SYMPTOMATOLOGY I37 



above gains support from the fact that, in the gouty process, an increased 

 production of uric acid occurs, and plays an important role. In the cases of 

 gout complicated with severe renal inflammation the complete retention of 

 the excretory function of the kidney for uric acid is proven beyond doubt by 

 the fact that, on the administration of food rich in nuclein, the amount of 

 uric acid in the urine of such persons may be increased. 



Associated with typical attacks of gout and occasionally without such 

 attacks having preceded, in a certain proportion of gouty patients deposits of 

 crystals which consist of acid sodium urate take place in the tissues. These 

 prove that we are dealing with gout. Most frequently they are found in the 

 joints in which one or more attacks of gout have occurred, and most commonly 

 in the first metatarsophalangeal joint, in which the lirst and the most fre- 

 quent paroxysms of gout are localized. However, it sometimes happens that 

 these deposits are absent even when many typical attacks of gout have pre- 

 ceded. A prerequisite for the production of such urate deposits is tissue 

 necrosis in the affected parts of the body. If the deposit of urate in the tissue 

 occurs in a nodular form, gout nodules (tophi) are spoken of. The number 

 of these in the same individual may be quite large. The size of the tophi 

 varies decidedly ; small at the beginning, they may attain the size of a chestnut 

 or even become larger. The analysis of two gouty nodules in the laboi'atory 

 of my clinic shows that the first consisted mainly of uric acid (59.7 per cent.) 

 and alkalies which formed urates with it (nearly 70 per cent.). These urates 

 are to be looked upon as monosodium urates (Tollens), though Eoberts desig- 

 nates them as biurates. There is also about 28 per cent, of animal matter 

 present. Phosphoric acid, calcium and magnesium — all three in combination 

 — were present only in traces. The analysis of the second gouty tophus showed 

 in the main analogous conditions. Here also uric acid made up the highest 

 percentage (61.27 per cent.) ; sodium oxid gave 12.28 per cent., and animal 

 matter 26.45 per cent. For the practitioner, of course, these gouty tophi 

 which are easily found and unquestionable are of chief interest from their 

 diagnostic value. Ko error in diagnosis can be made in the case of a gouty 

 patient with tophi in the ear, where they not infrequently develop in great 

 numbers. Gouty tophi may, however, develop at very different parts of the 

 body. The bursas mucosa which are usually implicated in primary arthritic 

 gout, and which are very frequently filled with urate containing material, be- 

 come the seat of such tophi. Every fresh gouty inflammation which is localized 

 there, as a rule, produces a paroxysmal increase of the tophus. The bursa 

 over the olecranon process appears to be the preferred seat of such gouty con- 

 cretions. Here in some patients the first gouty tophus develops. These uratic 

 deposits sometimes form without pain. There is at first swelling from which, 

 upon puncture, a white cream-like fluid consisting of acid sodium urate exudes. 

 Later these tophi become hard and firm. They may disintegrate, and form 

 gouty ulcers, the base of which is the previously mentioned urates. The ulcers 

 are slow in healing and may, according to their localization, etc., lead to seri- 

 ous consequences when suppuration develops. Even when the urate masses sep- 

 arate and the ulcers finally heal, they show a constant tendency to again form. 

 To illustrate the clinical history of gouty tophi some cases may be quoted : 



