ANOMALOUS SITES FOR INITIAL OUTBREAKS While _primary_ attacks are in the vast majority of instances localised to the _foot_, if not actually to the _toe_, it is well to recollect that very rarely the _knee_, the _wrist_, _elbow_, or _ankle_ may be the chosen spot. In such cases there is need for exceptional caution before committing oneself to a diagnosis of _gout_. Certainly not until all other known causes of _acute arthritis_ of _monarticular_ type have been excluded. If in the _knee_ or _wrist_, any possibility of _injury_ or _strain_ should be thoroughly canvassed. To make assurance doubly sure, a radiograph should always be taken. Specific infective forms of arthritis then call for careful elimination—_i.e._, gonococcal, etc. If there be no history of such, a painstaking search should be made for any local foci of infection, _e.g._, mouth and accessory cavities. If any be found, they should be radically treated, as it is much more likely that the arthritis is due thereto than to gout. If, notwithstanding a meticulously careful investigation, no cause can be assigned, we may entertain the possibility of its being _gout_, the more legitimately if the subject be a middle-aged man coming of gouty ancestry and exhibiting himself tokens of this diathesis, _i.e._, _tophi_. It would be confirmatory, too, if, apart from its exceptional localisation, the joint disorder in its course conformed to that typical of gout in the toe, in other words if it was of sudden nocturnal onset, showed marked daily remissions in temperature and pain, responded swiftly to the action of colchicum, and was not protracted beyond the usual week or ten days. Sir Hale White, discussing the diagnosis of acute gout of unusual localisation, remarks: “The real difficulty in acute cases comes when it is suggested that an acute arthritis with pyrexia and swelling and redness of a joint other than that of the great toe is caused by gout. I have recently seen the difficulty in one patient in the wrist, in another in the knee. Such cases, if they are not gout, are some bacterial arthritis.” CHAPTER XXI CLINICAL DIAGNOSIS (_continued_) ACUTE GOUTY POLYARTHRITIS In the pathways of medicine, as in other walks in life, we are apt to become stereotyped, to fall into grooves, and sooner or later the inevitable rude awakening comes. Thus, so prone are we to think of gout as belonging, so to speak, to the foot, that when it erupts elsewhere it is often the last contingency to dawn upon us. If we diagnose it too often and too readily in the foot, we do so too seldom when it appears in joints remote. Now, while in _initial_ outbreaks of gout it is exceptional for more than _one_ joint to be affected, it is not always so. For sometimes in those strongly predisposed by _heredity_ not one, but _many_ joints, may be implicated in the _primary_ attack. Such cases, however, are extremely rare.