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may be made also to gouty nodules beneath the periosteum and in the penis, as well as in the skin, particularly that of the face. Gouty ulcers occasionally result from gouty nodules. Under such conditions the overlying skin becomes reddened and inflamed, undergoes destruction, and chalky-white masses of stony hardness come into view, which, upon microscopic examination, are found to consist of fine needles. The latter yield the murexid-test (heating with nitric acid and appearance of a reddish discoloration on addition of ammonia, and of a bluish discoloration on addition of potassium hydroxid) and thus reveal their uric-acid composition. The surface of the ulcers exhibits a slight tendency to suppuration and granulation, and to cicatrization. Small gouty nodules, as, for instance, those in the auricles, are sometimes wholly exfoliated, and leave a small permanent depression.

Gout of the internal viscera is a serious disease, and indicates that the body, overladen with uric acid, is greatly predisposed to inflammatory processes of all kind. The kidneys and the heart are involved with particular frequency. The kidneys not rarely become the seat of chronic interstitial inflammation, with all its consequences (light, abundant urine of diminished specific gravity, small amount of albumin and sediment, hypertrophy of the left side of the heart, heaving apex-beat, wiry pulse), and in some gouty patients death results from uremia or cerebral hemorrhage. With reference to the heart, insufficiency of the myocardium and angina pectoris readily occur, but also endocarditis, pericarditis, and fibroid degeneration of the myocardium are not uncommon conditions. Arteriosclerosis and aneurysm, likewise, are often due to gout. In addition to the foregoing, inflammatory processes have also been observed in many other organs, as, for instance, pneumonia, pleurisy, inflammation of the bronchial, tracheal, and laryngeal mucous membrane, pharyngitis, rhinitis, ophthalmitis, interstitial connective-tissue hyperplasia in the liver, gastritis, enteritis, even inflammatory discharges from the urethra, etc.

If, in addition to the inflammatory processes in question, gouty changes in joints and gouty nodules are also present, the etiologic diagnosis is easy; but otherwise it may be impossible, or can be made if saturation of the body with uric acid is demonstrable. To this end the application of a cantharidal plaster and examination for uric acid of the contents of the blister that develops have been advised. For this purpose the thread-test of Garrod may be employed, the contents of a cantharidal blister being collected in a watch-glass, five drops of acetic acid added, a coarse cotton thread introduced, and from twelve to twenty-four hours permitted to elapse. Should uric acid in increased amount be present in the contents of the blister, colorless four-sided plates of uric acid will have been deposited upon the cotton thread, and whose identity can be readily demonstrated chemically by means

of the murexid-test already referred to. The thread-test described will also be of value if gouty nodules are not present in a case of gout, and the question arises whether the condition be one of gouty or of deforming arthritis.

Among the complications of gout the frequent association with obesity has already been referred to. In addition, diabetes mellitus and the formation of renal and biliary calculi may further be mentioned. Long continuance of the disease occasionally gives rise to amyloid degeneration. Gout is, under all circumstances, a serious disorder, which recurs from time to time with increased intensity, even in spite of a careful mode of life, to which naturally all gouty patients will not submit, and in addition life may be threatened in most varied ways. Accordingly, the prognosis of gout is grave, and particularly so with regard to cardiac and renal gout. Nevertheless, gouty patients not rarely attain advanced age, although frequently rendered helpless invalids, harassed by constant pain, and dependent upon the assistance of others.

Anatomic Alterations.-The peculiar anatomic characteristic of gout consists in the deposition of urates in the most varied viscera. When this is absent it is impossible to differentiate with certainty between inflammatory processes of gouty and non-gouty origin. In accordance with the clinical manifestations deposits of urates are encountered most frequently in the joints, where they are at first appreciable as small chalky-white dots and lines beneath the surface of the articular cartilage, but they progressively increase in size, coalesce into larger coherent surfaces, and give rise to destruction and deformity of the articular surfaces. The articular capsule, the bursa, the tendons, the periosteum, the auricle, and other structures are also the seat of more or less extensive deposition of urates. The heart frequently exhibits arteriosclerotic, often calcareous thickening, as does also the intima of the aorta; and it has been possible by means of the murexid-test to demonstrate the presence of uric acid in these structures. The myocardium not rarely contains fibroid areas, and even it may be the seat of uratic deposits. The kidneys often appear contracted. They are diminished in size; the capsule is frequently adherent to the cortex and the surface often exhibits a multinodular appearance. On section the cortex is diminished; at the same time the consistency of the kidneys is increased. That such contracted kidneys are gouty organs can be recognized only from the presence of whitish deposits of urates, which are situated in part in the cortex, in part in parallel lines in the medullary structure, and, on microscopic examination, are found partly within the uriniferous tubules, and partly within the interstitial connective tissue. The liver is often in a condition of chronic interstitial hyperplasia of the connective tissue, or cirrhosis.

