Vickipedia

GOUT (Fr. goutte, from Lat. gutta, a drop), a medieval term of uncertain date, derived from the humoral pathology (see rheumatism), indicating a well-known form of disease, which occurs for the most part in persons of more or less luxurious habits, and past the middle period of life. The acute attack of gout begins most commonly by a painful swelling of the ball of the great toe or of the instep, sometimes of the ankle or knee; much more rarely, it attacks both lower limbs at once; and more rarely still, it seizes first upon some other part of the body, the foot being either not attacked at all, or becoming involved at a later period. In the great majority of cases, the foot is not only the first part attacked, but the principal seat of the disease throughout; according to Scudamore, indeed, this is the order of events in not much less than four-fifths of the cases.

In exceptional instances, the ankle, knee, hand, elbow, &c., are attacked at first; now and then, the disease smoulders in the system in the form of disorders of the digestive or nervous functions, or oppression of the circulation for some considerable time before it takes the form of ‘ regular ‘ gout—that is, of an acute attack, or fit, of gout in the foot. The name podagra (Gr. pod, foot, and agra, seizure) indicates the leading character of the disease as apprehended by all antiquity; and the very numerous references to the disorder so called, not only in the medical writings of Hippocrates, Galen, Aretæns, Cælius, Aurelianus, and the later Greek physicians, but in such purely literary works as those of Lucian, Seneca, Ovid, and Pliny, show not only the frequency, but the notoriety of the disease. The allusions, indeed, are of a kind which give ample proof that the essential characters of gout have not been changed by the lapse of centuries; it is caricatured by Lucian in his burlesque of Tragopodagra in language quite applicable to the disease as now observed; while the connection of it with the advance of luxury in Rome is recognized by Seneca (Epist. 95) in the remark that in his day even the women had become goutj”, thus setting at naught the authority of physicians, which had asserted the little liability of women to gout. Pliny likewise (book 26, chap. 10) remarks upon the increase of gout, even within his own time, not to go back to that of their fathers and grandfathers; he is of opinion, further, that the disease must have been imported; for if it had been native in Italy, it would surely have had a Latin name. Ovid and Lucian represent gout as mostly incurable by medicine; from this view of it, Pliny dissents. The list of quack remedies given by Lucian is one of the most curious relics of antiquity.

In the present day, gout is observed to prevail wherever there is an upper class having abundant means of self-indulgence, and living without regard to the primeval law of humanity, ‘ in the sweat of thy face shalt thou eat bread.’ The directness, however, with which gout can be traced, in particular cases, to its predisposing causes is very various; and in many instances, a well-marked hereditary tendency to the disease may be observed, which even a very active and temperate life can scarcely overcome; while, on the other hand, the most gross forms of excess may be practised for a whole lifetime without incurring the gouty penalty. It is difficult to explain these variations; but they leave unaffected the general principle, that gout is a disease especially of the wealthy, and most of all of those who have little physical exertion, and give great scope to the bodily appetites. The prevention and cure, accordingly, have been at all times recognized as being mainly founded on temperance, combined with the cultivation of active and regular habits as to exercise. Many amusing stories are told having this moral, and showing how gout has been cured by the opportune occurrence of calamities which have created the necessity for labor, and removed the means of self-indulgence. With a few special exceptions, indeed, it may be said that the laboring class, and especially those that labor in the open air, are almost, if not altogether free from this disease. Those, again, that labor much with the mind, not being subject either to great privations, or to the restraint of unusually abstemious habits of life, are remarkably subject to gout; the more so if their bodily and mental constitution has been originally robust, and fitted by nature for a degree of activity which the artificial necessities of fashion or of occupation have kept within too narrow limits. Hence, the well-known saying of Sydenham, that gout is almost the only disease of which it can be said that it ‘ destroys more rich men than poor, more wise men than simple.’ And in this manner accordingly (he adds), there have lived and died ‘great kings, princes, generals, admirals, philosophers, and others like these not a few.

Gout is, therefore, the counterpoise in the scales of fortune to many worldly advantages; the poor and needy have it not, but suffer from their own peculiar calamities; the favorites of fortune are exempt from many privations, but this very exemption paves the way for the gout; whereby even in this world Dives suffers as well as Lazarus, and sometimes, it may be, learns the lesson of his suffering. Such is the sense, though not the exact words, in which, nearly two hundred years ago, Sydenham expressed the convictions of a lifetime on this subject.

