GOUT. 



551 



ordinary attacks of the disease, this not unfrequent condition is readily 

 recognized, and intercurrent acute attacks place the diagnosis of atonic 

 gout beyond doubt. 



The correct appreciation of the symptoms, and the diagnosis of the 

 disease from chronic wandering rheumatism, is far more difficult, if 

 there have been no precedent or intercurrent attacks of gout. It 

 seems to me there is no doubt that this atonic form of the disease is 

 also occasionally primary, and even when there have been no attacks 

 of gout I think it must be diagnosed, where there is an hereditary pre- 

 disposition, and where the disease has been preceded by luxurious liv- 

 ing, and where it is chiefly the smaller joints of the foot and hand that 

 become painful, red, and swollen. I have seen such cases where the 

 diagnosis was strongly supported by the experience of the patient. 

 The patients themselves have not only remarked that they could ex- 

 pose themselves to catching cold with impunity, while the return to 

 careless diet, and the use of beer and wine, always made them worse ; 

 but they have also observed that antirheumatic treatment did not im- 

 prove their case, while there was actual and permanent improvement 

 both of the local symptoms and general cachexia, by a course of treat- 

 ment hastening the transformation of tissue. 



I have no doubt that in gouty patients there is sometimes a de- 

 posit of urates, accompanied by hyperaemia and inflammation, in other 

 organs instead of in the joints ; or, in other words, that an anomalous 

 internal gout, the arthritis metastatica retrograda of the old authors, 

 actually occurs. For the support of this view, I lay less weight on 

 the observations of Zalesky, who, after ligating the ureters of chickens 

 and geese, found deposits of urates not only in the joints, but in al- 

 most all the organs, among others in the stomach, heart, and lungs, 

 than on a series of clinical observations, which admit of no other 

 interpretation. For instance, some time ago, in an old gentleman, 

 who had suffered for years from gout, I saw an angina begin simul- 

 taneously with a typical attack of gouty inflammation of the joints ; it 

 was characterized by a peculiar blue color of the fauces, by a very dif- 

 ferent course from ordinary forms of angina, and lasted as long as the 

 inflammation of the joints did. I have not the slightest doubt that 

 this was a case of gouty angina. In two other patients, who also suf- 

 fered from gout, I have seen cerebral troubles, which I must regard as 

 circumscribed gouty inflammation of the meninges. All other diseases 

 of the brain or membranes could be excluded with certainty, especially 

 when the symptoms, which appeared very dangerous, and had excited 

 great anxiety, disappeared in the one case with a copious excretion of 

 urates in the urine ; in the other, with an attack of gouty inflammation 

 of the joints. It is true, autopsy has not proved the occurrence of in- 

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