COURSE AND PROGNOSIS 145 



be found between gout and a number of other pathologic processes. From 

 such points of view we may explain the well-known relations of syphilis to 

 gout, which diseases frequently occur simultaneously. I believe that the 

 explanation of this association may be that syphilis in a person predisposed to 

 gout frequently precipitates an outbreak. It is a fact that in the beginning 

 of the secondary stage in syphilitics the limbs, and particularly the joints, 

 small and large, are especially implicated. Any one who fails sufficiently to 

 consider this in treatment misses a very important curative guide. It is cer- 

 tainly difficult, from the nature of the changes in the joints, and when gouty 

 tophi are not present, to say that this is a case of true gout and that is one 

 of rheumatism. These difficulties at once disappear if we consider the history 

 of the so-called Heberden's nodes. By this term we understand the thicken-' 

 ing of the joints of the middle and end phalanges of the three-jointed fingers. 

 Some authorities consider these joint deformities a* gouty; others look upon 

 them as of rheumatic origin. In my experience such processes certainly may 

 arise from a gouty basis; upon the other hand, we can by no means always 

 prove that gout is the cause of these joint thickenings. We are not justi- 

 fied in concluding from the same external manifestation of a pathologic 

 change a similarity in the cause of the disease. A case in point is the con- 

 tracture of the aponeurosis palmaris which has been named, after the cele- 

 brated surgeon Dupuytren, Dupuytren's contracture. It was incorrectly main- 

 tained that this by no means rare affection was always due to gout. This 

 may be the case : it is not, however, necessarily so. At all events such obscure 

 combinations in practice are not to be underestimated, since diversity of symp- 

 toms always awakens interest, and for the affected pji^tient, that is, for his etio- 

 logic treatment, the elucidation of such questions is of the greatest importance. 



COURSE AND PROGNOSIS 



The course of gout, as shown by the previous description, is subject to 

 many variations, the majority of which may be understood by supposing that 

 in individual cases there is a varying intensity in the predisposition to the 

 disease, as well as in the influence exerted by manifold occasional causes in 

 producing the condition. Gout is a disease of extremely chronic course. The 

 earlier the vital organs, such as the heart, the vascular system, and the kid- 

 neys, are implicated the sooner does a fatal result ensue. So long as gout 

 remains limited to the extremities, it is a comparatively harmless although 

 very irksome disease. As it is often caused by the fault of the patient, it 

 frequently makes him the sport of his associates and so irritates him. For 

 this reason, the gouty patient with his " Weh und Ach so tausendf ach " and 

 his "Zippern" is rarely the recipient of sympathy. People forget entirely 

 that even an apparently mild attack of gout may be very serious, either be- 

 cause it may throw itself upon the "internal parts," as the laity say, or, 

 to use a more scientific expression, when it becomes retrocedent, because com- 

 plications ensue or because the patients become cachectic. Nevertheless a 

 gouty patient, in spite of periodically recurring attacks of moderate intensity, 

 may. reach very old age provided no intercurrent affections arise. 

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