CLINICAL SYMPTOMS 255 



and after a critical analysis he came to the conclusion that coincidence can 

 be wholly excluded, since in his and other cases the affections show simul- 

 taneous exacerbations and improvement. 



Here, also, the relation existing between chronic arthritis and gout must 

 be considered. This much is certain: 1. That after gout has existed for a 

 long time in a joint, proliferation of the cartilage, exostoses and disappear- 

 ance of the capsules are found; 2. That atypical gout may give rise to poly- 

 articular swelling, resembling the exudative form of arthritis ; 3. That in gouty 

 families, individuals may present symptoms resembling chronic arthritis. 

 But if we do not wish to lose ourselves in a realm of unfruitful speculation, 

 we must adhere to the belief that gout is an affection characterized hy a 

 deposit of uric acid salts in the body and hy the presence of uric acid in the 

 hlood. The latter point will decide the differential diagnosis of doubtful 

 cases, in which we should place our dependence not upon the uncertain thread 

 test of Garrod, but upon the more difficult chemical analysis. 



We may, therefore, look upon gout as one of the causes of chronic arthritic 

 changes, while recognizing that the two diseases are by no means identical. 



The constitutional predisposition appears to be of especial importance in 

 one form of chronic arthritis, namely, that marked by Heberden's nodes. 

 They are found isolated, especially in the aged, and then are frequently hered- 

 itary; very often they are associated with asthma, migraine, neuralgia, sciatica 

 and muscular rheumatism and particularly with gout. Bouchard was the first 

 to describe nodosities of the middle Joints of the fingers due to swelling of 

 the second phalanx and occurring in cases of gastric dilatation ; he gave them 

 the name of " comptodactylie," and showed that this swelling disappeared 

 with improvement in the gastric affection. Pribram also observed one case 

 of this malady. 



I do not believe that it will be possible hereafter to deny the existence 

 of a constitutional arthritis; but it is not necessary to adopt the scheme of 

 the French, who look upon every non-infectious arthritis as an expression of 

 an " herpetisme or arthritisme." In the future accurate weighing of all the 

 circumstances will show whether definite anatomical lesions exist or an arthritis 

 runs a particular course in persons with a predisposition of the type described 

 by the French. 



The infectious theory of arthritis has many more supporters than has 

 dyscrasia. The febrile form which comes in paroxysms with a relatively 

 frequent endocarditis and severe general disturbances gives strong support to 

 this view, and on several occasions microorganisms have been cultivated (by 

 M. Schiiller, Bannatyne,' Blaxall and Wohlmann) from the contents of the 

 joint and their pathogenicity has been proven by animal experiment. Un- 

 fortunately, the microorganisms described are not all the same, and so careful 

 an investigator as Pribram found it impossible to detect any of them in the 

 cases he examined. The pathogenic agent, therefore, as in the case of articular 

 rheumatism, is not yet determined and the infectious nature of the disease 

 is only a hypothesis, although a very probable one. 



' As a third possibility, disease of the central nervous system has been con- 

 sidered. This is suggested by the symmetry of the affection, the atrophy and 



