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"THE PATHOLOGY AND TREATMENT OFGOUT."

To the Editors of THE LANCET.

SIRS,—In THE LANCET of Feb. 12th Dr. Rudolf raises,àpropos of my paper on the Pathology and Treatment ofGout published in THE LANCET of Jan. 15th last, theinteresting question as to whether the uric acid found in theblood and connective tissues in gout may not be a by-productin the obscure conditions producing that disease. In myopinion the reason why deposits of sodium biurate are sofrequently found at post-mortem examinations in the jointsof persons who have suffered from granular kidney diseasebut have never been known to suffer from ostensible goutduring life is that in such cases the deposition of thebiurate into the joints has been very slow and gradualand has never become excessive, whereas a somewhatsudden and copious deposit is required to produce an attackof acute or subacute gout and a considerable amountmust be present in the joints to produce the deformities ofchronic gout. Although I do not think that uric acid canbe considered a by-product in gout, yet I am quite at onewith Dr. Rudolf in considering that it is not the primarycause of the disease. The primary pathogenic factor in goutis, I believe, a functional or organic affection of the kidneyswhich interferes with the complete elimination of the uricacid manufactured in those organs and so allows absorptionof the non-excreted portion of the uric acid to take placeinto the general circulation. This view renders it quiteintelligible why uric acid can always be found in the bloodin cases of granular kidney disease and the fact that it isfound in smaller proportions than in cases of gout explainswhy the deposition of the biurate into the joints may be soslow and gradual as not to produce the symptoms ofostensible sout. I am. Sirs. vours faithfullv.Weymouth-street, W., Feb. 12th, 1898. ARTHUR P. LUFF.

To the Editors of THE LANOET.SIRS,-The following remarks are suggested by Dr. Rudolf’s

letter under the above heading in THE LANCET of Feb. 12th.Ostensible gout is unquestionably acute articular inflam-

mation. That the deposit of sodium biurate in articulartissues is a competent factor of inflammation is scarcely opento doubt. Hardly less doubtful can it be that if such depo-sition takes place very slowly there are many persons whosetissues so irritated will not react so energetically as to exhibitacute inflammation. This being so it fully explains how uratesmay be found post mortem in the joints of persons who havenever suffered from ostensible gout. Various as is thesusceptibility of the articular tissues of different individualsto inflammatory reaction on injury there are probably none soslightly susceptible as not to be acutely inflamed by a suddenand copious deposition of sodium biurate and probably nonesufficiently susceptible to be similarly affected if the depo-sition takes place by slow degrees. The "something more"than the presence of urates in the joints which is necessaryfor the production of ostensible gout is therefore simplysusceptibility of the articular tissues to inflammation, andthat this susceptibility varies in different persons and in thesame persons at different times experience daily tells us.

I am, Sirs, yours faithfully,P. GOWAN, M.D.Edin.

Upper Woburn-place,:W.C., Feb. 12th, 1898.

HEREDITY IN CANCER.To the Editors of THE LANCET.

SIRS,-May I take leave to point out that in your neces-sarily condensed report of the discussion on Cancer at theWest London Medico-Chirurgical Society in THE LANCET ofFeb. 12th you attribute to me a statement which, correct initself, yet apart from the context expresses the exact oppositeof what I said and have contended for years ?My reference was to a paper in the British Medical Journal

of Oct. 10th, 1885. This was an analysis of 1075 cancer caseswith some near relative similarly affected in 15 7 per cent.Three sets of control- statistics drawn from medical men,tuberculous patients, and people with miscellaneous ailmentsgave a rather larger ratio-roughly speaking, 20 per cent.-with cancer in the family." The necessary inference wasthat hereditary influences as a predisposing cause of cancer,

are nil. Apart from statistics, the strongest argumentagainst heredity to my mind is afforded by the fact thatno case ever arises without a direct and definite excitingcause whether there be cancerous relatives or not.

I am, Sirs, your obedient servant,Gloucester-place, W., Feb. 14th, 1898. HERBERT SNOW.

"THE NOTIFICATION OF INFLUENZA."To the Edatora of THE LANCET.

SIRS,-With due deierence to Dr. W. Woodward I beg tosubmit that his idea of notifying influenza is altogetherimpracticable. The means available for diagnosis as far as Iam aware in the hands of general practitioners are so equi-vocal and hence the diagnosis so uncertain that it is obviousinnumerable cases of common febricula accompanied withpain or other catarrhal conditions especially in the hands ofwhimsical practitioners would be notified as such and it wouldbe an extremely delicate and invidious task to gainsayany given practitioner on this account and as a consequencethe greatest confusion would prevail and an intolerableburden be thrust upon the already overburdened ratepayers,and the whole system of notification would probably bebrought into contempt. If I am correct with regard to theuncertainty of diagnosis it follows that the statistics fromwhich Dr. Woodward imputes from 50 to 100 deaths weeklyin London from the complaint in question must be swallowedwith a grain of salt.

I am. Sirs. vours faithfullv..I..

Peckham, S.E., Feb. 5th, 1898. CLEMENT H. SERS.

THE ASYLUMS BOARD "SCAPEGOAT."To the Editors of THE LANCET.

SlRS,—The dismissal of Mr. A. T. 0. White from the super-intendentship of the Darenth Imbecile Asylum for reasonswhich, as you have already pointed out, are obviously insuffi-cient calls imperatively for action on the part of our pro-fession to protect a professional brother. The facts (and manynow know them) do not warrant the punishment inflictedby the committee, which is equivalent to a fine of severalthousand pounds, besides the unjust moral infliction andsubsequent loss from damage to professional reputation. Amedical man with an imputation against him is often drivento practise abroad, so that the punishment in this case notonly represents a great loss of deferred pay in the prospectof pension, but may also be equivalent to life-long banish-ment from his native country.

I suggest that a committee or deputation be formed towait on the Poor-law Board to demand that a searchinginquiry be held. An inquiry by unbiased, independentmen, from what I know of the actual facts, could not, Ibelieve, arrive at any other conclusion than a condemnationof the Special Committee and a total exculpation of themedical officer.

In conclusion, I would add that in thirty years’ experienceof committees of institutions dealing with medical men Ihave never known or heard of so great an injustice.

T have the honour to be. Sirs. vour obedient servant

Feb. 16th, 1898. MEDICO-PSYCHOLOGICUS.

"DR. CLIFFORD ALLBUTT’S ’SYSTEM OFMEDICINE.’"To the Editors of THE LANCET.

SIRS,—A suggestion that a "tropical edition" of thiswork should be published is put forward in THE LANCET ofFeb. l2th by " Civil Surgeon." May I add on the same sidethat one copy at least would have a hearty welcome from,

Hire yours fnit.hfnllv

icas. TRAVANCORE.

ROYAL COLLEGE OF PHYSICIANS OF IRELAND.-The following candidates having passed the examination forthe Licence in Medicine of the Royal College of Physiciansof Ireland were admitted as Licentiates on Friday, thellth inst. : James Douglas Macdonogh, L.R.C.S. Irel., andWilliam Arthur Winter, M.D. Dubl.