GOUT. 



549 



less nights, he usually feels better than before the attack ; hence the 

 gouty attack has often been considered as critical, and it has been as- 

 serted that during or through it a materies peccans has been removed 

 from the body. There is no reason for assuming this hypothesis in 

 explanation of the improved condition. The attack of gout places the 

 patient under circumstances directly opposite to those which have in- 

 duced his illness. The transmutation of the constituents of the body 

 is greatly increased by the fever, while there is a very insufficient sup- 

 ply of replacing material ; the sleeplessness and pain also increase the 

 consumption, or hinder the change of tissue ; the disproportion between 

 supply and demand, which we have indicated as the most important 

 etiological factor in gout, and which also lies at the root of its compli- 

 cations, such as corpulence, piles, etc., is thus more than equalized by 

 ishe gouty attack and the accompanying fever ; and this is the simple 

 explanation of the improved condition of the patient after the fit. If 

 pain and suffering that have left no mark were not so soon forgotten, the 

 first attack of gout would often be the last. But, after following their 

 good resolutions and the advice of the physician for a few months, gouty 

 patients generally return to their previous habits ; the first attack is 

 followed by a second, this by a third, and so on by a series of parox- 

 ysms whose course corresponds with that of the first. At first, the 

 interval between the attacks lasts a year or more ; later, several at- 

 tacks occur in one year. As the intervals become shorter, the attacks 

 usually deviate more and more from the first type ; the free intervals 

 are then generally less perfect ; the gout, instead of being regular, be- 

 comes irregular, chronic instead of acute, atonic instead of tonic. 



We give the name of chronic gout to those irregular forms where 

 the attack is preceded for some time by premonitory symptoms, espe- 

 cially dyspepsia, where the seizures are accompanied by less pain and 

 fever, but last for weeks or months, and several joints are affected at 

 the same time, or in succession ; and the previously-described chalky 

 deposits of the urates in and about the joints occur chiefly in chronic 

 gout. The swelling and redness, which in acute attacks attain their 

 height the second day, develop more slowly in chronic gout ; the red- 

 ness is generally less intense, the swelling more diffuse and oedematous. 

 After the termination of the paroxysm, the swelling does not disap- 

 pear with desquamation of the cuticle, as it does in acute gout, but it 

 continues, feels soft and doughy at first, and later it contains firm bodies 

 of variable size, and at last a hard tophus is left. This is small in pro- 

 portion to the tumor whose remains it represents, but after repeated 

 attacks it grows by new deposits, and may attain a considerable size. 

 The deposits within the joints, the calcareous masses as well as the 

 inflammatory changes in the capsule and ligaments of the joint, induced 



