SYMPTOMATOLOGY I39 



year an attack of gout. People with slight gouty predisposition, in whom 

 gout develops under the influence of one or more favoring factors, may keep 

 the disease in check provided these predisposing factors are removed. Thus, 

 for example, if the patient modifies his mode of life he may conquer the 

 existing pathological predisposition which would otherwise enslave him. If 

 such persons have been exempt from gout for a longer period than usual, they 

 flatter themselves that they have been permanently cured of gout, although 

 the physician may have frequently cautioned them to the contrary; but they 

 learn only too soon, if they return to their former manner of life, that this 

 is by no means the case. A single excess is sufficient to reawaken the slumber- 

 ing predisposition to the disease. 



We now turn to the description of the peemonitoet and inteemediate 

 symptoms by which, as already remarked, I desire to have understood those 

 symptoms which precede the individual paroxysms or are present between 

 the attacks. When the individual attacks of gout have passed off, and during 

 the period free from attacks, gouty patients are often troubled with a number 

 of ailments. I shall here exclude entirely those symptoms which are due to 

 the implication of the internal organs, and also others which not rarely com- 

 plicate the pathological process; of these I shall speak later. In the period 

 free from attacks, there is often more or less decided discomfort, referred 

 particularly to the joints which have been affected, but also to those not 

 attacked in the paroxysms; these disturbances often affect the muscles and 

 bones of the surrounding areas. We must especially mention here that there 

 is sometimes marked sensitiveness to pressure in the periosteum; this is 

 elicited by pressure of the skin covering the bones, particularly the superficial 

 bones such as the shin, but also the sternum, and more often the ribs. More 

 troublesome, because often acute and ushered in with great severity, are the 

 muscular symptoms, especially the painful cramps in the legs which recur fre- 

 quently; no less unpleasant are the so-called rheumatic pains in the lumbar 

 region called by the Germans " Hexenschuss," popularly known in English as 

 " crich in the hach." To this may be added vague, wandering, muscular pains 

 and a sensation of extreme fatigue which have a particularly depressing effect 

 upon the patient. Although these muscular symptoms are by no means 

 pathognomonic of gout — for we observe analogous symptoms occasionally also 

 in diabetes — they have, notwithstanding, a certain diagnostic value. Between 

 gout, diabetes mellitus and obesity, there are intimate relationships. I have 

 included these three diseases in a pathologic group as " general diseases of the 

 protoplasm with a hereditary predisposition." ^ 



Similar to the intermediate symptoms are those which precede the attacks. 

 These may exist for years before the outbreak of a paroxysm. According to 

 my experience, such symptoms may be present in persons with slight gouty 

 predisposition who are of active habits and live temperately ; they remain the 

 only indication of the affection and a gouty paroxysm never appears. 



It is obvious that premonitory and intermediate symptoms may also occur, 



1 Deutsche med. Wochenschr., 1898, Nr. 44, und Verhandlunfjen der deutschen Watur- 

 forsoher und Aerzte, 70; Versammlung, 2. Halfte, Leipzig, 1899, p. 73. 



