gouty 
 tophi — are established. 
 
 (7) Vegetarianism has not wanted sturdy defenders in gout. 
 The Pythagorean formula — (1) pisa et olera;* (2) olera et 
 pisa ; (3) olera cum pisis ; (4) pisa cum oleribus — has been 
 specially applied to this disease. According to Reveille the 
 chief ingredients in the diet of the gouty should be vegetables 
 of the cabbage kind, ripe fruits, and farinaceous substances of 
 good quality, amongst which he puts potatoes in the first rank. 
 These and such-like teachings do not, however, satisfy modern 
 conceptions as to a scientific dietary of gouty patients. 
 
 (8) In spite of the slight choice of dishes that are allowed, 
 uniformity of diet, as giving the patient a disgust at eating, 
 
 * Pisa = peas ; olera = greens or cabbage. 
 
IN CASES OF GOUT. 51 
 
 must be very carefully avoided. The different sorts of animal 
 food, the different ways of preparing the same, and the great 
 variety of vegetables, make this an easy task. 
 
 (9) Naturally, the number of meals may be increased if the 
 condition of the digestive organs calls for it, as, for example, 
 when the stomach is not able to bear a larger meal than 
 usual at once — such a one, for example, as dinner. 
 
 If necessary, we may fall back on milk in individual cases, 
 but to recommend it as curative in gout should commend 
 itself to nobody nowadays, although there have been observers 
 who thought that nothing was better for gouty patients. 
 This point has evoked very lively discussion, and there 
 is a goodly quantity of literature on the subject. As the 
 exclusive use of milk is not specially adapted for the healthy 
 adult, so we may say at once that it is not so for the gouty 
 either. Milk-cures for gout may be considered as abandoned. 
 Beneke considered that whey-cures were indicated in gout 
 from a theoretical standpoint, on account of the increased 
 uric-acid formation, but in practice, so far as I know, they are 
 not extensively used. 
 
 (10) Similarly, with regard to the use of condiments we 
 find many contradictory opinions amongst writers. Falconer, 
 although he does not advise immoderate use of condi- 
 ments, allows the moderate use of vinegar, which A. von 
 Haller signalizes as salubre omnino et condimenti genus et 
 denique potus (" Elem. Physiol.," vol. vi.). Nor does Falconer 
 exclude mustard ; but Cadogan rejects both it and salt. 
 
 (11) Absolute prohibition- of wine in gout is not justified. 
 Patients up in years frequently cannot bear entire with- 
 drawal of their wine ; and if we wish to avoid undesirable 
 cases of collapse, we have to be very cautious even in re- 
 ducing their daily quantum to the lowest possible limit. I 
 have already said that in the manifold conditions of weak- 
 ness in which gouty patients find themselves, wine cannot 
 be withdrawn. I might express myself in similar terms 
 about beer. Beer may be allowed in small quantities, not 
 for pleasure, but as a nourishment or stimulant. 
 
 The question what sort of wine to drink is not difficult to 
 answer after what has been said. Champagne is, for good 
 
 E 2 
 
52 THE EEGIMEN TO BE ADOPTED 
 
 reasons, in universal disfavour among authorities. In the 
 choice of alcoholics Mooren has given the preference to 
 those which least increase the acidity of the urine. He 
 found that Dortmund beer did this least of all. Good 
 Pdiine wine increases acidity much more ; so do selected sorts 
 of Moselle, and good Bordeaux that has been laid down 
 some time ; most of all, perhaps, the ordinary qualities of 
 Moselle. Good pure brandy, if a powerful stimulant is 
 required, may be used under medical supervision in small 
 quantities. As soon as alcohol, however, is no longer neces- 
 sary, its use must be dispensed with. 
 
 (12) This opportunity may be taken to fix some points 
 with regard to the use of non-alcoholic drinks in gout. 
 Bontekoe (quoted by Barthez) asserted that the habitual 
 use of tea by the Chinese was the reason why neither 
 stone nor gout existed in that country. Though this can- 
 not seriously be maintained, yet tea is to be preferred to 
 coffee as more suitable for the stomach. The rule given 
 by Eeveille, that gouty people should take coffee if they 
 are stout and corpulent, and have no excessive nervous 
 irritability, if they are not over-heated or costive, or if 
 they have been long accustomed to the use of it, is not 
 sufficiently supported by observation. We may here re- 
 mark also, that there are isolated cases in which, through 
 some idiosyncrasy, tea cannot be taken. Such individual 
 characteristics have to be taken into account. 
 
 (13) Bodily exercises, active and passive, might be supposed 
 to be specially useful in cases of primary articular gout, 
 seeing that they act directly against that retention of the 
 fluids (p. 20) which favours the deposition of uric acid. 
 The same result follows from a series of observations which 
 find their expression in the questions which Hasse set him- 
 self to answer. These questions are — How are cartilages, 
 bones, and cellular tissue penetrated by the elements that 
 nourish them, and freed from their waste products ? also, 
 what power sets these fluids in motion ? For a reply to 
 these questions, he takes the standpoint of comparative 
 anatomy. Along with the propelling power of the heart 
 and the action of the respiratory muscles, the whole of 
 
IN CASES OF GOUT. 53 
 
 the muscles, striped and unstriped alike, contribute to the 
 movement of the blood and lymph. In the case of cartilage, 
 for example, the expression of these elements is secured by 
 the small canals and intervening spaces of the soft peri- 
 chondrium that surrounds them. Muscles with their fascia 
 take a support from this perichondrium, or are directly or 
 indirectly attached to it. We thus see that systematic 
 strengthening and exercise of the muscles are of powerful 
 assistance from this point of view also in checking the 
 development or advance of gout. 
 
 As far as the promotion of the circulation is concerned, the 
 object of these exercises is not merely to facilitate the reflux 
 of venous blood, but specially to direct the movement of the 
 fluids in the fine lymphatics, into which fall the waste pro- 
 ducts of tissue-change formed in the muscles and bone-medulla. 
 
 (14) Sydenham insists that the movements of gouty patients 
 should not be carried to the point of exhaustion. He re- 
 commends daily exercise to a moderate amount. He prefers 
 riding, and riding is an exercise that is in general suitable. 
 "Warner, too, besides rubbing and brushing of the affected joints, 
 recommends a morning ride in summer of two to three hours, 
 followed by a second in the evening during the same season. 
 If riding is unsuitable either through old age or other causes, 
 Warner recommends gouty patients to drive, but they should 
 have the springs of the carriage taken out, and fall back upon 
 leather straps as a substitute. Cadogan's advice, " Eemedium 
 in motu quaere sudando," has also its limits. A certain amount 
 of tiredness must not be exceeded. Of course, bodily exercises 
 must always be accompanied by strict regimen and frugal habits. 
 Those bodily exercises are specially to be recommended in 
 which the mind is pleasantly occupied. Of such we may call 
 special attention to skittles and billiards, as also to hunting. 
 For military men who are threatened with an attack of gout, 
 there is no better preventive than the exercise required in 
 attending one of the military manoeuvres. 
 
 (15) Hammond ("American Journal," Jan., 1855) observed 
 a diminution of the uric-acid secretion to result from active 
 movement, and the greater the exercise the greater was 
 the diminution. Genth and Fl. Heller (" Heller's Archiv ") 
 
54 THE REGIMEN TO BE ADOPTED 
 
 observed an increase of the uric-acid secretion after active 
 movement. Eckart found (1) that after prolonged rest there 
 is a diminution of the uric-acid secretion, and at once an 
 accumulation of it in the blood, in consequence of which he 
 observed a sudden attack of gout in the case of a patient ; 
 (2) that movement and bodily activity prevent uric acid 
 being formed in excess in the blood; and (3) that in con- 
 sequence of active movement there is not merely a simple 
 increased secretion of uric acid, but a more vigorous trans- 
 formation of uric acid into urea. Eckart deduced these 
 principles and conclusions from quantitative estimations of 
 uric acid. As he did not, however, use the whole quantity 
 of urine passed in a day, but only 300 c.c. of it, I do not 
 think his experiments conclusive. The same remark applies 
 to experiments of Eckart's in which he attempted to show 
 that the secretion of uric acid in the urine is diminished by 
 inhalations of oxygen. 
 
