GOUT. 



547 



tddneys, the affected persons get along tolerably well, or have no 

 trouble at all. But the case is different when the uriniferous tubules 

 are plugged up by deposits of the urates, and the excretion of urine is 

 impeded ; for then, just as in the animals above mentioned, there is a 

 collection of urates in the blood, and they are deposited in the joints 

 and other organs, and we have an attack of gout. If the deposit of 

 urates in the uriniferous tubules be soon washed away, and the red 

 sandy sediment form in the urine, which we sometimes find even on 

 the diapers of young children, the attack of gout passes over ; if this 

 do not take place, and the kidneys atrophy, the acute attack becomes 

 chronic gout. This hypothesis is strongly supported by the fact that 

 Garrod and other trustworthy observers have always found the kid- 

 neys diseased, they being irregularly* atrophied and the seat of uric- 

 acid infarctions, I am far from considering this theory, to which 

 Traube also is inclined, as proved ; but I think that it agrees with the 

 physiological and pathological facts better than any other theory. If it 

 should finally be proved that the blood of gouty patients always con- 

 tains more uric acid than normal, while the urine constantly contains 

 less than usual during the attack, our theory would receive a still fur- 

 ther support. 



ANATOMICAL APPEAKANCES. On autopsy of gouty patients, which 

 is of rare occurrence in hospital, in the affected joints we find the re- 

 mains of a more or less intense inflammation, and genuine gout is 

 characterized by incrustation of the surfaces of the joint by chalk-like 

 masses, consisting of urates. In mild grades of the disease, only a few 

 joints are changed in this way. Frequently only the first joint of the 

 great toe is in this state. In severe and old cases, we usually find 

 numerous joints diseased ; then* articular surfaces are covered with thick 

 layers of urates, the cartilages are rough, the ligaments, periosteum, 

 and the mucous bursae near the diseased joints, are covered with thick 

 deposits of these salts. In such cases the joints are often much de- 

 formed, and through the dark, bluish-red skin we may often see white 

 chalky masses. We may also find these deposits at other points, 

 especially in the knuckles, eyelids, and cartilages of the ears. In the 

 auricle, where they are only covered by thin skin, they form white 

 pearls surrounded by varicose vessels (a certain sign of arthritis). I 

 know nothing from personal observation of the above-mentioned 

 changes in the kidney. According to Grarrod, who has very carefully 

 described and pictured them, gouty kidneys very much resemble those 

 in the third stage of Blight's disease, except that, in the pyramids, 

 there are always white striae, consisting of urates running in the direc- 

 tion of the tubuli recti, and on the apex of each papilla a white point 

 of the same substance. 



