138 GOUT 



Observation IV. — ^This record shows what I have already emphatically stated that, 

 in comparatively young persons who are attacked by primary arthritic gout, an extensive 

 tophus formation may occur. This patient was a merchant, aged twenty-five, from 

 Cleveland ( Ohio ) , who was evidently always a great eater, whereas he took scarcely any 

 alcohol, nor was there any family predisposition. Even in his tenth year the patient 

 suffered from decided cramps in the calves, and in his sixteenth year he had an attack 

 of gout in the first left metatarsophalangeal joint. These attacks recurred frequently, 

 and as time- passed the intervals became shorter. In these paroxysms not only the various 

 small but also the large joints, occasionally several simultaneously, were involved. The 

 severest attacks always occurred in spring and late autumn. About a year and a half 

 after the first attack — in the patient's eighteenth year — the first gouty tophi appeared 

 in the left ear. The paroxysms almost always came on suddenly; only rarely were 

 drawing pains in the joints present as prodromes, and in these joints the attack was 

 usually localized. Psychical disturbance was said to favor the appearance of the 

 attacks. I saw the patient for the first time upon September 29, 1885. He weighed 124 

 pounds. His weight is said to have never been greater than this. He was a pale, medium- 

 sized man and had a large number of gouty tophi in both ears. The third phalanx of 

 the little finger of the left hand was thickened to more than double its size in conse- 

 quence of gouty deposits. Gouty swellings were also found in several of the other joints 

 of the finger. Between the first and second phalanges of the middle finger there was an 

 extensor tendon with a movable, indolent gouty nodule. A somewhat smaller one was 

 situated upon the radial side of the left index finger. Tophi were absent upon the right 

 hand. Upon the third toe of the right foot a tophus about the size of a hazelnut was 

 present. Upon the left foot there were two nodules which had ruptured. One of these 

 gouty ulcers was situated upon the nail phalanx of the great toe, the other at the heel. 

 The skin surrounding these ulcers was inflamed. Where these gout tophi had ruptured, 

 white, chalky, urate masses exuded. About fourteen days after the rupture of the 

 tophus at the heel, almost all of the urate masses had been discharged. In the large 

 joints no tophi were to be seen, nor were any deformities noted. The appetite of the 

 patient continued good; the bowels were regular. About September 20, 1885, nine days 

 before the patient came under my observation, he had an acute attack, running an 

 afebrile course, not accompanied by disturbance of the appetite nor of the general system 

 and localized in the left heel, the fingers of the right hand, and the right elbow-joint; 

 amelioration began upon the 6th of October. The internal > organs of the patient were 

 normal and he was by no means cachectic. The urine did not contain albumin nor sugar. 

 The daily excretion of urea at the height of the last mentioned attack varied between 

 23.3 and 27.1 grams in twenty-four hours. The uric acid estimations, at that time 

 made by Heintz's method, can no Ipnger be utilized. The examination of the sweat of 

 the patient by means of the murexid test for uric acid gave a brown color with nitric 

 acidj which upon the addition of ammonium changed to a yellowish brown. In the 

 following winter, in Abbazia, the patient had an attack of gout which lasted for two 

 weeks. In connection with this a gouty tophus developed upon the flexor side of the 

 second phalanx of the ring finger of the right hand which the patient showed to me 

 when he consulted me in the following May. After a stay in Abbazia, he also went to 

 other places in Italy, and although he had no further attacks of gout he felt by no 

 means well. 



We see in this observation a case of primary arthritic gout which began 

 early in life; paroxysms rapidly succeeded each other and very soon led to 

 quite extensive tophus formation. 



Gout shows a varying course. In regard to the paroxysm, it must be 

 emphasized here that with a slight gouty predisposition combined with a suit- 

 able manner of life, the typical attacks occur only rarely and pursue a short 

 and mild course. Attacks of gout which are of rare occurrence may assume 

 a definite periodic type. I knew an army officer of high rank who lived to 

 be over eighty years of age, and who, up to the time of his death, had each 