 (16) Dry rubbings with flannel, in spite of the greater vogue 
 nowadays of moist applications, deserve a special trial in 
 the case of weak patients with little resisting power, who 
 require to be carefully managed. The idea of these is found 
 as far back as Celsus. Amongst the ancients the art of friction 
 was highly developed. Although what Philagrius (quoted 
 by Aiitius) states is not correct, viz., that friction alone will 
 save gouty individuals from fresh attacks whatever their 
 errors of diet may be, yet Boerhaave's statement has much 
 more to recommend it. He advises gouty patients to give 
 themselves a good rubbing night and morning with dry 
 flannel, especially over the joints ; not merely do they feel 
 easier after it, but they may protect themselves from a 
 recurrence of the attacks. I do not think Boerhaave is right 
 in stating that gout never attacks people with sweaty feet. 
 Van Swieten advised rubbing as a substitute for active 
 motion. Weak patients may be rubbed softly with the hand ; 
 others may be rubbed with a big brush, the hardness or soft- 
 ness of which may be accommodated to the effect desired 
 and the tenderness of the skin. It is best to rub in the 
 direction of the hair growth. There are patients, however, who 
 cannot bear it, and they must be gradually accustomed to it. 
 
IN CASES OF GOUT. 55 
 
 These rubbings must be continued till the skin is red; when the 
 point of pain is reached they must be discontinued for the time. 
 
 Eeveille has given prominence to the use of massage in 
 gout, which began to be practised in Frankfort about the 
 end of the year 1830. He admits, however, that if pushed 
 to excess it may cause harm, and pains in the muscles 
 and joints. I myself have recommended, in my work on 
 Gout, the employment of massage in the intervals between 
 individual attacks. Eeibmayr says with reference to this 
 recommendation of mine, that its success cannot be very 
 encouraging, as the affection rests on a constitutional basis, 
 and a relapse may easily upset any good derived from massage. 
 As regards the kind of massage to be used, Eeibmayr is cer- 
 tainly right in saying that the fact of gout being a constitutional 
 disease is detrimental to the success of these as of all other 
 measures in gout ; nevertheless they are not to be despised 
 as supplementary aids. Massage, again, must not be allowed 
 to take the place of active muscular movements. The intro- 
 duction of gymnastic apparatus, in which the patient may 
 exercise himself in a sitting position, and in which these 
 exercises are adapted to every joint and every condition of 
 strength, is of great value to weak patients. Such apparatus 
 is to be found in Friedrichsbad in Baden-Baden (cf. Heiligen- 
 thal, " Literary Index," Xo. 26). 
 
 (17) Cold baths were considered useful even in antiquity, 
 'as we find in some passages of Strabo and Pliny, which 
 mention the cold water of the fast-flowing Cydnus as useful 
 in gout. Scudamore has recommended douches and cold- 
 water washings as preservative against gout. The body 
 should be immediately covered with warm flannel. Friction 
 should be used with or after the cold water. Eeveille has 
 given the following definite indications for the use or pro- 
 hibition of cold baths in gout : — (1) They are to be allowed 
 if the patients are young, and if a feeling of warmth and 
 comfort follows the bath ; (2) during a paroxysm they 
 should not be used [I may state that Pietsch has attempted 
 to show, in a series of observations, that cold baths are useful 
 even in the paroxysm] ; (3) results must be allowed to speak 
 for their use ; (4) the season must be favourable. Ofterdinger 
 
56 THE REGIMEN TO BE ADOPTED 
 
 lauds (amongst prophylactics) baths, especially river and sea 
 baths, except in cases of deficient bodily activity, or in 
 advanced age, where the joints are very stiff. The advantage 
 of sea baths is often evident in cases of persons with moderate 
 gouty tendency, should this advantage not be destroyed by 
 luxurious living, as is too often the case in bathing resorts. 
 Quite recently, Ktister has proved the favourable influence 
 of cold-water methods by experiments on himself and others. 
 He had a cold splash every morning as soon as he left 
 his bed, and then rubbed his body with a rough bath-towel. 
 
 (18) As regards warm baths, observers here also are not 
 agreed. This is easily accounted for, seeing that hydro- 
 therapeutic measures should be ordered not merely according 
 to individual circumstances, but specially according to the 
 stage at which the disease has arrived. In the case of warm 
 baths it is necessary to notice that they should be used by 
 patients in the same house as they live in. On this account 
 the arrangements to be had at Wiesbaden are particularly 
 praiseworthy. Warm baths have not merely a curative, but 
 also a prophylactic significance in the treatment of gout. In 
 this way baths and drink-cures may be combined with one 
 another, and may be specially used along with douches, 
 gymnastics, and massage in order to ameliorate the gout as a 
 constitutional ailment, and defer, or even prevent, the out- 
 break of new attacks. The necessary details may be found 
 in Pfeiffer, " Die Trinkkur in Wiesbaden," Wiesbaden, 1881 ; 
 Pfeiffer's " Balneologische Studien iiber Wiesbaden," Wies- 
 baden, 1883 ; Beissel, " Balneologische Studien mit Bezug 
 auf die Aachener und Burtscheider Thermalquellen," Aachen, 
 1882, p. 69; Beissel and GL Mayer, "Aachener Thermalkur 
 und Gicht," " Berl. Klin. Woch.," 1884, No. 13 ; Frey und 
 Heiligenthal, " Die heissen Luft- und Dampfbader in Baden," 
 Leipzig, 1881. Similarly, other thermal baths may be 
 employed, as Wildbad (cf. " Literary Index," Nos. 45 and 46) 
 and a number of similar cure-places. 
 
 (19) Warm clothing, but not too much of it, is recommended 
 by all doctors. The material which, above all others, is 
 suited to subdue gout, and more particularly to prevent it, 
 is, as Eeveille remarks, flannel, which some one justly calls 
 
IN CASES OF GOUT. 57 
 
 a clothing with god-like qualities. In summer it may be 
 the wisest plan to wear old flannels. "Woollen underclothing 
 has long been recognized as of value. 
 
 In the recognized handbook of military hygienics, by Both 
 and Lex (vol. iii, p. 83), we read : " In spite of all incon- 
 veniences which the use of woollen shirts may entail, they 
 are indispensable to the soldier on account of their capacity 
 for moisture, and as bad conductors of heat." 
 
 If the soldier has also disproportionately greater fatigues 
 to overcome than the gouty subject has under ordinary 
 circumstances, yet slight injuries inflict precisely as much 
 damage in the case of the gouty as considerable ones do in 
 the case of the soldier. The usefulness of woollen under- 
 clothes has been considerably advanced in late years by 
 improved methods of manufacture. 
 
 (20) Change of air has been credited with many good 
 results in the prophylaxis of gout. Warner, a clergyman, who 
 himself suffered from gout, ascribes two of his very worst 
 attacks to bad air ; he advises gouty people, as soon as they 
 notice the approach of a gouty attack, to go to the country. 
 Sydenham too, and others, have mentioned the influence of 
 good air in gout. It is difficult to say what influence better 
 air has of itself on gout. "We can only say that, as a rule, 
 the general hygienic conditions cannot be made too favourable 
 for gouty patients, and thus residence in a good atmosphere 
 may be an important factor. It need merely be indicated here 
 that residence in the country, with mountain air, etc., generally 
 brings into play a series of other favourable influences. 
 
