SYMPTOMATOLOGY 133 



afEected tissue occurs. If tissue necrosis has taken place, then acid sodium 

 urate is deposited in the form of crystalline needles. That necrosis of the 

 tissue is the primary condition is shown from the fact that the necrosed area 

 is larger than the urate deposits. Around the necrotic areas, more or less 

 round cell infiltration is often found. I have proven that such gout foci, i. e., 

 necroses with crystalline urates (completely analogous processes), may be 

 experimentally produced in birds. In these experiments urate deposits also 

 occur to a greater or less extent in normal tissue, i. e., in tissue which has 

 not become necrotic. Of course, this has absolutely no connection with gout, 

 but merely explains the post mortem finding that, with cessation of life, the 

 tissues are saturated with urates, and these are excreted in a crystalline form. 



The symptoms of primary gout are as follows: In primary arthritic gout 

 the first phenomena are the manifestations of the gouty predisposition. They 

 may be designated as the premonitory or initial symptoms and they precede 

 the first attack. It is possible that where the predisposition is not very great, 

 and especially where an exciting cause is lacking, these so-called premonitory 

 symptoms of gout may remain the only ones, so that a true gouty paroxysm 

 does not develop at all. Generally, however, this is not the case. Under any 

 circumstances, however, these premonitory symptoms may make it difficult 

 properly to interpret the underlying condition. Not infrequently these pro- 

 dromal symptoms, previously quite unintelligible to the physician, are at once 

 explained 'by the sudden appearance of an attack of gout. Similar to these 

 premonitory symptoms are the pathologic phenomena which have been desig- 

 nated by me as intermediate symptoms. They occur in the intervals between 

 the attacks of gout, show remarkable similarity to the premonitory symptoms, 

 but are much more difficult to explain, as the preceding gouty paroxysms have 

 closed the path to their proper recognition. We shall later consider more 

 minutely these premonitory and intermediate symptoms. It appears expedient 

 first to direct attention to the typical condition in primary arthritic gout, 

 namely, to the acute paroxysm of gout, the typical attack. 



The clinical history of the physician suifering from primary arthritic gout 

 (Observation I) shows that the first attack of gout may occur in very early 

 life. I shall later demonstrate that this is also true of the appearance of 

 extensive gouty tophi. As a rule, however, this is not the case. The first 

 typical attack of gout usually occurs shortly before or after the fortieth year 

 of life. The gouty attacks frequently recur at certain seasons of the year, 

 especially at the beginning of spring and at the beginning of winter. Besides 

 certain premonitory symptoms, the true attack may be preceded by prodromes 

 in the part of the body that is to be the seat of the paroxysm, such as drawing 

 pains, or slightly disagreeable sensations to which the patient pays no atten- 

 tion, and of which we only learn by careful questioning. Much more fre- 

 quently the attacks begin suddenly, often coming like a thief in the night, 

 and surprising the calm sleeper. As a rule, the first attacks are prone to be 

 localized in the most peripherally situated parts of the body, and especially 

 in the joints of the lower extremities. The joints of the feet, chiefly the 

 first metatarsophalangeal joints, are most frequently attacked. The typical 

 attack of gout is a more or less severe process characterized by an inflamma- 



