THE PATHOGENESIS OF GOUT 129 



phalangeal joint. This ran its course within three days, was mild, and accompanied 

 with only slight redness and swelling of the affected joint and no disturbance of his 

 general health. After the patient began the practice of medicine he had no attack of 

 gout for years. He lost his excessive weight, and when I met him in consultation a 

 number of years ago I was astonished to find him rather thin. He followed minutely 

 my dietetic regulations, and under this treatment only " premonitions " of his old 

 trouble occurred. His constantly increasing, very extensive and exhausting practice 

 now made it impossible for him to live in accordance with the rules previously followed. 

 The attacks of gout recurred, and in the winter of 1899-1900 he suffered almost every 

 two months from severe typical attacks, with violent onset, and constantly accompanied 

 with fever. But while these formerly lasted for a few weeks, they now disappeared in 

 a few days. These paroxysms were always associated with large effusions into the 

 joints, and the seat of the attacks was in the toe and the talocrural joint upon both sides. 

 The attacks were cured by the use of wine of colehicum seed, potassium iodid and sodium 

 bicarbonate. Pain in the right shoulder joint, however, which had troubled him off and 

 on for some time, now became chronic. The influence of trauma in the occurrence of 

 typical gout was shown when, upon April 30, 1900, the patient fell from his bicycle, 

 causing a contusion of the right talocrural and of the left knee joint. As early as the 

 next day, in both of the previously mentioned joints, a typical attack of gout developed 

 which affected the patient greatly. He never had venereal disease; he smokes much — 

 according to reports 8 mild cigars daily — and consumes a bottle of light wine daily, 

 but no beer. The patient considers the wine necessary, as, without it, he has inter- 

 mittent heart action. Appetite and digestion are good. His maximum weight was in 

 1883, when he weighed 209 pounds; now he weighs 176 pounds. During the attacks 

 the urine is said to be scant and dark in color, but returns to the normal after the 

 paroxysm has passed off. Albumin and sugar have never been present. The patient, 

 when I examined him, had a pulse of 64, cardiac dulness was not increased, the second 

 aortic sound was loud but not quite clear. Organic changes were not evident. The 

 patient was very much enfeebled, and as he desired to undergo a bath and mineral 

 spring treatment, I advised him to go first to the Allgan Alps at Obersdorf. On the 

 2d of August, 1900, the patient wrote me from the " Nebelhornhaus " (2,251 meters 

 high), stating that he felt very well there and that without much trouble he could 

 climb quite high mountains. Besides the observance of a strict dietetic regime, absti- 

 nence from alcohol and a decided limitation of smoking were required. 



The case just cited is in many respects interesting, and I shall take oppor- 

 tunity to revert to it later. At this time, only the factors which bear upon 

 the pathogenesis of gout are to be considered. We note that the family predis- 

 position of the patient was only in the ancestral line of the mother, the latter 

 herself remaining free from the affection. The maternal grandfather and two 

 of the maternal uncles, on the other hand, had gout. As the clinical history 

 shows, the patient was inclined to date the beginning of his disease from his 

 youth. It is evident that gout may come on early in life. A very skilful 

 physician who had suffered from gout, but who died of a severe diabetes mel- 

 litus complicated by nephritis, told me that even in his ninth year he had 

 seizures of so-called rheumatism in the ball of the great toe of his left foot. 

 In children, attacks of gout frequently follow trauma, and it has been main- 

 tained that gout is the consequence of trauma. As a matter of fact, I have 

 seen gout in adolescents, but always in boys, an observation which is confirmed 

 by medical literature. The cramps in the calves with which my patient was 

 affected between his sixteenth and eighteenth years may, in consideration of 

 the course which the disease took, be regarded as premonitory gouty symptoms. 

 From this, however, and also from numerous other experiences at hand, it 

 10 