 (21) As regards sleep, we may note that both too much and 
 too little sleep are unfavourable to gouty patients. In parti- 
 cular should patients who have a disposition towards gout, 
 and those actually ill of it who are tolerably strong, not 
 indulge in too long sleep. The patient in any case should 
 have as much sleep as will maintain his strength, and regard 
 must be had to the actual necessities of the case. Sydenham 
 condemns late sitting at night, and advises early going to bed, 
 especially in winter. 
 
 Ofterdinger's advice carries with it much that is worthy of 
 consideration : " Much sleep is not good, but prolonged rest, 
 
58 THE REGIMEN TO BE ADOPTED 
 
 covered up in bed, is beneficial to all gouty subjects, and such 
 as have had several severe attacks." Sleep in the daytime is 
 in general unadvisable. Mattresses and blankets are almost 
 always to be preferred to feather beds, except in the case of 
 old and decrepit patients, who have been accustomed to a 
 softer couch from their youth. The hardening treatment 
 should be tried with this as long as it is possible. Kiister 
 sleeps in an unheated room, with one of the upper windows 
 often left open even in the depth of winter to admit fresh 
 air (cf. Note 17). 
 
 As to the treatment of sleeplessness, from which many 
 gouty patients suffer owing to different causes, scarcely any 
 general rules can be given. Each case must be treated on its 
 own merits. Musgrave thinks rubbing with a soft hand will 
 procure sleep and lessen pain. Avoid drugs to procure sleep, 
 such as morphia, chloral hydrate, and large doses of bromide 
 of potassium. These should only be used if the pain is too 
 great to be bearable, and cannot be subdued in any other 
 way. 
 
 (22) The regulation of the bowels in gouty patients, who 
 suffer so frequently from constipation, is made more easy by 
 the regimen here recommended. Grant, quoted by Barthez, 
 long ago called attention to the fact that the best means of 
 regulating the bowels was a moderate regimen with vigorous 
 physical exercise, and if supplementary aid was required he 
 gave four to eight grammes of flowers of sulphur every even- 
 ing in a little milk. In the case of children with inherited 
 gout, who suffer from flatulence and indigestion, he combined 
 magnesia with the prescription. I have carefully avoided 
 purgatives, and in any cases where diet or the use of fruit has 
 not sufficed to regulate the bowels, have recommended injec- 
 tions to be used. In such cases the syringe should be used 
 daily whether there is a motion or not, and the best time to 
 use it is just before getting up in the morning. The result is 
 generally either a permanent cure or marked improvement of 
 the constipation. The fluid I use is a 1 per cent, solution 
 of common salt, at a temperature of 70° to 80° Fahr., and 
 the quantity \ to \ litre. No great force should be used in 
 injecting it. "When the fsecal masses are very hard, a Hegar's 
 
IN CASES OF GOUT. 59 
 
 funnel should be used at night to inject some castor oil, which 
 may be made up in emulsion with gum-arabic. 
 
 In this way the energies of the digestive canal are conserved, 
 we attain our end in the easiest and surest fashion, and are 
 soonest in the position to restore the normal activity of the bowel. 
 
 (23) Of old times, in order to obviate the gout, very drastic 
 cures were in vogue. The idea was to remove the materia 
 peccans, either through stimulating the natural secretions or 
 by withdrawing fluids from the organism of the patient. 
 Elias Anhart, in his " Consilium Podagricum," recognized a 
 yearly evacuatio, along with right diet and exercise, as the 
 three things in which the cure of gout was to be sought. 
 
 The sweat-cures are the relatively mildest of these methods. 
 Boerhaave recommended spirits of hartshorn to be taken every 
 morning, and a woody infusion every night, for three months. 
 Quarin (Joe. cit, p. 288) thought the recurrence of the attacks 
 could be prevented by the administration of definite drugs at 
 definite times, by means of which the activity of the skin and 
 bowel was to be stimulated. For this purpose he used elder 
 flowers, sulphur, guaiacum, and antimony. Others tried to 
 get the peccant material ejected through the urine ; and the 
 means they used for the purpose were not always harmless. 
 Martius (see Barthez) made a patient, whose attacks often 
 lasted six months, take, at every change of the moon, eight 
 fruits from the Winter-cherry (Physalis alJcekenyi), and this 
 was said to carry away some very rotten stuff from the 
 system. To the last-named category belongs the use of 
 setons or issues as a favourite means of preventing gout, as 
 well as repeated venesections from time to time. Stisser 
 gives a warning against venesections and laxatives employed 
 in spring and autumn with a view of modifying the attacks. 
 The temporary use of drastic purgatives was also recom- 
 mended. Sydenham was one of the first to reject vene- 
 section and purgation. Nowadays all these means have 
 fallen into disuse, and justly too, for their benefits are 
 problematical, and the harm they do often too evident. The 
 more sensible the habit of life is, the more easily can every 
 sort of treatment by removal be dispensed with. The patient 
 is also in a position better to maintain the activity of his 
 
60 THE REGIMEN TO BE ADOPTED 
 
 organs and the strength of his body. If the gouty subject 
 follows the advice of Sir William Temple (p. 26) he will 
 not require to flush out his system by increasing his quantity 
 of drink, either by taking inordinate quantities of water, by 
 indulging in wonderful combinations of different kinds of 
 tea (which used to be a favourite plan), or by drinking those 
 natural or artificial mineral waters which are nowadays so 
 common. As regards increased water-drinking, which has 
 found so many advocates up to the most recent date, I may 
 mention the recommendation of Cadet de Vaux — who, 
 horribile dictu ! condemned the wretched patient to drink 
 every hour 180 to 240 grammes of warm water, at 120° to 
 140° Fahr., until he had taken about 12 litres in as many 
 hours. The mere fact that many people can stand even this 
 amount gives us no right to recommend so nonsensical a plan, 
 modified though it has been, and still finding some friends to 
 recommend it. I have said plainly enough (p. 32) what I 
 think of the use of water as a drink in gout. As regards 
 drinking water, Von Eenz very justly remarks : " Flushings 
 of the system with hot water I do not care for, and I speak 
 from experience." All means of this class, as far as we have 
 to deal with them in general, nowadays, should only be 
 thought of if the patient has not carried out his regimen long- 
 enough or carefully enough, or if the gouty tendency is too 
 strong to be subdued in a simple and natural way (although I 
 think that in such circumstances only strengthening means 
 should be appealed to), or finally, if, in consequence of the 
 gouty process, complications have occurred requiring special 
 aid. Under these circumstances the well-known spas deserve 
 first mention, but in this place, having only to deal with 
 regimen, I shall not go further into their merits. Here, too, 
 I may utter a warning against excess. Von Eenz says 
 severely, but with justice (" Literary Index," No. 45, p. 64) : 
 " There are some kidney and bladder washers that I could 
 name, as regards whose prescriptions I could wish, in the 
 interest of the patient, that the pre- Aristotelian anatomy were 
 right, which maintained that the water which was drunk 
 found its way by distinct channels to the kidneys, there 
 to be filtered through in the shortest possible time." 
 
IN CASES OF GOUT. 61 
 
 THE LITEEATUKE QUOTED. 
 
 (Alphabetically Arranged.) 
 
