WELLS ON GOUT AND ITS COMPLICATIONS. * ONE of the most
characteristic traits of this volume is the applied tion of chemical discovery to an inveitigation of the cause of dis- ease and its subsequent treatment. The principle, indeed, is not new ; the analysis of the blood, the perspiration, and other excre- tions, having of late been often made, with a view to determine their difference in health and disease, and hence to deduce the probable origin of particular complaints. The treatment, too, has often been suggested on the results of this analysis, so as to en- deavour to supply the elements in which the blood is deficient, or to prevent the secretory organs from furnishing elements which are injurious. We have not, however, met with this principle more neatly or systematically applied than in the treatise of Mr. Wells on Gout.
The merit of a system which promises more hereafter than it has yet performed, even in those diseases which originate in con- stitutional causes independently of skyey influences or any exter- nal circumstances, is due to Liehig's great discovery that the stomach separates but does not create. The elements of nutrition necessary to support animal life must therefore be contained in the food ; for if not, the system cannot produce them. The ad- vance of course was obvious, to apply this principle to diseases held to originate in some vicious state of the blood, as had been already done more empirically in the case of stone and gravel. Much, however, is still to be achieved by chemical investigation; for as yet theory and fact are sometimes at odds. Probably there are elements we cannot yet detect ; and after all, Nature may be too strong for physic or diet; and men must suffer, as they certainly must die, in spite of the efforts of doctors or of themselves.
The pith of this system as regards gout is, that the blood of gouty patients 'contains lithic acid in considerable quantity. As long as the kidneys and the skin act vigorously enough to carry it off, the patient, if in other respects healthy, may remain free from attack. If from over-exertion or other causes these two ex- creting organs become torpid, or a greater quantity of lithic acid is produced than usual, or some of those inscrutable causes which
• Practical Observations on Gout and its Complications, and on the Treatment of Joints stiffened by Gouty Deposits. By T. Spencer Well., Fellow of the Royal Col- lege of Surgeons of England, 145 Assistant Surgeon in Malta Hospital, Re. Pub- lished by Churchill,
often give rise to disease are in operation, the patient has a fit of the gout ; the peccant matter being sometimes got rid of by those depositions commonly called chalk-stones. According to a theory of Liebig, though a rather complicated theory and one diffi- cult to establish experimentally, animal food should prevent and vegetable food should produce lithic acid. Practice and experi- ment, ho wever, establish the reverse.
"Dr. Gairdner, as we have just seen in his recent work on gout, supports these views, which, though very ingenious, unfortunately for the theory, are completely contradicted by observation at the bedside. According to them, a vegetable, carbonized, or non-nitrogenous diet, should increase the formation of lithic acid ; while an animal or nitrogenous diet should dimi- nish it. Tet observation proves that the very opposite of this is the case. Other things being equal, an animal diet increases and a vegetable diet diminishes the formation of lithic acid. Magendie found that lithic acid disappeared from the urine of carnivorous animals on restricting them to a vegetable diet. It is not present in the urine of herbiverous animals, and it was difficult to procure the converse of Magendie's experiment by making herbiverous animals take animal food. They will not do so. Lately, how- ever, M. Bernard thought of the ingenious though cruel plan of subjecting them to a prolonged fast. In this way they nourish themselves ; they are fed by the absorption of their own tissues, and thus become for a time car- nivorous animals. Then lithic acid appears in the urine. Dr. Lehmann of Leipzig proved, by ascertaining the quantity of urea and lithic acid excreted by himself in twenty-four hours, under four different systems of diet, namely, exclusively animal, mixed animal and vegetable, exclusively vegetable, and of food containing no nitrogen whatever, that a vegetable and non-nitro- genous diet diminishes, and an animal or nitrogenous increases, the quan- tity both of urea and Whig, acid. More recent experiments, performed on ducks by Boussingault, to show the quantity of acid excreted after the injestion of various articles of food, confirm this view."
If rules sufficed for this world, all would be plain sailing. Feed the patient chiefly on vegetable and farinaceous food—let him eschew beer and dark-coloured wines, drinking moderately of Rhenish—with a proper diet combine proper exercise, baths, and what is called hygiene—and his business would be done. However, the doctor has to deal with men ; and there are men, perhaps many men, who would rather bear a smart fit of the gout, when they cannot help it, than undergo the unceasing constraint and discomfort consequent upon a great change of their habits of life: Something of this rather common feeling may be as much morbid as moral. It may be a questiolf whether a man with a virulent gouty diathesis, strengthened by the habits of years, can entirely subdue the complaint by any regimen that will keep him in health. Hence, possibly, a malaise which is to be ascribed to latent gout as much as to the deprivation of his usual indulgences. Mr. Wells has found women, (whose diet and habits of life are less adapted to develop gout,) and in Southern Europe (where the con- stitution and habits of males are more feminine,) he has found men, continually unwell in various ways, he is convinced, from lurking gout, which the constitution wanted vigour to throw off. A fit of the gout, when it can be developed relieves such patients. Then rules of regimen cannot be indiscriminately applied. A strong man may probably be subjected to them with advantage ; but we have just seen that constitutional vigour is requisite to enable the patient to throw off the complaint, as well as to resist the disease itself. In the case of delicate or broken-down consti- tutions, or patients advanced in years, attempts to subdue the gout by too stringent dietary, &a. may induce evils as bad as the disease. It is with the children of gouty parents that regimen avails the most; and Mr. Wells thinks that by pursuing a proper system of training the constitutional tendency may generally be subdued.
