132 GOUT 



Besides the extremities, in this form of gout the most distant parts of the 

 body, i. e., those situated at the actual periphery, are implicated, as, for in- 

 stance, the concha auris. For the explanation of these phenomena in primary 

 extremity (arthritic) gout, an insufficiency of the kidneys which causes gen- 

 eral uric acid stasis is by no means necessary. Following Garrod's reasoning, 

 this is still frequently assumed, although the reasons mentioned by him have 

 been shown to be incorrect. "We shall revert to this later. Besides this pri- 

 mary extremity (arthritic) gout there is also a primary renal gout. Here, 

 in consequence of a primary severe renal affection, most likely based upon a 

 gouty predisposition, there is an incapacity on the part of the kidneys to ex- 

 crete the waste of metabolism, i. e., the uric acid. Consequently a generalized 

 uric acid stasis develops which affects all the parts of the body. The patients 

 frequently die before a typical attack of gout occurs. They succumb, there- 

 fore, to the renal affection, usually while still young, whereas in primary 

 extremity (arthritic) gout they will live to old age. In primary arthritic gout 

 the kidneys suffer as well as all the other organs; but there are numerous cases 

 of primary arthritic gout in which the patients die from intercurrent diseases, 

 and in which the kidneys show absolutely nothing abnormal. Primary arthritic 

 gout is fortunately by far the most frequent form of the disease, and the 

 one we shall first consider. Formerly it was thought absolutely necessary to 

 differentiate various forms of gout. I do not think it expedient to dilate upon 

 this point, and will only mention that to-day designations are not infrequently 

 used for some of these varieties, between which no important differences exist: 

 thus we hear of latent gout, larval gout, pseudo-localized gout, retrocedent 

 gout, etc. Yet I have not been satisfied with Garrod's differentiation of a 

 regular and an irregular form; even in professional practice it does not sim- 

 plify the condition. 



SYMPTOMATOLOGY 



We will now discuss the symptomatology of primary arthritic gout, and in 

 order to make the condition clear I shall include the necessary pathologico- 

 anatomical data. I shall retain the designation primary arthritic gout, as in 

 the great majority of cases the joint symptoms are still the most prominent, 

 and as I do not, desire, by another designation, further to complicate a subject 

 which is already rich in superfluous names. To avoid prolixity, in enumerating 

 the possible limitations in the pathogenesis of gout, among the noxa which 

 produce it I shall refer exclusively to uric acid as the materia peccans. This 

 materia peccans which produces the disturbances, the totality of which, there- 

 fore, forms the gouty symptom-complex, is in part a purely functional dis- 

 turbance, for which up to the present no constant pathologico-anatomical 

 material lesion is known ; in part, however, a disturbance for which the mate- 

 rial substratum has been discovered. The latter depends in some degree 

 upon inflammatory, also upon degenerative, changes in the organs and tissues. 

 Suppurative processes are not produced by uric acid; it is not a septic, but 

 chiefly a chemical, poison. The degenerative changes in gout from the influ- 

 ence of uric acid show nothing characteristic of gout until necrosis of the 