 Besides referring to my own writings — " Die ISTatur unci 
 Beliandlung der Gicht," Wiesbaden, 1882 ; " Die ISTatur und 
 Beliandlung der Harnsteine," Wiesbaden, 1884; "Die Fettlei- 
 bigkeit (Corpulenz) und ilire Beliandlung," 6 Auflage, Wies- 
 baden, 1884, — I have made use of the following works : — 
 
 1. Anhaut, Elias von Graetz aus der Steyermark "Consilium poda- 
 
 gricum d. i. Wie man sich vor dem Podagra hiiten / oder in 
 Zeit dieser Krankkeit curiren tmd trosten soil / alien Lagen so 
 Podagrisch sein / zu Gutem gestellt." Erffurdt, 1614. (Another 
 edition, Ingolstadt, 1631.) 
 
 2. Baethez, P. J., " Traite des maladies gotitteuses." Paris an X. — 
 
 1802. (2 vols.) 
 
 3. Bizet (de Brest) " Nouvelles opinions snr les pkenomenes, la 
 
 marcke, la cause et le siege de la goutte et nouvelle methode 
 curative pour guerir radicalement cette maladie." Paris, 1842. 
 
 4. Blake a art, Stephajstjs, " Verhandelinge van ker Podagra u. s. w. 
 
 als ook un korte besclrrihvinge van de kraekten des Melks, 
 toonende dat des zelfs vocasel, zoo voor gesonde als ongesonde 
 (voornamelijk in ket Podagra) zur dienstig is." Amsterdam, 
 1864. (In tkis book is a treatise witk tke title : " Besckryvinge 
 van Philipp Jae. Sacks a Luvenkeimb acktende dat de Melkeen 
 troost der Podagristen is.") 
 
 5. Boedekee, C, "Zeitsckr. f. ration. Medicin." Third Series, 
 
 Vol. X., p. 165. 1861. 
 
 6. Bostoce, Johannes (Britannus) ' ' Tentamen medicum inaugurale 
 
 de artkritide." Edinbui'gk, 1768. 
 
 7. JStjschoof, H., sen., "Das genau untersuckte und auserfundene 
 
 Podagra." From tke Dutch. Breslau, 1677. 
 
62 THE KEGIMEN TO BE ADOPTED 
 
 8. Cadet de Vaux, A. A., " Neue HeiLniethode der Gicht und des 
 
 Rheumatismus, durch praktische Erfahrungen bewahrt." Trans- 
 lated by Koehy. Ilmenau, 1826. 
 
 9. Cadogan, William, " Traite de la goutte." Translated from the 
 
 English. Paris, 1873. 
 
 10. Cash, Ph., "Arch. f. Anat. und Physiologie." 1880. Physiol. 
 
 Abtheilung, pp. 323 ■ — 333. Physiologisches Laboratorium, 
 Leipzig. 
 
 11. Corradi, "Delia odierna diminuzione della podagra e delle sue 
 
 caussa." Bologna, 1860. (Estratto dal Vol. delle Mem. dell' 
 Acad, delle Science dell' Istiduto di Bologna.) 
 
 12. Cullen, "William, " Kurzer Inbegriff der medicinischen Nosologie." 
 
 Nach der 3. Ausgabe, Deutsch. Part I., p. 169. Leipzig, 1786. 
 
 13. Dankwart, Che. G., " Es wird gefraget, ob das Podagra zu 
 
 kuriren sei ? " Alten-Stettin, 1683. 
 
 14. Duckworth, " Brit. Med. Journ." 1883. 
 
 15. Dtxringe, "Monographie de la goutte et decouverte du moyen de 
 
 la guerir." Third edition. Paris, 1829. 
 
 16. Ebstein, W., "Die Therapie der Gicht, inch einer Beurtheilung 
 
 der Cantani' schen Therapie." Vereinsblatt d. deutschen arzt- 
 lichen Vereinsbundes. January, 1883. 
 
 17. ■ " Fett oder Kohlenhydrate ? " Wiesbaden, 1885. 
 
 18. Eckart, A., " Die acute Gicht und ihre Behandlung." Miinchen, 
 
 1864. 
 
 19. Eulenburg, H., "Das Medizinalwesen in Preussen." Third 
 
 edition, pp. 165 and 179. Berlin, 1874. (Regulation of August 8th, 
 1835.) 
 
 20. Falconer, W., " Bemerkungen iiber Herrn Cadogmi's Schrift von 
 
 der Gicht." Translated from the second English edition. Berlin,- 
 1773. 
 
 21. Frey, A., und Heiligenthal, F., "Die heissen Luft- und Dampf- 
 
 bader in Baden." Leipzig, 1881. 
 
 22. Garrod, "Lecture on Uric Acid, its Physiology and its Relation to 
 
 Renal Calculus and Gravel." Lecture III. "The Lancet," 
 April, 1883, p. 669. 
 
 23. Greisel, J. G., " De cura lactis in arthritide, in quo etc. diaeta 
 
 lactea optima arthritidem curandi methodus proponitur." Editio 
 secunda auctior et correctior. Budissinae, 1681. 
 
 24. Hasse, "Pfliiger's Archiv," XXXIII. 
 
 25. Halghton, "The Dublin Quart. Journ.," August, 1859, p. 1 
 
 (quoted in Funke's " Physiologie," sixth edition, published 
 by Gruenhagen. Leipzig, 1876). 
 
IN CASES OF GOUT. 63 
 
 26. HJELLiGEifTHAL, F., "Die Anstalt fur mechanisehe Heilgymnastik 
 
 im gross -herzogl. Friedrichsbade in Baden-Baden." 1884. 
 
 27. HErtfsn, Nic. F., Wahrhaff tiger Erwiss / dass die sogenante Milch. 
 
 Cur/ in Scharboek/ Gicht/ Podagra und alien anderen aus dem 
 Sauer berkommenden Krankbeiten iiberaus schadlich sei u. s. w." 
 Aus dem. Hollandischen in's Hoehdeutsche versetzet und mit 
 einer Vorrede verseben iiber Stepban Blancards geriihmten 
 Milcbnutz von J. Schreyer Med. Doct. Leipzig, 1694. 
 
 28. Hoffmaxk", " Opuscul. med. pract. Diss. IX de saluberrimo seri 
 
 lactis virtute pag. 238 und de podagra praeservanda." 
 
 29. Htjtchinsox, J., "Med. Times and Gaz." May 20, 1876. 
 
 30. Kttstee, Ko:ne., "Zur Bebandlung der Gicht mit kaltem "Wasser." 
 
 Berl. klin. Wocbenscbr., 1883, ]S T o. 12, p. 183. 
 
 31. Le Febitee, F., "Traite de la goutte etc." La Rochelle, 1720. 
 
 32. Letdex, E., "Ein Fall von Bleivergiftung." Zeitscbr. f. klin. Med., 
 
 Vol. Vn., p. 85. 1884. 
 
 33. Meyee, Gr. H., "Die riebtige Gestalt der Sebube," p. 14. Zurich, 
 
 1858. 
 
 34. Ofteedingee, G. L., " Das Podagra and seme Heilung." Ulm, 
 
 1813. 
 
 35. Pajtsa, Master, " Consilium antipodagrieum." Leipzig, 1613. 
 "Consilium antipodagrieum secundum speciale." 
 
 Leipzig, 1615. 
 
 36. Pattlmtee, " Grundlieher Unterricht vom Podagra." Translated 
 
 from tbe Frencb. Dresden, 1780. 
 
 37. Pedell, " "Wahre Gicbt und Merenscbrumpfung bei Bleiintoxi- 
 
 cation." Deutsche med. Wocbenscbr., No. 9. 1884. 
 
 38. Pietsche^ t , J. G., "Geschicbte practiscber Falle von Gicbt und 
 
 Podagra." 4 parts. Halle, 1774 — 1776. 
 
 39. Pxjtnak, "Boston Med. and Surgic. Journal," p. 556. Dee. 13, 
 
 1883. 
 
