54 CLINICAL APPLIED ANATOMY. 



are frequently diseased. It may be that all these factors conspire 

 in determining the localisation of gout in the joint in question. 

 The first manifestation of gout may, however, occur in some 

 other joint than that of the great toe ; the knee, the ankle, and 

 the metacarpo-phalangeal joint of the thumb are sometimes first 

 attacked. These joints are exposed to slight injuries which may 

 appear to determine the incidence of the inflammation. 



After the great toe joints, the articulations most commonly 

 affected are the joints of the instep, the ankles, the knees, the 

 joints of the fingers, and the wrists. Less commonly the elbows, 

 shoulders and hips may suffer. When the joints are superficial, 

 and thinly covered, as for instance is the case with the great toe 

 joints, the ankles, wrists, and joints of the thumb and fingers, 

 the accompanying infiltration and dusky erythema may simulate 

 an ordinary cellulitis. 



The tendency of fasciae, ligaments, and tendons to become the 

 seats of uratic deposit may be explained by the poor blood supply 

 afforded to these structures. The tophi are very likely to ulcerate 

 through the skin if they are exposed to slight injury or constant 

 irritation. This tendency may be noticed in connection with 

 gouty deposits in the olecranon bursa, whilst tophi around the 

 great toe joint may, by ulceration, actually lay open the joint 

 cavity. Uratic deposit in important bursae and in the tendons 

 and ligaments of a joint may cripple a limb as effectually as 

 actual articular gout would. 



The deformities produced in the hands by affection of the finger 

 joints are characteristically irregular, the fingers appearing knotted 

 and bent like the gnarled roots of an old tree. The great toe 

 joint becomes deformed and often ankylosed ; the knee and elbow 

 may become fixed in a flexed position and some degree of rigid 

 talipes may be also induced. 





 KlCKETS. 



Although bone changes are not the sole lesions in rickets, 

 they form the most striking feature of the disease, and it is with 



