146 GOUT 



DIAGNOSIS 



The diagnosis of primary gout depends upon the presence of two symp- 

 toms, namely, the typical attack and the gouty tophi. Either of these, pro- 

 vided that it has been determined with absolute certainty, may in itself be 

 looked upon as proof positive. It is not necessary to repeat here by what 

 means we may determine beyond doubt the presence of these two symptoms. 

 I have endeavored in the description of the symptomatology to mention these 

 factors briefly, but to characterize them definitely. Neither the joint phe- 

 nomena, nor skiagraphy of the affected joints, are by any means such positive 

 proof as to deserve the confidence of the physician in the diagnosis of primary 

 arthritic gout. The same is true of the uric acid contents of the blood, of 

 the serum from blisters, which is used in Garrod's so-called thread test, as 

 .well as of the uric acid contents of the urine. Such findings are by no means 

 to be undervalued; but the data gained in this way cannot as yet well be 

 utilized in practice. They do not increase our diagnostic certainty. On the 

 other hand the recognition of a family predisposition, as well as the history 

 of the patient in other respects, is of inestimable value. 



There are certain symptoms the consideration of which is important, par- 

 ticularly those which we have learned to recognize as premonitory or inter- 

 mediate. These, too, are by no means positive, yet they often as pathfinders 

 lead us to success. This is true, for example, of lumbago, especially if it 

 occurs frequently without other determinable etiologic factor, and is quite 

 persistent. It is likewise true of the frequently recurring severe cramps in 

 the calves, and of neurasthenia. I have always laid stress upon the fact that 

 a great number of neurasthenics owe their neurasthenia to a gouty predispo- 

 sition which acts by limiting their energy. Special difficulty in diagnosis is 

 often met with in women, when no typical well-developed attacks of gout 

 occur. Here the characteristic gouty tophi are sometimes absent, but, on the 

 other hand, we may find the Heberden nodes. I have previously mentioned 

 that in women true typical gouty paroxysms occasionally occur even although 

 they do not have the same acuteness and intensity as the gouty attacks of 

 men. In such cases the investigation of the etiology is important. It must 

 also be maintained that not infrequently gouty paroxysms can be recognized 

 as consequences of trauma. To the category of these belong a number of joint 

 affections which are called " sprain of the ankle," " stretching of the tendons," 

 etc. Such errors are especially prone to happen in dealing with children as 

 gout is usually not looked for in them. These mistakes may be explained by 

 the fact that, as a rule, a slight trauma precedes the gouty attacks, and this is 

 just as predisposing for the onset of the gouty attacks as the other etiologic 

 factors that have been enumerated. 



TREATMENT 



For all practical purposes the treatment of primary arthritic gout may be 

 divided into two parts. First, we will consider the treatment of gout as a 

 whole, including the treatment of the gouty predisposition, and secondly, the 