Sydenham’s treatise on gout is interesting not only as containing the well-considered views of a master in the medical art, but also as the faithful description of the disease by one of the victims of it. His account of the paroxysm of regular gout may be given here with some abbreviation. After some weeks of previous indigestion, attended with flatulent swelling and a feeling of weight, rising to a climax in spasms of the thighs, the patient goes to bed free from pain, and having had rather an unnaturally strong appetite the day before. In the middle of the night, he is awakened by a pain in the great toe, or sometimes in the heel, the ankle, or the calf of the leg. The pain resembles that of a dislocated bone, and is accompanied by a sense as if water not perfectly cold were poured over the affected limb; to this succeeds chilliness, with shivering, and a trace of feverishness, these last symptoms diminishing: as the pain increases. From hour to hour, until the next evening, the patient suffers every variety of torture in every separate joint of the affected limb; the pain being of a tearing, or crushing, or gnawing character, the tenderness such that even the weight of the bed-clothes, or the shaking of the room from a person’s walking about in it, is unbearable. The next night is one of tossing and turning, the uneasy limb being constantly moved about to find a better position; till towards morning the victim feels sudden relief, and falls over into a sleep, from which lie wakes refreshed, to find the limb swollen; the vinous distention usually present in the early stage having been succeeded by a more general form of swelling, often with itching between the toes, and a peeling-off of the cuticle. This individual attack may be repeated many times, in the course of what is termed ‘a lit of the gout,’ which commonly extends over a period of weeks, or even months, before the patient is completely relieved; or the attacks may occur in both limbs, or in several other parts of the body in succession, the real termination of the ‘fit’ being at last indicated by an apparently complete restoration of health, and even, in some cases, by a period of improved condition and capacity for exertion, as compared with the state of the patient before the attack.

Such are the principal features of the ‘ regular gout.’ In this form, it might almost be called a local disease; although the connection of the attacks with deranged digestion, or with a variety of other minor ailments too complex to be described here, and the obvious relief obtained through the ‘ fit’ from the symptoms of constitutional suffering, point to a cause of the disease operating over n larger range of functions than those included in the ordinary local manifestations at this period. Regular gout, accordingly, forms only part of a nosological picture, in which the so-called irregular, atonic, metastatic, or retrocedent forms have to be included before it can be said to be at all complete. These, indeed, form almost all the darker shadows of the picture; for regular gout, though a very painful disorder, can hardly be said to be dangerous to life, or even to the limb affected, at least until after many attacks.

It is the tendency, however, of gout, when recurring often, to full into irregular forms, and herein lies its danger. One source of local aggravation is, indeed, soon apparent, and it leads rapidly to other evils. The joints which have been repeatedly the seat of the regular paroxysm, become more or less permanently, crippled and distorted. A white, friable, chalk-like material is gradually deposited around the cartilage and ligaments, and sometimes in the cellular tissue and under the skin. Sometimes this material is discharged externally by ulceration, and then usually with relief. At other times, it accumulates into irregular masses, or ‘ nodosities,’ which entirely destroy, or at least greatly impair, the movement of the limb. The patient is laid up more or less permanently in his arm-chair; and exercise, the great natural specific remedy of the gouty, is denied by the very conditions of the diseased state itself.

Then follow aggravations of all the constitutional sufferings; the more so, perhaps, in proportion as the local attacks in the foot become obscurely marked. Indigestion continues, or becomes constant, assuming the form chiefly of acidity after meals; the liver becomes tumid, the abdomen corpulent, the bowels disposed to costiveness; the kidney discharges a vitiated secretion, and not (infrequently there is a tendency to gravel and Calculus (q. v.); the heart is affected with palpitations, or fainting-fits occur, sometimes with spasmodic attacks of pain; the arteries become the seat of calcareous deposits, and the veins are varicose in the limbs and in the neighborhood of the lower bowel (see piles); the temper is singularly irritable, and often morose; then, sooner or later, the appetite fails, or is only kept up by very stimulating and unwholesome diet, with an excess of wine or of alcoholic liquors; in the end the body emaciates, the energy of all the functions becomes enfeebled, and the patient falls a prey to diarrhœa, or to some slight attack of incidental disease. Sometimes the end is sudden, as by apoplexy or structural disease of the heart; sometimes, on the other hand, it occurs in the midst of one of those violent spasms which have popularly acquired the name of ‘ gout in the stomach;’ the true character of these attacks, however, being by no means well understood.