Much discussion has been waged with regard to the nature of gout, and even at the present time there is no unanimity of opinion on this subject. It may be considered as established that the condition is attended with abnormally increased production of uric acid, as uric acid can be demonstrated in the blood and in the contents of cantharidal blisters in cases of gout, and not in individuals free from gout. While formerly the increased formation of uric acid was attributed to diminished oxidation-processes in the albuminous materials of the food, the uric acid and its chemically related alloxuric bodies are at present thought to be derived from the nuclein-bodies of the cell-nuclei, and it has been contended that by means of Ehrlich's triacid solution peculiar granules have been found in the colorless bloodcorpuscles in cases of gout, which are looked upon as the material out of which uric acid is formed. Nevertheless, it should not be imagined that the formation of uric acid is confined solely to the blood. Obviously, it takes place in the most varied viscera. That a body saturated with urie acid is predisposed to inflammatory processes of all kind should not appear remarkable. That particularly articular gout occurs with especial frequency and constancy is probably dependent upon the fact that the joints are peculiarly exposed to traumatism and pressure, that of the great toe in the erect posture, and that joints become more readily susceptible to injurious toxic and bacterial influences the more severe the mechanical injuries to which they have been subjected. The periodic occurrence of articular gout, and of gouty manifestations generally, would yet require explanation. This might be dependent upon temporary increase in the formation of uric acid, or upon periodic diminution in the elimination of uric acid through the kidneys. Nevertheless, cases of gout occur, and such a one was recently under my care, in which the elimination of uric acid through the urine was diminished at the time of an attack of acute articular gout. This does not, however, take place unexceptionally, and under such conditions it must be assumed either that a diminution in the amount of uric acid had taken place some time in advance of the attack of articular gout, and which had been compensated for at the time of the attack, or that in these cases there occurs a temporary increase in the formation of uric acid. The occurrence of gouty deposits has been explained by assuming that local stasis in the movement of the fluids of the body gives rise to stagnation of the uric acid in various tissues, where the uric acid causes necrosis. The dead tissue acquires an acid reaction, and thereby causes precipitation of the soluble neutral sodium urate in the form of acid sodium urate. Recently the correctness of this explanation has been questioned.

Treatment.-Causal treatment should be directed to regulation of the diet and the mode of life, and gluttons, drunkards, and indolent persons should observe all the regulations laid down on pp. 278, 279 for the relief of obesity. The gouty patient should especially avoid food rich in nuclein (thymus, liver, kidney, brain, game, salt meat, cheese). In cases of plebeian gout generous indulgence in meat should be advised, and in cases of gout due to lead, potassium iodid (5.0: 200; 15 c.c.-one tablespoonful— thrice daily), and sulphur-baths (potassium sulphid 150.0 for a full bath at a temperature of 35° C.-28° R.-95° F.) should be prescribed, and the patient be permanently removed from the influence of lead. Drugs have been recommended as specific remedies that are capable of dissolving uric acid and its salts, although it is highly questionable whether these are capable of exerting any effect in the great dilution in which they are intro

duced into the body. In this group belong the lithium-salts (lithium carbonate, lithium salicylate, lithium chlorate), artificial lithiawater and lithium-springs (Assmanshausen, Baden-Baden, Dürkheim, Elster, Homburg, Kissingen, and Obersalzbrunn). The lithium-salts are given in doses of from 0.3 (4 grains) to 0.5 (7 grains) thrice daily, but gastric derangement should be looked for, as this may readily occur from the use of these salts. Among the solvents of uric acid are also lysidin, lycetol, piperazin, uricedin, and urotropin, all of which may be administered in doses of 1.0 (15 grains) thrice daily. Among the actual specifics for gout colchicum must yet be mentioned, constituting the principal ingredient of a number of secret remedies, among others also the widely known Liqueur Laville. Care should be taken to avoid excessive doses of colchicum, as they may readily induce alarming cardiac weakness:

R Tincture of colchicum,

Tincture of aconite,

each, 5.0 (75 minims).-M.

