SYMPTOMATOLOGY I35 



the age of fifty-six of diabetes mellitus. The patient previously had two attacks of 

 pyorrhea. He admits prior and occasional marked abuse of alcohol; since practising 

 his profession he drinks moderately. He has always been a great eater, and takes but 

 little exercise. At the age of twenty-one or twenty- two he had a slight attack of gout 

 in a joint. The attack came on suddenly at five o'clock in the afternoon while in his 

 office. In the following June the iirst severe attack occurred, and confined him for 

 almost three months to his room. Remedies — external and internal — were ineffectual 

 until finally the American remedy ( ?) — potassium iodid, colehicum and colocynthitin — 

 brought relief. The attack was in the left foot, and localized especially to the great toe. 

 The paroxysms now recurred yearly, and the right foot also became implicated. In the 

 year 1888, after a, prolonged, exhausting ride upon the tricycle, an attack of gout 

 occurred which was localized in the left knee-joint. In November, 1895, a severe attack 

 of gout came on after drinking a somewhat larger quantity than usual of cognac with 

 which the patient hoped to abort an attack of influenza. At first both feet and the 

 knee-joints were implicated ; the patient was compelled for almost five months to remain 

 uninterruptedly in the recumbent posture. Relapses constantly occurred in which also 

 the right elbow-joint was involved. He reports that, when free from attacks, the urine 

 was dark and frequently contained sediment. The patient was under observation in my 

 private hospital from the 6th to the 13th of July. He had tophi in the concha auris. 

 The daily excretion of urine upon a mixed diet amounted to 0.6-0.8 gram in twenty- 

 four hours with an excretion of urea of about 40 grams and a phosphate excretion of 

 from 3.1-2.3 grams. I regulated the diet and advised him to spend his summer in the 

 Tyrol or in Switzerland. He did the latter. In the main, the patient apparently fol- 

 lowed directions. That he rigidly adhered to the diet, and absolutely avoided alcohol, 

 cannot, however, be asserted. The best proof of this is furnished by the reappearance 

 of gouty paroxysms. In the first year during which he adhered to the dietetic regime, 

 he had no attacks. 



I cannot enter into details here; the following fact will suffice. When the patient 

 celebrated his fiftieth birthday, he thought he could not do without champagne. I know 

 not how much he drank, but this I do know, that the patient had a very severe paroxysm 

 of gout upon the following day. 



The following case also is instructive. It proves that persons with a gouty 

 predisposition can, by a proper mode of life, keep the disease in check. If they 

 fail to do it, not only may severe attacks of gout appear in rapid sequence, 

 but it is occasionally observed that the paroxysms soon attack a greater number 

 of Joints. 



Obseevation III. — The Commercial Councilor and City Councilman, X, aged forty- 

 nine, a very busy man, whose grandfather suffered greatly from gout, states that he 

 comes from a family in the main very healthy. Toward the end of the sixth decade of 

 the last century, he had Asiatic cholera in Vienna ; as a- young man he had a severe 

 attack of gonorrhea. The patient was under observation in my private hospital from 

 the nth to the I4th of August, 1899. Regarding his gout the patient wrote for me the 

 following history: "About six years ago I was attacked with gouty pains in the great 

 toe, which appeared every six months and very rapidly passed away. I went to Kissingen 

 every year, which benefited me greatly. Last year (1898) I had a very painful attack 

 of gout in the foot, particularly in the small joints, and in September, 1898, I went to 

 Wiesbaden. At the beginning of February of the following year (1899) another and 

 also very severe attack of gout occurred, mainly in the right knee, but also in the small 

 joints of the right foot, which kept me confined to bed for about three weeks. In May, 

 1899, I went to Aix-la-Chapelle, where I took the bath cure for four weeks, and used 

 douches. Shortly after my return, gouty pains recurred, but disappeared in a few days. 

 At the present time, upon prolonged sitting, slight pains occur in the joints of the right 

 foot but soon pass away." This closes the report. The patie.it had gouty tophi in the 

 right ear. The urine showed a trace of albumin. The intestines appeared to be filled 

 with feces. The gouty joints were sensitive to pressure. The patient relates that the 