The sketch here given of the leading external phenomena of gout is very incomplete, as every popular description, to be at all intelligible, must necessarily be. But the reader will not fail to see in it the type of a disease occurring under a number of remarkably varied forms, and lurking in the constitution, at times, under the most strangely anomalous disguises, or even under the general aspect of robust or rude health. It has been an object, accordingly, with physicians to trace out the gouty predisposition under the name of a habit of body, or diathesis, cognizable previously to any of the local manifestations. At this point, however, the ideas of authority usually become hazy, and their descriptions correspondingly ill defined or contradictory. The anomalous forms of the disease itself are also exceedingly difficult to describe accurately, and must on this account be left out of the present summary of the characters of the more usual aspects of gout, as it presents itself to physician and patient. The causes of the disease have been sufficiently indicated above.

One fact in regard to gout has relation to its intimate chemical and structural pathology, not less than to its outward characters; and forms, in fact, the pathological connection of a great number of its phenomena. The concretions found in the joints in all cases of well-marked and highly developed gout have nearly a uniform composition, into which the urate of soda (see uric acid) enters as a considerable proportion. Uric acid has long been known as one of the constant organic elements of the urine, through which it seems to be habitually expelled from the system. In certain circumstances, uric acid is deposited also in the form of

urinary gravel or Calculus (q. v.); and it is this particular kind of gravel to which the gouty are especially subject, as we have indicated above. A conjunction of facts so striking as these could not but arrest the attention of pathologists; and it is long since Sir Henry Holland and others threw out the hypothesis, that uric acid was to be regarded as the very materies morbi of gout, of which ancients and moderns had been so long in search. It would be out of place to enter on the discussion of this subject here; but it must be indicated as a fact of recent discovery, that uric acid in a certain excess has been shown by Dr. Garrod to be characteristic of the blood of the gouty, although a minute amount of this substance is probably present even in perfect health. The most recent speculations, accordingly, tend to connect the gouty predisposition either with an excessive formation, or a checked excretion, of this important nitrogenous organic acid, the product, as physiology teaches, of the vital disintegration of the flesh and of the food, after these have subserved the daily wants of the system. At this point, the inquiry rests for the present.

The cure of gout, in the highest sense of the word, demands the careful consideration of all its predisposing causes in the individual, and the strict regulation of the whole life and habits accordingly, from the earliest possible period. It is the difficulty of accomplishing this which makes gout a disease proverbially intractable; for the regular attacks of the disease seldom occur till pretty late in life, long after the habits have been fully formed which are most adverse to the cure. Rigid temperance in eating and drinking, with daily exercise proportionate to the strength and condition of the individual, in reality constitute the only radical cure of gout, the lesson of ages of experience as read to the gouty by the light of science. But the lesson is not learned, or only learned when too late. It should never be forgotten that a man of gouty family, or individually much exposed to the causes of the disease, can only hope to escape it in Ids old age by habits of life formed at an early period, and by a careful avoidance of most of the common dissipations of youth. That the disease may be warded off in this way, there is ample evidence; and it is not less certain that there is no other way of living secure from gout. The treatment of the fit, in so far as it does not resolve itself into the celebrated prescription of ‘patience and flannel,’ must be a subject of medical prescription. The well-known virtues of Colchicum (q. v.) are perhaps somewhat overrated by the public; and its dangers are not legs striking than its virtues. It is certain, however, that in cautious medical hands colchicum is a remedy of great value in the gouty paroxysm; and of equal value perhaps are certain natural mineral waters, as those of Vichy and Carlsbad. Alkalies and their salts, especially potash and lithia waters, as prepared artificially, with minute doses of iodine and bromine, have likewise been much recommended for the cure of gouty deposits. For the distinctions of gout and rheumatism, and the presumed relation between them in some cases, see rheumatism.