 40. Q,u ares', J., " Animadversiones practicae in diversos morbos." 
 
 Viennae, 1786. (" On Gout," p. 287.) 
 
 41. Rastee, BZ., " Beobachtungen und Versucbe iiber die Ausscbeidung 
 
 der Harnsaure." Miincben, 1858. 
 
 42. Reibmayb, A., " Die Massage und ibre Verwendung in den ver- 
 
 scbiedenen Disciplinen der practiscben Medicin," p. 87. Wien, 
 1884. 
 
 43. Reichel, WiLHELir, " Leber das Wesen der Gicbt, ibre verscbie- 
 
 denen Formen und die Bebandlung derselben." Erlangen 1850. 
 
 44. Rejtott, H., Art. " Goiitte " in "Diet, des Sc. Medic." par 
 
 Decbambre. Paris, 1884. 
 
64 THE EEGIMEN TO BE ADOPTED IN CASES OF GOUT. 
 
 45. Renz t., " Die Heilkrafte der sogen. indifferenten Th.erm.en." 
 
 Bonn, 1879. 
 
 46. " Literaturgeschiehte von Wildbad." Stuttgart, 1881. 
 
 47. Reveille-Paeise, " Guide pratique des goutteux et des rhuma- 
 
 tisans." Second edition. Paris, 1839. 
 
 48. Rothaed, J. E., " Versuch, wie die Gicht auf die beste, griind- 
 
 lichste und sicherste Art zu curiren sey?" Bernburg, 1773. 
 
 49. Roth, Wilh. and Lex, Rudolf, " Handbucb der Militar-Gesund- 
 
 heitspflege." Three vols. Berlin, 1872—77. 
 
 50. Stisseei, J. A., " Solamen arthriticorum." Helniestadi, 1690. 
 
 51. Stole, M., " Heilungsmethode in dem practisehen Krankenhause in 
 
 Wien." Translated into German by Eabri. Part II., Vol. II., 
 p. 63. Breslau, 1784. 
 
 52. Teichmetee, " Ob nicht der zarte Huhlstein-Staub, den man tag- 
 
 lich mit dem Brote und anderen Hehlspeisen geniesset, mit eine 
 Ursaehe vom Stein und Podagra sein konne ? " Jena, 1728. 
 
 53. Temple, Ser Welt ta m, The Works of. London, 1814. (Vol. III. 
 
 of Health and Long Life, p. 411 ; of the Cure of the Gout, 
 p. 271.) 
 
 54. TrjECK, S. A., " Traite de la goutte et des maladies goutteuses." 
 
 Bruxelles, 1838. 
 
 55. Todd, R. B., " Vorlesungen iiber Gicht und Rheumatismus." 
 
 German translation. Leipzig, 1844. 
 
 56. Veedego, J. G., "Contribution a 1' etude de la Goutte saturnine." 
 
 These de Paris, Nr. 269. 1883. 
 
 57. Yeein& vo^ T , Ritter Joseph, "Heilart der Gicht," p. 8. Wien, 
 
 1832. 
 
 58. Viechoav, R., "Berl. klin. Wochenschrift," J\ T o. 1, 1884. 
 
 59. Waenee, Pekden-ajstd, " Vollstandige deutliche Beschreibung von 
 
 der Gicht." Translated from the English. 1770. 
 
 60. Zepefel^, Joxas, " Podagrischer Triumj>h, d. i. kurzer und doch 
 
 grundlicher Bericht/ vom Griess/ Sand/ Stein/ und Podagra/ was 
 sie seyn/ woher sie entspringen/ und mit was solche fundamenta- 
 liter zu curiren?" Printed at Altenburgh, 1659. 
 
INDEX 
 
 Of all Subjects and Authors referred to. 
 
 The names of Authors are in italics. 
 
 Aetius, 54 
 
 Air and vapour baths, 56 
 Air, change of, 57 
 Alcoholic drinks, 32, 51 
 Alkaline carbonates, their disadvan- 
 tages, 31 
 Anhart, E. von, 59 
 Antimony, 59 
 Aretceus of Capjxcdocia, 1 
 Arthritis rachialgica, 40 
 Articular gout, 14, 45 
 
 Baden-Baden, 55 
 Baths, 36, 37, 55, 56 
 Barreswil, 28 
 Bartels, 12, 28, 48 
 Beer, 31, 51 
 Beissel, 56 
 Beneke, 33, 51 
 Bernard, 28 
 Billiards, 35, 53 
 Bleeding, 59 
 Boecker, 24 
 Boedeker, 12 
 Boerhaave, 2, 3, 54, 59 
 Bontekoe, 52 
 Bouchard, 12 
 Bouchardat, 28 
 
 Cadet de Vaux, 60 
 C'axlogan, 2, 53 
 Cantani, 22, 23, 24, 32 
 Carbo-hydrates, 23, 28 
 Cartilages, 8 
 
 Cash, 28 
 
 Celsits, 54 
 
 Charcot, 15 
 
 Cherry cure, 31 
 
 Children, gout in, 3 
 
 Climate, 38 
 
 Clothing, 37, 56, 57 
 
 Cceliits Aureliamis, 2 
 
 Coffee, 34, 52 
 
 Cohnheim, 47 
 
 Coitus, 47 
 
 Cold •water, use of, 36, 55 
 
 Constipation, 58 
 
 Contagiousness of gout, 3 
 
 Contracted kidney, 41 
 
 Corpulence, 27, 28, 30 
 
 Corradi, 18 
 
 Coste, 47 
 
 Country air, 37, 57 
 
 Cullen, 4, 40 
 
 Defecation, 58 
 
 Deichmilller, 48 
 
 Diathesis, uric acid, 18 
 
 Disinfection in cases of gout, 4 
 
 Dogs, gout in, 3 
 
 Douches, 55 
 
 Drink, 33, 51, 60 
 
 Driving, 53 
 
 Duckworth, 7 
 
 Dyspepsia, 23, 27, 28 
 
 Eckart, 54 
 Eggs, 22 
 
66 
 
 INDEX. 
 
 Elder-flowers, 59 
 
 Electro-chemical process as a cause of 
 
 gout, 7 
 Exercises, bodily, 52, 58 
 Exhaustion, condition of, 35, 53 
 Ewald, 28 
 
 Falconer, 2, 51 
 
 Fat, 23, 24, 28, 29 
 
 Feather beds, 58 
 
 Finger-joints, gout in, 15 
 
 Fish, 22 
 
 Flannel, 55, 56, 57 
 
 Flesh-meat, 21, 22 
 
 Foot-coverings, 15, 38 ' 
 
 Foot, joints of, 15 
 
 Forest residence, 38 
 
 Fourcroy, 6 
 
 Frerichs, 28 
 
 Frey, 56 
 
 Freymuth, 42 
 
 Friction, 36, 54 
 
 Friedrichsbad in Baden-Baden, 55 
 
 Fruit, 31 
 
 Functions of bowels, 38, 58 
 
 Garrocl, 7, 11, 12, 13, 14, 24, 41 
 
 Genth, 33, 53 
 
 Gicht, etymology of the word, 40 
 
 Gmelin, 28 
 
 Gold chains as a preservative against 
 gout, 7 
 
 Gout, attack of, 16 
 course of, 17 
 dietary in, 29, 30 
 disposition towards, 17, 18 
 
