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GOUTY PERICEMENTITIS. 521

evidence of true gouty disease is that derived from the presence of
uratie salts in the tissues." The immediate cause for the deposition of
urates in individual tissues is to be sought for in a special vulnerability
of the tissues, a loss of vitality, the result of mechanical, chemical, or
vital influences. The views of Ebstein concerning the deposition of
uratie salts have found general acceptance. He has apparently demon-
strated that, in all connective tissues, pjrvious to the deposition there is
a primary necrosis of tissue elements "without which the crystallization
could not take place that this disturbance of tissue vitality is the
;
predisposing factor and the crystallization the exciting factor of gouty
changes. The blood plasma transuding through the walls of the capil-
lary vessels carries with it urate of sodium in solution ; in the partially
devitalized tissue inspissation occurs and in consequence crystallization.
The urate of sodium as it accumulates acts as a specific irritant to
the tissue, giving rise to a variety of phenomena in accordance with the
character of the tissue involved. The gouty manifestations may be
either acute or chronic. In the acute forms the signs and symptoms
are those of an acute specific inflammation of a joint, usually that of the
great toe. Clinical study of pyorrhea cases strongly indicates that the
disease frequently attacks the dento-alveolar articulation before other
articulations in point of time. The local symptoms, pain, heat, tume-
faction are associated with marked constitutional reactions, disordered
digestion, and numerous evidences of general disturbance of nutrition.
The duration of the attack may be from a few days to several weeks.
Repeated attacks lead to an impairment of the functions of the joint
and a permanent alteration of its structure.
In the chronic forms the symptoms are more widely distributed and
their intensity is less pronounced according to the tissues involved.
The various manifestations may be classified as follows :
Articular gout, in which the deposit occurs in joints.
Tcf/tnnentari/ gout, in which the deposit takes place in the skin and
mucous membranes. Disease of the skin, such as eczema and psoriasis,
and catarrhal affections of the mucous membranes, such as pharyngitis,
chronic bronchitis, gastric and intestinal catarrhs, have long been
recognized as expressions of gout.
Visceral gout, in which the deposit occurs in the viscera, such as the
lungs, heart, bloodvessels, spleen, liver, kidneys, i. e. giving rise to
various diseased conditions or giving a peculiar cast to disease already
established.
Nervoufi gout, in which the nervous tissue is invaded, manifesting
itself in a loss of mental energy, despondency, irritalulity of temper,
headaches, neuralgia, etc.
The limits of this chapter do not permit, nor is it desirable, to enter