general predisposition. In hay fever certain patients present a peculiar idiosyncrasy, often inherited, almost always neuroarthritic. But to say with the French school that the arthritic diathesis (trivial diathesis, commonplace diathesis, diathèse banale) is the only cause of hay fever is to make a mistake that leads to inefficient treatment."

Conclusion. How this discussion of the gouty nature of hay fever escaped English and American authors is a strange thing. British physicians frequent French hospitals and are familiar with French medical writings. In 1868 American physicians studied in Paris as they went later to Vienna and Berlin. It is strange that they never brought back with them this French theory of the gouty nature of hay fever and that no British or American author seems to have quoted from their books.

I must make one partial exception to this statement. In his Diseases of the Nose, Throat, and Ear, Philadelphia, 1906, Professor Grayson says that, in hay fever, there is "some diathetic state that is rooted in defective nutrition. Whether we term this lithæmia or gout or uric acid diathesis is immaterial, the central fact being that through intestinal toxæmia or some disturbance of normal metabolism we have resulting a persistent poisoning of the blood-current."

Now this is simply substituting one theory for another without proof of either; for the origin of hay fever in auto-intoxication is as little proved as its origin in gout or uric acid. Auto-intoxication has simply replaced uric acid in the Doctor's mental picture gallery; for, like uric acid, auto-intoxication often exists in the imagination of the physician and not in the patient. For further discussion of this point, the reader is referred to the next chapter, on the Uric Acid Theory.

A novel and interesting article in Grayson is the description of angioneurotic œdema as affecting the nose and throat, page 182. He writes:

"I have no doubt that in this disease, as in hay fever, the gastro-intestinal tract is the birthplace of the toxic material. Although the disease may occur in gouty or rheumatic individuals, there is scarcely sufficient reason for ascribing any pathological connection between it and these other affections."

The comment on this is that, until we know what gout is, which we do not at present, we cannot argue satisfactorily either way. Some day I shall tell a listening world what I know about gout. I shall elaborate my favorite theory that the American neurasthenia, now rapidly increasing in other countries, is a form of gout, a gout of the nervous system. And here, too, I find that Frenchman, de Mussy, anticipating me in his remark that "Behind a vast number of nervous troubles, behind a vast number of functional anomalies stamped with a nervous imprint, we find arthritism." The name neurasthenia was not known in de Mussy's day, but he hit off the condition neatly as "functional anomalies stamped with a nervous imprint."

The defect in all these discussions of the gouty or non-gouty nature of hay fever or of neurasthenia is our lack of a sure diagnostic sign of the disease gout. Gout occurs in two forms, typical and atypical, irregular gout. In typical gout, with the deposits of urates in the joints and cartilages, the diagnosis may be easy. In atypical or irregular gout we may have a group of inflammations or functional disturbances in any tissue of the body. From their frequent occurrence in gouty people, we suspect them to be gouty, but can prove nothing. When they appear in people who have never had typical gout we can only say that a gouty origin is probable. There is no sign in the blood or in the urine or anywhere else by which we can say that gout is or is not present. It is in this class of atypical gout that hay fever and neurasthenia belong, if they be gouty at all. Until somebody discovers a diagnostic sign of gout that is available in these irregular cases, the evidence of the gouty nature of hay fever and neurasthenia must remain exactly what it was to de Mussy fifty years ago, analogies of symptom groups, and not an exact laboratory diagnosis based on physiological or chemical tests such as we have come to depend upon with such confidence in recent years.

One matter that should be made clear in the reader's mind is that the so-called uric acid poisoning or uricacidæmia is not the same thing as gout by any means, though Grayson confuses it with gout, as do nearly all American authors. For fuller discussion of this point, we will pass to the next chapter.