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gouty habit, and the functions of the kidneys and liver, both in health and disease.
7. And that the same state of habit, or predisposition, which in some persons produces the acute attack of gout, or slower deposits about the joints, does in others, and particularly in females, testify itself solely by disorder of internal parts, including the nervous system, as well as various secreting and excreting organs of the body.
To these heads others might be added, in relation both to the predisposing and exciting causes of the disease, but less definite than the foregoing. I am aware that several even of these points are liable to dispute; and as regards more especially the existence of a material cause for gout, formed and circulating in the system, and eliminated from it by the gouty fit or in other ways, that there have been high authorities opposed to this belief. Nevertheless I see cause to suppose that the opinion, now entertained by many, will in the end be generally adopted. All the facts and analogies furnished by recent inquiry, some of these from unexpected sources, come in evidence of it; —and though the proofs are yet insufficient for its establishment as a physical fact, there are on the other hand no arguments to attest its being either impossible or improbable; nor any different view proposed, so well capable of solving the difficulties of the question.
In the observations which follow, I have kept this principle mainly in view; convinced that in every discussion as to the origin, nature, or treatment of gout, the condition most essential to be maintained is, that of its being a malady of the general habit; capable of showing itself in various ways; and of affecting, directly or indirectly, almost every part and function of the body. The progress of exact observation furnishes continually new proof as to these points: and their better determination must lead us to attach less impor
tance than formerly to the actual fit of gout; regarding this as one only of a series of changes taking place within the system; though perhaps the most characteristic and interesting, in its obvious effect of relieving the constitution for the time from the causes of the malady.
This distinction is in every respect of much moment to the true pathology of gout. It solves some of its most singular anomalies; and furnishes the principle to which we may best resort in all difficulties of practice. Any future progress that is made in the knowledge of the disorder, will probably depend on such mode of viewing the subject, in connexion with a material cause. And if so established by reasonable proof, this disease becomes the index and interpreter of many obscure and anomalous affections, which have hitherto perplexed all inquiry; as well as of numerous relations with other diseases, the thorough development of which is singularly important to medical science. The proper theory of gout is in every sense an object worthy of the most sedulous research: and to this some aid may be given, even by new methods of arranging and considering the facts best ascertained in its history.
Looking first to the hereditary character of gout (a topic noticed in a former chapter), it may be inquired whether this diathesis consists in the tendency to form or accumulate the matter of the disease, by secretion or retention, within the system? or whether what is transmitted is some peculiarity of texture in solid parts, and particularly in the fibrous membranes of the joints, rendering them liable to inflammation of a peculiar kind, and to occasional deposition of this morbid principle, when abounding in the body from other causes?
Though it is not easy to answer these questions unequivocally, yet the whole history of the disease makes it probable that the former opinion is nearest the truth. If the latter
were correct, gout, in its most general sense, would be simply a disposition from the peculiar texture of certain parts, to show topically, what in other cases, from difference of structure, produces no like effect. This view cannot well be admitted, in contravention of the many proofs that there is some peculiar substance generated within the system, which, either by its morbid nature or morbid excess, gives cause to the active phenomena of the disease, or to other effects more anomalous and uncertain with our present knowledge, yet not less due to the same morbid agent. Without speculating at present upon the nature of this matter, it is presumably the same, whether there be hereditary predisposition, or not; -it affects the same textures and in similar manner, as respects both the kind of inflammation, and the nature of the deposits which occur;-its metastases and irregular effects are seemingly alike in each case.
We have no reason then to regard hereditary gout as more than a disposition to generate a certain morbid matter within the body; in effect of certain circumstances of structure, either favouring its formation, or preventing that excretion of it from the system, which is essential to a healthy state. Or in other words, gout as an hereditary disease, may depend upon some transmitted peculiarities either in the organs of assimilation, or in those by which certain parts are separated from the mass of the blood. And we must further admit (which analogy allows us readily to do), that the same peculiarities may exist from other and independent causes; — in explanation of the many cases, where gout present in the habit, cannot authentically be traced through the parents or families on either side.*
* Sir C. Scudamore, in his valuable work on gout, states that, out of 213 cases, 84 only did not admit of being referred to hereditary predis
This question of relation between hereditary gout and that generated in the individual, is obviously of much moment to a right theory of the disease. It connects itself closely with the important consideration already noticed, viz. that the fit of gout in the joints is but a local declaration of a disorder of the whole habit, or more especially of the circulating fluids. And, regarded in itself, it involves merely the inquiry why this particular texture should be so prone to give an active and outward shape to the general malady of
Under this view, as well as from other considerations, we may fairly receive into the class of gouty affections, those indolent swellings and permanent thickenings of joints, which are evidently constitutional in cause, and admit of little relief but by constitutional treatment. The habits in which these swellings occur; their connexion with urinary derangements; the textures they affect; and the nature of the deposits taking place; all prove a similarity if not identity of origin. In fact, there is very little difficulty in conceiving that the same morbid material cause, which in some cases produces the sudden and acute attack, may in others act by a slow process of chronic inflammation, making its deposits as gradually in the parts affected. There is not less diversity of form in other diseases, from the same cause acting upon different temper
aments or textures.
These views are the more important, inasmuch as it is certain that the greater or less tendency to deposition, whether depending on structure or not, is an essential circumstance in the pathology of gout, influencing the whole
position. The liability to error is chiefly, perhaps, that of making the latter class too numerous; from the frequent difficulty of obtaining proof, even where the fact exists.
course and character of the disorder. Though this tendency seems in part to depend on the frequency of the previous fits, and is perhaps augmented in rate by articular deposits already begun, there are many cases where it shows itself in the earlier occurrence of the disease; and where the gouty virus, after producing a few acute inflammatory attacks, seems to expend itself chiefly in these deposits, with comparatively little activity of any other kind.
Another point of great interest in the 'pathology of the disease, is the singular frequency with which its morbid actions are shifted, rapidly and without apparent reason, from one place to another. In the degree of this tendency, gouty inflammation differs remarkably from most others. Though ignorant for the most part why such translations take place, or how their direction is determined, we may presume that very slight causes are capable of producing them, from the readiness with which we can bring gouty inflammation into a joint by trifling external provocation; removing it from another before affected. This facility of translation cannot be due alone, or even chiefly, to the texture of the parts concerned. It is more probably connected with the peculiar nature of the morbid matter of gout, in its relation to the general mass of blood, and to the secretions and excretions taking place within the system. We do not indeed by this supposition obtain any actual solution of the difficulty; but we connect it with the general causes which lie at the root of the disease; and to which all its variety of aspects, as well as every question of treatment, must more or less be referred.
It may be noticed here that some authors of eminence have considered the translation of gout to depend altogether on the agency of the organic nerves: deriving argument for this from those cases, where the reciprocal shifting of the disease