Page:Encyclopædia Britannica, Ninth Edition, v. 11.djvu/17

joints in the form of urate of soda. Uric acid is formed in the system in the processes of nutrition, and is excreted by the kidneys, the amount passing off by the urine being esti mated at about 8 grains daily. In the healthy ( human subject the blood contains the merest trace of this acid, but in gout it may be detected in abundance in the blood-serum both prior to and during the acute attack, while in chronic gout it becomes a constant constituent of the blood and of other fluids of the body, both natural and morbid. Accord ing to Dr Garrod it is not merely the presence of the uric acid in the blood but its deposition in the inflamed part that gives rise to the attack of gout, the inflammation being the effect and not the cause of the deposit. The gouty paroxysm thus induced appears to rid the system to a certain extent of the accumulated uric acid, although such relief is generally of but temporary duration. Whether the accumulation of urates in the blood be due, as some affirm, to their excessive formation in the system as the result of functional derangement of the liver, or, as others hold, depends simply on the defective excreting power of the kidneys of the daily amount, is disputed, although it has been often observed during an attack of gout that the amount of uric acid excreted was markedly deficient. The likelihood is that both these conditions concur, and that while the kidneys retain their functional integrity even an excessive amount of uric acid in the system may be got rid of, but that these organs, becoming themselves affected by the deposition of urates in their tubular struc ture, lose to a large extent their excreting power, and thus the blood is overcharged with the product which the kidneys can no longer entirely remove. Another view of the patho logy of gout recently advanced regards the disease as re sulting from special degenerative changes in the fibrous textures of the body, one of the effects of which is the deposition of urates in the affected parts whence they pass into the blood. This theory has not, however, as yet been extensively supported, and the weight of opinion remains on the whole in favour of the views of Dr Garrod. It must nevertheless be admitted that many points in the pathology of this disease still remain unexplained, for, as remarked by Trousseau, " the production in excess of uric acid and urates is a pathological phenomenon inherent like all others in the disease ; and like all the others it is domin ated by a specific cause, which we know only by its effects, and which we term the gouty diathesis." This subject of diathesis (habit, or organic predisposition of individuals), which is universally admitted as an essential element in the pathology of gout, naturally suggests the question as to whether, beside s being inherited, such a peculiarity may also be acquired, and this leads to a consideration of the causes which are recognized as influential in favouring the occurrence of this disease. It is beyond dispute that gout is in a marked degree hereditary, fully more than half the number of cases being, according to Sir C. Scudamore and Dr Garrod, of this character. But it is no less certain that there are habits and modes of life the observance of which may induce the disease even where no hereditary tendencies can be traced, and the avoidance of which may on the other hand go far towards weakening or neutralizing the influence of inherited liability. Gout is said to affect the sedentary more readily than the active, but this cannot be taken as a very constant rule. If, however, inadequate exercise be combined with a luxurious manner of living, with habitual over-indulgence in animal food and rich dishes, and especially in alcoholic beverages, then undoubtedly the chief factors in the pro duction of the disease are present. Much has been written upon the relative influence of various forms of alcoholic drinks in promoting the develop ment of gout. It is generally stated that fermented are more injurious than distilled liquors, and that, in particular, the stronger wines, such as port, sherry, and madeira, are much more potent in their gout-producing action than the lighter class of wines, such as hock, moselle, &c., while malt liquors are fully as hurtful as strong wines. If this alleged difference in their tendency to induce gout be correct, it cannot be said that any satisfactory explanation of it has been furnished; but indeed the point has not been clearly proved, and it may be fairly questioned whether, other things being equal, an individual in abandoning the use of wines and substituting that of spirits would improve hie position in relation to this disease. It seems quite as pro bable that over-indulgence in any form of alcohol, when associated with the other conditions already adverted to, will have very much the same effect in developing gout. Even those who affirm the mischievous effects of fermented liquors in this way are obliged to admit that they are injurious in proportion to the amount of alcohol they con tain. The comparative absence of gout in countries where spirituous liquors are chiefly used, such as Scotland, is cited as showing their relatively slight effect in encouraging that disease ; but it is to be noticed that in such countries there is on the whole a less marked tendency to excess in the other pleasures of the table, which in no degree less than alcohol are chargeable with inducing the gouty hubit. Gout is not a common disease among the poor and labouring classes, and when it does occur may often be connected even in them with errors in living. It is not very rare to meet gout in butlers, coachmen, &c., who are apt to live luxuri ously while leading comparatively easy lives. Gout, it must ever be borne in mind, may also affect persons who observe the strictest temperance in living, and whose only excesses are in the direction of over-work, either physical or intellectual. Many of the great names in his tory in all times have had their existence embittered by this malady, and have died from its effects. The influence of hereditary tendency may often be traced in such instances, and is doubtless called into activity by the depressing consequences of over-work. It may, notwithstanding, be affirmed as generally true that those who lead regular lives and are moderate in the use of animal food and alcoholic drinks, or still better abstain from the latter altogether, are little likely to be the victims of gout even where an un doubted inherited tendency exists. Gout is more common in mature age than in the earlier years of life, the greatest number of cases in one decennial period being between the ages of thirty and forty, next between twenty and thirty, and thirdly between forty and fifty. It may occasionally affect very young persons, but such cases are generally in a marked degree hereditary. After middle life gout rarely appears for the first time. Women are much less the subjects of gout than men, apparently from their less exposure to the influences (except ing of course that of heredity) which tend to develop the disease, and doubtless also from the differing circumstances of their physical constitution. It most frequently appears in females after the cessation of the menses. Persons ex posed to the influence of lead poisoning, such as plumbers, painters, &c., are apt to suffer from gout; and it would seem that impregnation of the system with this metal markedly interferes with the uric-acid-excreting function of the kidneys. Attacks of gout are readily excited in those predisposed to the disease. Exposure to cold, disorders of digestion, fatigue, and irritation or injuries of particular joints will often precipitate the gouty paroxysm. With respect to the treatment of gout the greatest variety of opinion has prevailed and practice been pursued, from the numerous quaint nostrums detailed by Luciau to the " expectant" or do-nothing system recommended by Syden-