When all these facts are united, the clinical story, the examination of the joint and of the urine, and the aspect of the Roentgen photogram of the affected parts, the diagnosis will in most cases offer no insuperable difficulty.
Etiology and Pathogeny.—Gout is a markedly-hereditary disease affecting men much more frequently than women. As it often occurs in subjects having pre sented indubitable signs of gravel or uric-acid calculi, it seems to be in some way related to that complaint; it has often been observed that, in a family dis posed by inheritance to gout, cases of this malady alternate with cases of uric acid gravel or calculi; hence the conclu sion was drawn that both diseases had a common origin: the uric-acid diathesis.
Developed gout is rarely met with before the thirtieth and fortieth years; it begins rarely after the forty-fifth year, but may in hereditary cases even affect children.
Persons who live freely, eat much meat, indulge in alcoholic drinks, and take little or no exercise are most subject to the disease; but it may also be observed in nervous, lean, underfed subjects, espe cially when they take much ale or porter and by their employment are exposed to cold and dampness. All sorts of ex cesses and overwork, bodily or mental, seem to be apt to provoke the attack of gout. Sydenham states that he always had an attack of gout following pro longed mental labor.
Workmen employed in lead-mills, painters, plumbers, and all persons ex posed to absorption of lead are extremely disposed to be attacked by gout. (Gar rod, Lancereaux, and others.) At the Johns Hopkins Hospital in the past thirteen years 36 eases of gout have been treated,-0.24 per cent. of all med ical cases. In London gout constitutes 0.37 per cent. of medical cases in St. Bartholomew's Hospital. In America heredity does not seem to be active in the etiology of the condition. On the other hand, alcohol is an active factor, particularly the fermented liquors. Lead poisoning is also an important condition in the etiology. Twenty-seven of the 36 patients reported were native Ameri cans. All the patients were males, the majority of whom were in the lower walks of life. Before the acute symp
toms of the attack begin the excretion of uric acid is below normal ; and late in the attack and in the intervals of the attack the output of uric acid is very low. The excretion of phosphoric acid is parallel to that of uric acid. Tophi were usually present, most frequently in the ears. There were definite evi dences of arteriosclerosis in 23 cases; in 14 cases the specific gravity of the urine was low; albumin was present in 21 cases and in 23 cases casts were found. These facts indicate that in a large pro portion of the cases chronic interstitial nephritis was present. The occurrence of a uric acid sediment in the urine does not indicate a gouty tendency, as is so commonly supposed. There was no such sediment in any of the 36 eases treated. Tophi arc important in the diagnosis of gout; they should contain crystals of sodium 'irate. T. B. Ditcher (Phila. Med. Jour., Jane 2], 1902).
The disease prevails chiefly in cold and temperate climates, especially when the latter is at the same time damp and changeable; gout may, however, be found also in countries where the climate is warm and equal. Cantani found it to be not uncommon in Naples, and it is fre quently observed among the Arabs of Algiers.
Indulgence in alcoholic drinks and ex cessive consumption of animal food pre disposes to gout; it has therefore been called a disease of the well-to-do classes. Of alcoholic drinks, wines containing a large percentage of alcohol—such as sherry, port, and champagne—have the worst effect; the lighter wines, as claret or Rhine wine—are not so hurtful. Among the malt-liquors ale and porter are reputed to be much more conducive to the development of gout than the lighter kinds of beer; distilled alcoholic beverages — such as gin, brandy, and whisky—are by many authors believed to be less liable to cause the development of gout than beer or strong wine.
Although gout is a malady which has been known to physicians for thousands of years, its pathogeny and real nature is still a subject of debate.