 Gout, goutte, gutta, 40 
 
 Grant, 58 
 
 Grape cure, 31 
 
 Guaiacum, 59 
 
 Gymnastics, 55 
 
 Hallcr, 51 
 Hamilton, 4 
 Hammond, 53 
 Hartshorn, spirits of, 59 
 
 Hartz region, gout and lead-poisoning' 
 in, 42 
 
 Hasse, G, 52 
 
 Haughton, 21 
 
 Heiligenthal, 56 
 
 Heller, 53 
 
 Hclmont, Van, 47 
 
 Hemiplegia, influence of, on the locali- 
 zation of the gouty foci, 15 
 
 Henle, 7, 15 
 
 Hereditary nature of gout, 2, 3, 4, 18 
 
 Heyne, M., 40 
 
 Hippocrates, 1, 27 
 
 Hoffmann, Frederick, 2 
 
 Hunting, 53 
 
 Hutchinson, 2 
 
 Infectiousness of gout, 3 
 Inflammatory processes in gout, 7, 8 
 Injections, 58 
 Issues, 59 
 
 Jacob, 42, 43, 44, 45 
 Jahns, 25, 33 
 Jones, Hence, 21 
 
 Kidney gout, primary, 13, 41 
 Kidneys of birds, capacity of resistance- 
 to uric acid, 10 
 human, in gout, 8, 11, 13 
 human, interstitial deposits of 
 urates in, 50 
 Koch, R., 24 
 Kiistcr, K., 56, 58 
 
 Lead-poisoning, 4, 40 
 Lccorclii, 12 
 Lc Febure, 6 
 Leguminous plants, 30 
 Lelimann, 12, 21 
 Leube, 18 
 
 Leukemia, 18, 19, 48 
 Lex, 57 
 Ley den, 46 
 Linnceus, 31 
 Lobe of ear, 15 
 Luxury, 1, 4, 17 
 Lymphangioitis in gout, 50 
 
INDEX. 
 
 67 
 
 Magnesia, 58 
 
 Manner of life in gout, 34, 35 
 
 Martins, 59 
 
 Massage, 36, 55, 56 
 
 Materia peecans, 5 
 
 seminalis, 47 
 Mattresses, 58 
 Mayer, Gf., 56 
 Meals, times of, 29 
 Meissncr, 67., 24 
 Mental labour, 35 
 Mering, Von, 12 
 Meyer, 67. #.,15 
 Michel, 13 
 
 Milk and whey cures, 51 
 Mixed diet, 22 
 Moderation, 26 
 Mountain climbing, 35 
 
 homes, 38, 57 
 Muscular symptoms in gout, 47, 48 
 
 movements, influence of, on the 
 local uric acid retention 15 
 Musgrave, 58 
 Mustard, 51 
 
 Necrosis-foci in gouty subjects, 8 
 Nervous affections as cause of gout, 7 
 Neubauer, C, 11 
 
 Ofterdinger, 55, 57 
 
 Paracelsus, 5 
 
 Pedell, 50 
 
 Pfeiffer, E., 37, 56 
 
 Philagrius, 54 
 
 Pietsch, 47 
 
 Plumecke, 42 
 
 Potatoes, 30, 50 
 
 Prussian sanitary regulations against 
 
 gout, 4 
 Purees, 30 
 Purging, 59 
 
 Quackery, 5 
 
 Quarin, J. Von, 3, 59 
 
 Ranke, H., 12, 21, 35 
 
 Reibmayr, 55 
 
 Reichel, 7 
 Relishes, 30 
 Remedies in gout, 1 
 Renz, Von, 60 
 Residence, 38, 57 
 Reveille, 50, 52, 55, 56 
 Rosenstein, S., 3 
 Roth, 57 
 Rubbing with flannel, 54 
 
 Salad, 23 
 
 SoJkoiuski, 18 
 
 Salt, 5, 51 
 
 Sandras, 28 
 
 Scudamore, 6, 12, 24, 55 
 
 Sea, 38 
 
 baths, 56 
 Secret remedies against gout, 5 
 Seneca, 1 
 
 Sexual influence, 47 
 Skittles, 35, 53 
 Sleep, 38, 57, 58 
 Soup, 22 
 
 Specifics in gout, 39 
 Starvation-cures, 30 
 Stisser, 59 
 Stoll, 41 . 
 Strawberry-cure, 31 
 Sulphur, 58, 59 
 Sweat-cures, 59 
 Stvicten, Van, 2, 3, 41, 54 
 Sydenham, 2, 26, 31, 38, 48, 53, 57, 
 59 
 
 Tartarus, 5 
 
 Tea, black, 34, 52 
 
 Teeth of gouty subjects, 30 
 
 Temple, Sir William, 2, 26, 47, 60 
 
 Tennant, 6 
 
 Thermal cure at Aix-la-Chapelle, 56 
 
 Thirst, its diminution under a fatty 
 
 diet, 33 
 Tiedemann, 28 
 Toes, joints of, 15 
 Turck, J. A., 6 
 
 Uniformity of diet, 29, 50 
 
68 
 
 INDEX. 
 
 Urate deposits, crystalline, in gouty 
 
 organs, 8 
 Uric acid a chemical poison, 7 
 acid in the blood, 7, 11 
 
 destruction of, in the bodies of 
 
 gouty patients, 12 
 infiltration of cornea produced by, 
 
 10 
 the materia peccans in gout, 6 
 secretion of, in gout, 11 
 
 „ in healthy people, 12 
 ,, in leukremia, 19, 48 
 ,, with vegetable diet, 
 
 21 
 ,, with flesh diet, 21 
 „ with fat, 24, 25 
 , , with increased drink, 
 
 33 
 ,, with baths, 37 
 ,, with movement, 53 
 increased formation of, 11 
 in cases of gout, 19 
 formation of, in anomalous situa- 
 tions, 14, 20 
 retention of, universal, 1 1 
 ,, ,, localized, 14, 50 
 
 Uric acid, retention of, experimentally 
 produced, 9 
 
 Vegetable acids, 31 
 
 diet in gout, 22, 50 
 Velocipeding, 35 
 Vering, Von, 3 
 Vinegar, 30, 51 
 Vvrchow, 40 
 
 Warner, 53, 57 
 Washing, 55 
 
 Water-drinking, 31, 32, 60 
 Weakening of the gouty tendency, 1 8 
 Weigcrt, C, 46 
 Wiesbaden, 56 
 Wildbad, 56 
 Wine, 34, 51 
 Winter-cherry, 59 
 WoUer, 31 
 Wollaston, 6 
 Women, gout in, 1, 3 
 Woody infusions, 59 
 Woollen clothing, 37, 55, 56, 57 
 
 Zipffell, 5 
 
 Pardon <(■ Sons, Printers, Paternoster Roiv, and Wine Office Court, London, E.C. 
 
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J. &■ A. CHURCHILL'S RECENT WORKS. 
 
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 13 
 
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14 
 
 J. # A. CHURCHILL'S RECENT WORKS. 
 
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 By the sa?ne Author. 
 
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 than 300 Cases of the Affection. By 
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 dent of the Hunterian Society ; Surgeon 
 to the London Hospital. 8vo, 5s. 6d. 
 
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 In Childhood, Youth, Adult Age, and Ad- 
 vanced Life, considered in their Physio- 
 logical, Social, and Moral Relations. By 
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 Edition. 8vo, 12s. 
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 used in the various Departments of Medical 
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 By R. G. Mayne, M.D., LL.D. Fifth 
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 various Subjects and Terms of Medicine, 
 
 &C. By ROBLEY DUNGLISON, M.D., 
 
 LL.D. New Edition. Royal 8vo, 28s. 
 
 Abridged Medical Account 
 
 Books. The "Expedite" Method. By 
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 cil, 5s. 
 
 Medical Education 
 
 And Practice in all parts of the World. 
 By H. J. Hardwicke, M.D., M.R.C.P. 
 8vo, 10s. 
 
INDEX. 
 