Dose: 15 drops thrice daily after meals.

The persistent use of alkaline waters should be recommended to gouty patients, particularly those of Fachingen, Kronenquelle, Obersalzbrunn, Offenbach, Kaiser Friedrichsquelle, Wiesbaden Kochbrunnen, Evian, and Vals. Recently the generous use of oranges or lemons-the so-called orange-cure or lemon-cure-has been recommended, although the results are highly doubtful.

For the relief of acute articular gout rest and elevation of the part are especially to be recommended. Little success will, as a rule, be secured from the administration of salicylic acid, sodium salicylate, lithium salicylate, antipyrin, phenacetin, salophen, salipyrin; nevertheless they should be employed (1.0-15 grainsevery two or three hours). In addition, the affected joint should be massaged morning and night with salicylated ointment and be wrapped in salicylated cotton :

R Salicylic acid,
Wool-fat,

Lard,

Use by inunction thrice daily.

5.0 (75 grains);

each, 25.0 (ounce).—M.

For the relief of chronic articular gout saline, sulphurous, and indifferent thermal baths have been recommended, while visceral gout is to be treated in the same way as corresponding disturbances due to other than gouty influences.

DIABETES MELLITUS.

Etiology.-Diabetes mellitus results from excessive accumulation of glucose in the blood-hyperglycemia (instead of from 0.04 to 0.1 per cent., as much as 0.48 per cent. of sugar)—which gives rise to persistent excretion of sugar with the urine. It is customary to distinguish two varieties of diabetes mellitus, and these

are designated idiopathic and symptomatic respectively. In cases of idiopathic diabetes mellitus anatomic alterations in the body are wanting. The disorder is generally an hereditary one, which in some families is transmitted from generation to generation, or in other families occurs in alternation with central neuroses, particularly hysteria, neurasthenia, epilepsy, or mental disorders. Not rarely idiopathic diabetes mellitus results from emotional disturbances, as, for instance, speculations on the stock exchange, grief, anxiety of all kind, as well as excessive mental activity. Violent mechanical agitation of the nervous system in consequence of falls, blows, railway-accidents, and the like, are also capable of giving rise to diabetes mellitus.

At

Symptomatic diabetes mellitus develops in the sequence of some nervous diseases. Thus, it has been observed in association with hemorrhage, softening, suppuration, and neoplasms in the brain, involving the diabetic puncture-center on the floor of the fourth ventricle either directly or through a remote influence. times diabetes mellitus occurs as a complication of diseases of the spinal cord, among which tabes dorsalis and multiple sclerosis may be mentioned. Diabetes mellitus occurs as a complication not only of anatomically demonstrable disease of the central nervous system, but occasionally also of central neuroses, as, for instance, neurasthenia, epilepsy, and mental disorders, and of exophthalmic goiter and akromegaly. Some cases of diabetes mellitus are dependent upon chronic disorders of the stomach, intestine, liver, or pancreas. It is noteworthy that long-continued excessive indulgence in carbohydrates may give rise to diabetes mellitus, whence this disease occurs frequently in countries (Italy) in which the inhabitants are especially fond of pastry and sweets. At times diabetes mellitus has been observed to develop in the sequence of infectious diseases, as, for instance, typhoid fever, influenza, cholera, syphilis, and malaria.

In a number of instances diabetes mellitus has been observed in husband and wife, in all probability because both have been exposed to the same injurious influences. Experience has shown that diabetes mellitus occurs but rarely in children; it generally develops after the twentieth year of life. Men are attacked more commonly than women, because they are more freely exposed to the injurious influences named. The better classes of society furnish more diabetic patients than the poorer classes. The statement that the disease has become more frequent in recent times is not incredible, because modern methods of living afford more favorable opportunities for nervous disturbances and injuries. Nevertheless, it should not be overlooked that at the present day patients are more carefully examined, and therefore disease is more frequently detected.

Symptoms.-The single trustworthy symptom of diabetes

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