There is this solace to the afflicted, that gout is " a gentleman's disease "; using the word " gentleman " in the sense of fortune and accomplishments, as well as other qualities. The genial good- nature, the disposition to self-indulgence, and the sedentary ten- dency which the cultivation of elegant studies mostly involves, the easy rather than vigorous exercise which these habits, ad- vancing years, and perhaps a dread that rough exertion may in- duce a strain and bring on the enemy, all produce the habits that induce gout.
"Closely connected with hereditary predisposition to derangements of the process of nutrition, is the subject of undue or irregular development of cer- tain.parts of the nervous system, as a cause of such derangement. It is the opinion of some persons that they could produce gout in any man by keeping i him in idleness in a large town, and feeding him excessively upon stimu- lating and highly nutritious food. I believe that in cases where there was no hereditary predisposition to gout, they would only succeed in men endowed with a highly organized condition of the nervous system even when they had fulfilled all the above conditions. Sydenham observed, that gout killed more wise than fools.' Cullen said, that it affected especially ' men of large heads.' And to come to one of the most careful observers of our own times, Dr. Watson refers to the fact' that gout is 'peculiarly in- cidental to men of cultivated minds and intellectual distinction.' Doubtless, the more sedentary habits of men of cultivated minds, and the depressing effects of mental anxiety and intellectual labour too ardently pursued, tend to diminish bodily vigour; but this is not all. Among the present Members. of the Houses of Parliament, those who are known to be subject to gout are among the most distinguished for an ancestry rendered illustrious by 'high thoughts and noble deeds,' for their own keen intelligence, for the Resistance they have afforded to improvements in arts, science, and agriculture, and for the manner in which they have led the spirit of the age. If it were _proper to mention names, I believe I could prove this to be the case; and I neve? met with a real case of gout, in other classes of the community, in a person not remarkable for mental activity, unless the tendency to gout was clearly inherited."
In fact, it is the decided opinion of Mr. Wells, that neither habits nor proximity will bring on gent unless there is something of the gentleman in the patient.
"It is perfectly true that butlers, hall-porters, and other individuals M equally easy circumstances, are often subject to gout ; but many such persona are the sons of parents who have lived in similar situations, and have received from their progenitors hereditary predisposition. I have seen a great many examples of the rule, and scarcely an exception, that when a person of an in-
ferior station is subject to gout, and one of his Parente was not similarly affected, he is a person of superior abilities or attainments,- and I feel per- fectly convinced that the state of general fulness of the blood-vessels, the corpulency, the apoplectic, and erysipelatons affections, the ulcers on the extremities, and other diseases, which prove so fatal to the idle and over- fed servants of our aristocracy, differ as much from the gouty diseases of their masters as the brains of the two classes do in their organization. Some may doubt whether there really is such difference of organization ; but, putting aside all question of race, let us ask whether it be reasonable to suppose that a father and mother, descended from persons who had cultivated their minds and thereby kept the delicate fibrils of the brain in regular ex- ercise, and who themselves continue to perfect the organism they have in- herited by a continuance of the same habits of mental culture, will impart to their children a brain precisely similar in size, composition, and arrange- ment, to that of children whose parents and earlier progenitors have lived in a state of mental sloth, who have never exercised their brains, have never called forth its powers, and have consequently never attained the perfection which use imparts to every organ of the body."
This notice of Mr. Wells's treatise has merely extended to a few of the more popular points. The book will be found to contain a full inquiry into the cause of gout ; an investigation of its compli- cation with various other disorders—as rheumatism ; and the best mode of endeavouring to cure or alleviate it by regimen, as well as its medical treatment. In this last section, Mr. Wells conceives that the specific colchicum may be safely used if the quantity is only reduced ; and he advances instances of the apparently bene- ficial effects of very small doses. Ile also strenuously recommends iodide of potassium. In his third chapter, on " gout as modified by syphilis," he gives some extraordinary cases of the appearance of secondary symptoms years after apparent cure. The view is both curious and important if true, not merely in reference to gouty complication, but as explanatory of facts which sometimes affect reputation.
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