136 GOUT 



attacks constantly appear, and so suddenly and so decidedly that even ten minutes after 

 the onset of an attack he is unable to walk. Lately the patient has suffered from 

 cramps in the calves. His nutrition is good. He is extremely excitable, and lives in 

 constant dread of the appearance of a sudden attack. The patient tells me that the 

 liqueur Laville helps him, and purges him decidedly. I ordered the observance of purely 

 dietetic rules, and upon the 7th of March, 1900, he wrote to me that he was adhering 

 to my regulations, and since that time he has had no attack of gout. Nevertheless, I 

 have reason to believe that the patient will not long continue this mode of life, although 

 it is beneficial to him. 



In regard to the gouty paroxysms and the relative frequency with which 

 the individual joints are attacked by the gouty process, what has already been 

 stated may be amplified by the following account. The joints of the knee, 

 elbow, and vertebra are far less frequently attacked than the joints of the 

 toes and the tarsal joint, but among these rarer localizations that of the knee- 

 joint is perhaps the most frequent. I once saw in a patient aged fifty-four, 

 after all the peripheral joints had been attacked by gouty paroxysms, an acute 

 gouty inflammation of the left sternoclavicular joint. Any joint may be 

 attacked by gout; even the small joints of the larynx have been found in- 

 volved. This much is evidently certain, that gouty changes in the joints of 

 the legs are not only earlier but also far more common than in the joints of 

 the upper extremities. The joints of the hand and of the elbow are as a rule 

 simultaneously involved. The premonitory as well as intermediate symptoms, 

 to be discussed later, may become aggravated with the appearance of an acute 

 paroxysm of gout. 



In connection with this description of an acute attack of gout it appears 

 necessary to say a few words in regard to the composition of the urine, espe- 

 cially as to the excretion of uric acid. Garrod assumed that during the acute 

 attack the amount of uric acid excreted was diminished. He considered this 

 to be due to a functional disturbance of renal activity, apparently because he 

 was unable to find material changes in the kidneys. This diminished excre- 

 tion of uric acid led Garrod, as already stated, to believe the gouty attack 

 due to a retention of uric acid in the body, i. e., a generalized uric acid 

 stasis. Garrod's view is vulnerable from more than one point. It must be first 

 stated that a product of metabolism which may be still further decomposed 

 in the body may, during this further decomposition, appear in diminished 

 amounts in the urine; hence it cannot be concluded from its lessened excre- 

 tion in the urine that it is also produced in diminished amount in the 

 organism. Furthermore, if the view of Garrod were actually correct, it is 

 incomprehensible why — as in the majority of eases — the attack of gout should 

 be localized in the metatarsophalangeal joint of the great toe. ISTow, however, 

 since the old, quite untrustworthy methods of estimating uric acid in the 

 urine have been replaced by reliable ones, it has been demonstrated not only 

 that the amount of uric acid excreted during an attack of gout is not decreased 

 but that it is either normal or decidedly increased. It is by no means necessary 

 that uric acid sediment or urate sediments should be found in the urine. An 

 increased excretion of uric acid during an attack of gout is in the main due 

 only to the attack itself. It has been shown to be independent of the nature 

 of the food and of the total albumin metabolism. Thus the view expressed 



