And the greater the disposition, the less need be the exhaustion that will suffice: while in those in whom there is only the least, if any, disposition to insanity, nothing less than the utterest exhaustion from excess may suffice to produce it, if even this may. The drunkards and sensualists who live and die sane are too many to let us speak of hard drink, or masturbation, or sexual excesses as causes of insanity, unless under many reserves and conditions.

And what is true in respect of insanity is true in respect of other assigned consequences of sexual disorders. These disorders are effectual exciting causes of only such diseases as the patients are prone to; and the proneness or predisposition is much nearer to the essence of the disease than is the exciting cause.

GOUTY PHLEBITIS.

I HAVE met with certain cases of phlebitis, the like of which I cannot find on record. I propose, therefore, to give some account of them. They are all examples of the so-called adhesive phlebitis; the disease in which inflammation of the coats of a vein is associated with clotting of blood in its canal, but not with suppuration or pyæmia. Of many of them, indeed, I cannot tell, any more than of certain other forms of phlebitis, whether the inflammation or the clotting were the first event, nor, therefore, whether they are to be referred more properly to phlebitis or to thrombosis. But I give the former name to them all because it is in most common use amongst us; and is probably correct for at least one part or stage of every case.

Many of the varieties of adhesive phlebitis have been so well described, that I need only refer to them for the sake of comparison.1 Such are

1 Such descriptions may be found in, or by means of, Callender, Art. 'Pyæmia;' Holmes's Syst. of Surgery, vol. i., and Diseases of Veins,' in the same, vol. iii.; S. Weber, Handbuch der Chirurgie, von v. Pitha u. Billroth, B. iii. Abth.; Humphry, 'On the Coagulation of the Blood in the Venous System during Life, 1859;' Mackenzie, Pathol. and Treatment of Phlegmasia Dolens, 1862; Henry Lee, Diseases of the Veins, 1866; Virchow, Cellular Pathology; by Chance, lect. x. 1860; Rokitansky, Pathologische Anatomie, B. iii.

1. The traumatic; including those due to distension. 2. Those occurring in exhaustion during, or after, either acute or chronic disease.

3. Those due to extension of inflammation or of blood-clotting from ulcers, morbid growths, or gangrenous or acutely inflamed parts.

4. Those of the so-called idiopathic, or rheumatic
form which Dr. Mackenzie very fully described;

but
among which I am convinced that a closer
study would lead to the distinction of different
forms associated with as many differences of con-
stitutional affections.

5. The pyæmial.

6. The puerperal; among which it is probable that examples of all kinds, only modified by the puerperal state, are grouped.

Any of these forms of phlebitis may be modified by occurring in veins already varicose; but, passing by these, I proceed to the more proper subject of the paper.

Gouty Phlebitis.-The use of this name is, I believe, justified by the number of cases in which phlebitis is associated with ordinary gouty inflammation in the foot or joints, and occurs, with little or no evident provocation, in persons of marked gouty constitution or with gouty inheritance. In such cases the phlebitis may have no intrinsic characters by which to distinguish it; yet, not rarely, it has peculiar marks, especially in its symmetry, apparent metastases, and frequent recurrences. Gouty phlebitis is far more frequent in the lower limbs than in other part; but it is not limited to the limb that is,

any

or has been, the seat of ordinary gout. It affects the superficial rather than the deep veins, and often occurs in patches, affecting (for example) on one day a short piece of a saphenous vein, and on the next day another separate piece of the same, or a corresponding piece of the opposite vein, or of a femoral vein. It shows herein an evident disposition towards being metastatic and symmetrical; characters which, I may remark, by the way, are strongly in favour of the belief that the essential and primary disease is not a coagulation of blood, but an inflammation of portions of the venous walls. The inflamed portions of vein usually feel hard or very firm; they are painful, aching, and very tender to the touch; such pain, indeed, often precedes the clearer signs of the phlebitis, and not rarely begins suddenly. The integuments over the affected veins (where they are superficial) are slightly thickened, and often marked with a dusky reddish flush. When superficial veins alone are affected there may be little ædema; but when venous trunks, as the femoral, the whole limb assumes the characteristics of complete venous obstruction. It becomes big, clumsy, featureless, heavy, and stiff; its skin is cool and may be pale, but more often it has a partial slight livid tint, which may be discerned by comparison with the other limb, and has mottlings from small cutaneous veins visibly distended. The limb thus enlarged feels oedematous all through; but firm, and tightskinned, not yielding easily to pressure, and not pitting very deeply. By this state almost alone the disease must sometimes be recognised, for it may be very marked when only a small portion of vein is affected, and that (as

the lower part of the popliteal) so deeply seated as to be scarcely felt.

The constitutional disturbance associated with this condition is at most that of slight feverishness, or of an ordinary gouty attack, more or less acute in different cases. The effects of the disease I have never had an opportunity of examining by dissection; for in the only fatal case that I have seen, no autopsy was allowed. So far as one may judge of them, by after-events during life, the veins which may have been obstructed become, in some cases, pervious again; for in some instances the clearing-up of the oedema, and the restoration of the healthy condition of the limb, are complete. Yet the veins remain apparently very susceptible :-they ache exceedingly during fatigue or trivial illness or in changing weather; and I have known phlebitis excited by trivial causes in the same veins three or four times. In other instances, however (but I think they are rarer than in other forms of phlebitis), the obstruction of the veins appears complete, and permanent; and then, if they be trunk-veins, the limb remains permanently enlarged, cumbrous and heavy. Its superficial veins may, after some time, become varicose; and others may enlarge for collateral blood-streams; and I believe that an increased growth may take place in some of the tissues, especially the muscles of the limb.

Equally with the other forms of phlebitis, but as rarely as in any, that which occurs in gout may be fatal or very dangerous by embolism. I think that incomplete pulmonary embolism occurred in two cases in whichduring gouty or rheumatic phlebitis - embarrassed