A text-book of medicine : for students and practitioners.

  • Adolph Strümpell
Date:
1893
Catalogue details

Licence: Public Domain Mark

Credit: A text-book of medicine : for students and practitioners. Source: Wellcome Collection.

    1017/1108 page 989
    uric acid or urates, in stripes, both in the lumen of the urinary tubules and also in the epithelial cells and the intei-stitial tissue. In the connective tissue it is probable tliat a necrosis precedes the deposit. The lesions presented by the heart, blood-vessels, and remaining’ parts of the body are not especially characteristic of the disease. The blood of gouty subjects, as Garrod demonstrated, contains an excess of uric acid. There are many theoretical questions which remain unanswered: Whether in this disease there is an over-production, or merely a defective excretion of uric acid ? What the true cause of this strange anomaly in metamorphosis may be ? What conditions are essential to the crystallizing out of uric acid in the tissues ? Why certain pai’ts, particulaidy the joints, and still more particularly the first joint of the great toe, are especially liable to suffer ? And, finally, What chcumstances decide the course of the disease, and determine its separate attacks ? Not one of these questions has been satisfactorily answered. The fact that gout is prone to attack individuals who have led a luxurious life has led to the belief that in every case of gout the ingesta are not completely oxidized, and an excess of uric acid is consequently accumulated in the system. We have already pointed out that this assumption is too sweeping. And, indeed, our present knowledge with regard to the manufacture of m-ic acid out of the albuminoids, and its further transfoi’ma- tions, is not at all adequate for the establishment of any hypothesis of this sort. We must simply confess that the true cause of the accumulation of uric acid in the tissues is unknown. It may be conjectured, however, that the deposit of crys- tals of uric acid is either occasioned or pi’omoted by an excessively acid reaction of the blood or lymph in which that acid is dissolved. It is not known what acids give rise to this reaction, nor how they are formed. It has been seen that the articular cartilages are especially apt to present a gouty deposit. Perhaps this is occasioned by the sluggishness of the circulation in these pax’ts. It is doubtful whether the ixric acid is produced in the cartilage itself. Ebstein believes that it originates mainly in the muscles and bone-marrow, and is thence conveyed to the cartilage. Others, and among them Cantani, believe that the uric acid is formed in the cartilage and the connective tissue. Diagnosis.—It is usually easy to recognize an acute attack of gout. The sudden onset of the pain at night and its localization in one of the great toes are very chai’acteiistic symptoms, and render it easy to distinguish between it and other acute affections of the joints. The diagnosis is more difficult in the advanced stages, where symptoms are more confused. Here the history of the case will often include the description of typical attacks and also aetiological factors, such as heredity and mode of life, which may assist in diagnosis. It must be said that many gouty subjects are reticent as to their past experiences, and sometimes even deny previous attacks of gout. If there is a chronic gouty arthritis, it may be necessary to make a differential diagnosis between it and arthritis deformans. The deformities of arthritis deformans are usually seen first of all in the hands and fingers, and it has a x>Gmistent, chronic course. Furthermore, in gout we sometimes can feel the characteristic deposits in the tendons or skin (for instance, in the eyelids or external ear). If there is chronic nephritis of gouty origin, its source can be recognized only from its association with other indubitable symjxtoms of gout, unless possibly the knowledge of certain aetiological factors, such as a history of gout in the family or of chronic lead-poisoning, should put us upon the right track. Ebstein has reported cases of “priinary renal gout” where there was no arthritis during the whole course of the disease. Such cases can seldom be correctly diao-nosticated during life. ” Brief mention should here be made of an experiment performed by Garrod,
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