128 GOUT 



reviews differed decidedly from my own, just mentioned, as I think I suffi- 

 ciently emphasized in my theses; yet, as the subject is a very difficult one, 

 this diversity of views is not to be wondered at. Nevertheless, our views have 

 so much in common that we may hope, sooner or later, to come to some agree- 

 ment regarding the most important points in the pathogenesis of gout. I base 

 my remarks upon the review in the " Semaine medicale," No. 30, 1900, pp. 

 202, 203, which reports the address of the reviewer, Dr. Le Gendre, and of the 

 co-reviewer. Sir Dyce Duckworth. 



Of course, if Sir Dyce Duckworth believes that the kidney is the only 

 organ in which the synthesis of uric acid is carried out, i. e., in which uric acid 

 is formed — in which opinion he and his countryman Luff occupy quite an 

 isolated position not only among pathologists but also among physiologists 

 — unanimity in regard to the most important question in the pathogenesis of 

 gout is not to be arrived at. Sir Dyce Duckworth maintains, with Garrod, 

 that uric acid is the materia peccans in gout and that the latter results from 

 a hindrance to the excretion of uric acid through a faulty action of the kid- 

 ney which can by no means be demonstrated from anatomically determinable 

 changes. Sir Dyce Duckworth, therefore, in all cases of gout, assumes a 

 uricemia from a faulty excretion of uric acid. Le Gendre laid great stress 

 in his paper upon the influence of functional disturbances of the kidney in 

 the production of gout and also referred to the functional disturbances of the 

 nervous system; these result in nutritive changes in the tissue and cells, 

 and thereby cause irregularity in the formation, that is, in the excretion, of 

 toxic products of metabolism from the influence of which gout develops. In 

 regard to these doubtful points in the pathogenesis, it appears to me advisable 

 to wait for the publication of Le Gendre's complete paper. On the other hand, 

 there are a number of factors which may be designated as occasional- causes of 

 gout, particularly family predisposition and the influence of the mode of life, 

 etc., concerning which there is complete unanimity. 



Instead of voluminous descriptions, it will best serve our purpose to cite a 

 few cases from practice. 



Observation I. — Dr. X., from H., a physician about thirty-nine years of age, con- 

 sulted me June 22, 1900, on account of gout. About fifteen years before, while he was 

 a medical student, I had repeatedly treated him for this. As a jolly fraternity student, 

 he probably drank more beer than was good for him, and had acquired a decided embon- 

 point at too early an age. In addition to a plentiful use of alcohol, he ate a great deal, 

 and took very little exercise. In spite of these facts he was by no means dissipated, but 

 passed a very good examination, and is now an extremely busy practitioner. The 

 patient's family has a, predisposition to gout ; although his parents did not suffer from 

 it, his maternal grandfather late in life had a severe form of gout, and two of his 

 maternal uncles also suffered from it. 



As early as between his sixteenth and eighteenth years, the patient had repeated 

 attacks of cramps in the calves, and he is inclined to regard as " gouty " an attack of 

 " stiff knee " which appeared in his boyhood after a salt-water bath, and was accompanied 

 by very severe pain. The first typical attack occurred in his twenty-first year in the 

 metatarsal phalangeal joint of the right great toe. The attacks recurred twice in the 

 next year; the fourth attack, in June, 1885, which was accompanied with fever was 

 more severe than the preceding ones. The fifth attack, in September 1885 which 

 appeared three days after " turning " the left foot, was localized in the first metatarsal 