 Abercrombie's Medical Jurisprudence, 4 
 Acton's Reproductive Organs, 14 
 Adams (W.) on Clubfoot, n 
 
 on Contraction of the Fingers, 11 
 
 on Curvature of the Spine, n 
 
 Alexander's Displacements of the Uterus, 6 
 Allan on Fever Nursing, 7 
 
 Allbutt's Visceral Neuroses, 9 
 
 Allingham on Diseases of the Rectum, 14 
 
 Anatomical Remembrancer, 3 
 
 Anderson (McC.) on Eczema, 13 
 
 Aveling on the Chamberlens and Midwifery Forceps, 6 
 
 on the Influence of Posture on Women, 6 
 
 Balfour's Diseases of the Heart and Aorta, 8 
 Balkwill's Mechanical Dentistry, 12 
 
 Barnes (E. G.) How to Arrest Infectious Diseases, 5 
 Barnes (R.) on Obstetric Operations, 5 
 
 on Diseases of Women, 5 
 
 Beale's Microscope in Medicine, 8 
 
 Slight Ailments, 8 
 
 Bellamy's Surgical Anatomy, 3 
 
 Bennet (J. H.) on the Mediterranean, 10 
 
 on Pulmonary Consumption, 10 
 
 on Nutrition, 10 
 
 Bentley and Trimen's Medicinal Plants, 7 
 Bentley's Manual of Botany, 7 
 — Structural Botany, 7 
 
 Systematic Botany, 7 
 
 Binz's Elements of Therapeutics, 7 
 Black on the Urinary Organs, 14 
 Braune's Topographical Anatomy, 3 
 Brodhurst's Anchylosis, n 
 
 Curvatures, &c, of the Spine, 11 
 
 Orthopaedic Surgery, 11 
 
 Bryant's Acute Intestinal Strangulation, 9 
 
 Practice of Surgery, n 
 
 Bucknill and Tuke's Psychological Medicine, 5 
 Bulkley's Eczema, 13 
 Burdett's Cottage Hospitals, 5 
 
 Pay Hospitals, 5 
 
 Burnett on the Ear, 12 
 
 Burton's Midwifery for Midwives, 5 
 Butlin's Malignant Disease of the Larynx, 13 
 
 Sarcoma and Carcinoma, 13 
 
 Buzzard's Diseases of the Nervous System, 9 
 Carpenter's Human Physiology, 4 
 
 Carter (H. V.) on Spirillum Fever, 8 
 Cayley's Typhoid Fever, 8 
 Charteris' Practice of Medicine, 8 
 Clark's Outlines of Surgery, 10 
 Clouston's Lectures on Mental Diseases, 5 
 Cobbold on Parasites, 13 
 Coles' Dental Mechanics, 13 
 
 Deformities of the Mouth, 13 
 
 Cooper's Syphilis and Pseudo-Syphilis, 14 
 Coulson on Diseases of the Bladder, 14 
 Courty's Diseases of the Uterus, Ovaries, &c, 6 
 Cripps' Diseases of the Rectum and Anus, 14 
 Cullingworth's Manual of Nursing, 7 
 
 Short Manual for Monthly Nurses, 7 
 
 Curling's Diseases of the Testis, 13 
 Dalby's Diseases and Injuries of the Ear, 12 
 Dalton's Human Physiology, 4 
 Day on Diseases of Children, 7 
 
 on Headaches, 9 
 
 Dobell's Lectures on Winter Cough, 8 
 
 Loss of Weight, &c, 8 
 
 Mont Dor6 Cure, 8 
 
 Domville's Manual for Nurses, 7 
 Druitt's Surgeon's Vade-Mecum, 11 
 Duncan on Diseases of Women, 5 
 
 on Sterility in Woman, 5 
 
 Dunglison's Medical Dictionary, 14 
 Ellis's Manual for Mothers, 6 
 
 of the Diseases of Children, 6 
 
 Emmet's Gynaecology, 6 
 
 Fayrer's Climate and Fevers of India, 7 
 
 ; — Tropical Dysentery and Diarrhoea, 7 
 
 Fenwick's Chronic Atrophy of the Stomach, 8 
 
 Medical Diagnosis, 8 
 
 Outlines of Medical Treatment, 8 
 
 Fergusson's Practical Surgery, 10 
 Flint on Clinical Medicine, 8 
 
 on Phthisis, 8 
 
 Flower's Diagrams of the Nerves, 4 
 
 Foster's Clinical Medicine, 8 
 
 Fox's (C. B.) Examinations of Water, Air, and Food, 4 
 
 Fox's (T.) Atlas of Skin Diseases, 13 
 
 Frey's Histology and Histo-Chemistry, 4 
 
 Galabin's Diseases of Women, 6 
 
 Gamgee's Treatment of Wounds and Fractures, n 
 
 Glenn's Laws affecting Medical Men, 4 
 
 Godlee's Atlas of Human Anatomy, 3 
 
 Goodhart's Diseases of Children, 6 
 
 Gorgas' Dental Medicine, 13 
 
 Gowers' Diseases of the Spinal Cord, 9 
 
 Epilepsy, 9 
 
 Medical Ophthalmoscopy, 9 
 
 Pseudo-Hypertrophic Muscular Paralysis, 9 
 
 Granville on Nerve Vibration and Excitation, 9 
 
 Guy's Hospital Reports, 2 
 
 Habershon's Diseases of the Abdomen, 9 
 
 Stomach, 9 
 
 Pneumogastric Nerve, 9 
 
 Hamilton's Nervous Diseases, 9 
 Hardwicke's Medical Education, 14 
 Harley on Diseases of the Liver, 9 
 Harris's Dentistry, 13 
 
 Harrison's Lithotomy, Lithotrity, &c, 13 
 
 Surgical Disorders of the Urinary Organs, 13 
 
 Hartridge's Refraction of the Eye, 12 
 Heath's Injuries and Diseases of the Jaws, 10 
 
 Minor Surgery and Bandaging, 10 
 
 Operative Surgery, 10 
 
 Practical Anatomy, 3 
 
 Surgical Diagnosis, 10 
 
 Higgens' Ophthalmic Out-patient Practice, 11 
 Hillis' Leprosy in British Guiana, 13 
 Holden's Dissections, 3 
 
 Human Osteology, 3 
 
 Landmarks, 3 
 
 Holmes' (G.) Guide to Use of Laryngoscope, 12 
 
 Vocal Physiology and Hygiene, 12 
 
 Hood on Gout, Rheumatism, &c, 9 
 Hooper's Physician's Vade-Mecum, 8 
 Horton's Tropical Diseases, 8 
 Hutchinson's Clinical Surgery, n 
 —— — Pedigree of Disease, n 
 
 Rare Diseases of the Skin, 13 
 
 Hyde's Diseases of the Skin, 13 
 
 Tames (P.) on Sore Throat, 12 
 Jones' (C. H.) Functional Nervous Disorders, 9 
 Jones (C. H.) and Sieveking's Pathological Anatomy, 4 
 Jones' (H. McN.) Aural Surgery, 12 
 
 Atlas of Diseases of Membrana Tympani, 12 
 
 Spinal Curvatures, n 
 
 Jones' (T. W.) Ophthalmic Medicine and Surgery, 12 
 Jordan's Surgical Enquiries, 10 
 Journal of British Dental Association, 2 
 
