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of unanimity as to the nature of the malady, and the discrepancy which exists as to the most efficacious mode of treatment, amongst men well informed on professional subjects, and with whom, on most points, no difference of opinion would exist, is the most conclusive proof that the complicated and eccentric nature of this malady has hitherto enabled it to evade the efforts which have been made to show with scientific precision and certainty its true nature, in order that its successful treatment may be based, not as at present, on empirical traditions and observations, but on those rational principles which enable us to predict a cure not as a precarious probability but as a moral certainty. This great discrepancy of opinion, both as regards the nature of the malady and the most appropriate treatment of it, is in a great measure due to its having been regarded at one time as too exclusively dependent on an inflammatory condition of the fibrous tissues; at another time, and by another set of pathologists, as too exclusively dependent on the presence of a materies morbi in the blood; whereas I believe the true solution of the complicated nature of this malady and of its eccentric and variable peculiarities is to be found in the fact that cold and moisture, the commonly recognised exciting
causes of the disease, give rise to the formation at one and the same time both of the morbific matter and that peculiarly enfeebled condition of the fibrous structures that renders them prone to become the nidus of that morbific matter, and it is to the presence of this morbific matter in the circulatory system that the high vascular excitement which characterizes the disease is due, while the local symptoms are attributable to the accumulation of the particles of this irritating matter in the dense unyielding structures which are the especial seats of the disease.
I believe the urate of soda to be the materies morbi of both gout and rheumatism, and that the difference in form and degree between the two diseases depends, partly on the difference in the chain of events which has preceded and led to the formation of the morbific matter, and which has, at the same time, exercised an important influence on the character of the vital fluid itself, and partly to the different effect which this animal irritant exercises on two opposite conditions of the blood.
This opinion is in some degree confirmed by the fact that in synovial rheumatism, which is popularly, and I think properly designated rheumatic gout, the constitutional symptoms partake in a greater or less degree of the character of either gout or rheumatism, according to the extent to which the vital powers of the patient have been impaired from mal-assimilation of food, sedentary habits, hereditary predisposition, or any of those peculiar circumstances which generate that condition of the circulation most favourable to gout; we, moreover, see that in both diseases the morbific matter follows the same general law in fixing its habitat in those particular fibrous tissues which
the lowest degree of vitality, whether that impaired vitality arises from the depressing influence of cold on structures at all times possessing a low degree of organization, or from their having been the seat of recent disease or injury, or from their being furthest removed from the centre of the circulation. But before entering on the pathology of either of these diseases, it is essential to consider, and if possible arrive at, some definite conclusion on that quæstio vexata, the physiology of urea and uric acid.
The origin of urea and uric acid is one of those mysteries of vital chemistry which the light of modern science has hitherto been unable to penetrate. That they are the means by which both effete nitrogenous matters which have already discharged their office in the animal economy, and by which superfluous nitrogenous
elements arising from an excess of nitrogenous ingesta or from imperfect animalization of the chyle are eliminated from the circulation, there can be no doubt. It is equally certain, from their absence in the chyle and from their presence in the blood in small quantities, even in health, as proved by the researches of Dr. Garrod, that although the nature and quantity of the ingesta, and defects in one or all the functions of chymification, chylification, and sanguification which constitute the primary assimilation of Dr. Prout may increase the quantity of both urea and uric acid, and alter their healthy and relative proportions to each other, that they are the immediate products of vital changes which take place during the second stage of the secondary assimilation of Prout, or the metamorphosis of tissue of Liebig.
The theory of the formation of urea which is at the present day generally taught, although it is very universally doubted, is that of Liebig, who considers that uric acid is the primary product resulting from the action of oxygen on nitrogenous elements which have already discharged their office in the animal economy, and that urea is the secondary product arising from the action of oxygen and water on the uric acid. He says—“When uric acid is subject to the action
Gouty complications--Obstinacy of local injuries in persons of a
gouty tendency--Undeveloped gout very common in femalesThe organic changes which occasion angina pectoris caused by the long-continued circulation of gouty blood-Comparison of the most remarkable symptoms in gout and rheumatism, showing in what respects they most resemble and differ from each other, and why
Treatment of gout-General observations-Bleeding-Purgatives,
Colchicum; its modus operandi—Ill effects of colchicum ; how induced; the best mode of administering it-Vegetable salts of potass-- Vapour baths and hot-air bath-Pure air promotes recovery--Inhalation of an atmosphere largely surcharged with oxygen-Diet - Local treatment Convalescence — Remedies during
General observations on the prophylactic treatment, or the preven
tion of gout