 Mental Science, 2 
 
 Lancereaux's Atlas of Pathological Anatomy, 4 
 
 Lee (H.) on Syphilis, 14 
 
 Lewis (Sevan) on the Human Brain, 4 
 
 Liveing's Megrim, Sick Headache, &c, 9 
 
 London Hospital Reports, 2 
 
 Macdonald's (A.) Chronic Disease of the Heart, 6 
 
 Macdonald's (J. D.) Examination of Water and Air, 4 
 
 Alackenzie on Diphtheria, 12 
 
 on Diseases of the Throat and Nose, 12 
 
 McLeod's Operative Surgery, 10 
 Maclise's Dislocations and Fractures, 10 
 
 Surgical Anatomy, 3 
 
 MacMunn's Spectroscope in Medicine, 8 
 Macnab's Medical Account Books, 14 
 Macnamara's Diseases of the Eye, 12 
 Madden's Principal Health-Resorts, 10 
 Mann's Manual of Psychological Medicine, 5 
 Marcet's Southern and Swiss Health-Resorts, 10 
 Marsden's Certain Forms of Cancer, 13 
 Mason on Hare-Lip and Cleft Palate, 12 
 on Surgery of the Face, 12 
 
 Mayne's Medical Vocabulary, 14 
 
 Notes on Poisons, 7 
 
 Therapeutical Remembrancer, 7 
 
 Middlesex Hospital Reports, 2 
 
 Mitchell's Diseases of the Nervons System, 9 
 
 Moore's Family Medicine for India, 7 
 
 Health-Resorts for Tropical Invalids, 7 
 
 Morris' (H.) Anatomy of the Joints, 3 
 
 Mouat and Snell on Hospitals, 5 
 
 Nettleship's Diseases of the Eye, 12 
 
 Nunn's Cancer of the Breast, 13 
 
 Ogston's Medical Jurisprudence, 4 
 
 Ophthalmic (Royal London) Hospital Reports, 2 
 
 Ophthalmological Society's Transactions, 2 
 
 Oppert's Hospitals, Infirmaries, Dispensaries, &c, 5 
 
 Osborn on Diseases of the Testis, 14 
 
 on Hydrocele, 14 
 
 Owen's Materia Medica, 7 
 
 [Continued on the next page. 
 
inutA — cant- 1 
 
 Page's Injuries of the Spine, n 
 Parkes' Practical Hygiene, 5 
 Pavy on Diabetes, 9 
 
 on Food and Dietetics, 9 
 
 Pharmaceutical Journal, 2 
 Pharmacopoeia of the London Hospital, 7 
 Phillips' Materia Medica and Therapeutics, 7 
 Pollock on Rheumatism, 9 
 
 Porritt's Intra-Thoracic Effusion, 8 
 
 Purcell on Cancer, 13 
 
 Pye-Smith's Syllabus of Physiology, 4 
 
 Quinby's Notes on Dental Practice, 13 
 
 Ramsbotham's Obstetrics,' 6 
 
 Raye's Ambulance Handbook, 10 
 
 Reynolds' (J. J.) Diseases of Women, 6 
 
 Notes on Midwifery, 6 
 
 Rivington's Rupture of the Urinary Bladder, 14 
 Roberts' (C.) Manual of Anthropometry, 5 
 
 Detection of Colour-Blindness, 5 
 
 Roberts' (D. Lloyd) Practice of Midwifery, 5 
 
 Robinson's Endemic Goitre or Thyreocele, 12 
 
 Ross's Diseases of the Nervous System, 9 
 
 Roth on Dress : Its Sanitary Aspect, 4 
 
 Routh's Infant Feeding, 7 
 
 Royal College of Surgeons Museum Catalogues, 2 
 
 Royle and Harley's Materia Medica, 7 
 
 St. Bartholomew's Hospital Reports, 2 
 
 St. George's Hospital Reports, 2 
 
 St. Thomas's Hospital Reports, 2 
 
 Sanderson's Physiological Handbook, 4 
 
 Sansom's Diseases of the Heart, 9 
 
 Savage on the Female Pelvic Organs, 6 
 
 Sayre's Orthopaedic Surgery, n 
 
 Schroeder's Manual of Midwifery, 6 
 
 SewiU's Dental Anatomy, 12 
 
 Sibson's Medical Anatomy, 3 
 
 Sieveking's Life Assurance, 14 
 
 Smith's (E.) Clinical Studies, 6 
 
 — — Disease in Children, 6 
 
 Wasting Diseases of Infants and Children, 6 
 
 Smith's (Henry) Surgery of the Rectum, 13 
 
 Smith's (Heywood) Dysmenorrhcea, 6 
 
 Smith (Priestley) on Glaucoma, 12 
 
 Snell's Electro-Magnet in Ophthalmic Surgery, 11 
 
 Snow's Clinical Notes on Cancer, 13 
 
 Southam's Regional Surgery, n 
 
 Sparks on the Riviera, 10 
 
 Squire's Companion to the Pharmacopoeia, 7 
 
 Pharmacopoeias of London Hospitals, 7 
 
 Starkweather on the Law of Sex, 4 
 
 Steavenson's Electricity, 10 
 
 Stille and Maisch's National Dispensatory, 7 
 
 Stimson on Fractures, 11 
 
 Stocken's Dental Materia Medica and Therapeutics, 13 
 
 Swain's Surgical Emergencies, 10 
 Swayne's Obstetric Aphorisms, 6 
 Taylor's Medical Jurisprudence, 4 
 
 Poisons in relation to Medical Jurisprudence, 
 
 Teale's Dangers to Health, 5 
 Thompson's (Sir H.) Calculous Disease, 14 
 
 Diseases of the Prostate. 14 
 
 Diseases of the Urinary Organs, 14 
 
 Lithotomy and Lithotrity, 14 
 
 Stricture of the Urethra, 14 
 
 Surgery of the Urinary Organs, 14 
 
 : Tumours of the Bladder, 14 
 
 Thorowgood on Asthma, 8 
 
 on Materia Medica and Therapeutics, 7 
 
 Thudichum's Pathology of the Urine, 14 
 Tibbits' Medical and Surgical Electricity, 10 
 
 Map of Motor Points, 10 
 
 Tidy and Woodman's Forensic Medicine, 4 
 Tilt's Change of Life, 6 
 
 Uterine Therapeutics, 6 
 
 Tomes' (C. S.) Dental Anatomy, 12 
 Tomes' (J. and C. S.) Dental Surgery, 12 
 Tosswill's Diseases and Injuries of the Eye, n 
 Tuke's Influence of the Mind upon the Body, 5 
 
 Sleep- Walking and Hypnotism, 5 
 
 Van Buren on the Genito-Urinary Organs, 14 
 Vintras on the Mineral Waters, &c, of France, 10 
 Virchow's Post-mortem Examinations, 4 
 Wagstaffe's Human Osteology, 3 
 
 Waring's Indian Bazaar Medicines, 7 
 
 Warner's Guide to Medical Case-Taking, 8 
 
 Warren's Hernia and Rupture, n 
 
 Waters' (A. T. H.) Diseases of the Chest, 8 
 
 Waters (J. H.) on Fits, 9 
 
 Wells (Spencer) Abdominal Tumours, 6 
 
 on Ovarian and Uterine Tumours, 6 
 
 West and Duncan's Diseases of Women, 6 
 West (S.) How to Examine the Chest, 8 
 Whistler's Syphilis of the Larynx, 12 
 Whittaker's Primer on the Urine, 14 
 Wilks' Diseases of the Nervous System, 9 
 Wilks and Moxon's Pathological Anatomy, 4 
 Wilson's (Sir E.) Anatomists' Vade-Mecum, 3 
 
 Lectures on Dermatology, 13 
 
 Wilson's (G.) Handbook of Hygiene, 5 
 
 Healthy Life and Dwellings, 5 
 
 Wilson's (W. S.) Ocean as a Health-Resort, 10 
 Wolfe's Diseases and Injuries of the Eye, 11 
 Year Book of Pharmacy, 2 
 
 Yeo's (G. F.) Manual of Physiology, 4 
 Yeo's (J. B.) Contagiousness of Pulmonary Consump- 
 tion, 8 
 Zander Institute Mechanical Exercises, 10 
 
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