Gout.

Gout is closely related to articular rheumatism; indeed, by some
the two diseases are regarded as essentially identical. However,
they are so distinct in their symptoms and course as to be generally
recognized and described as distinct diseases. They may be
regarded as allied, just as typhoid and typhus fever are allied.
Gout occurs both as an acute and a chronic disease.

Symptoms.—In describing the symptoms, it becomes neces­
sary to distinguish between the transient acute cases, and those of
long duration, called chronic. The acute attack usually occurs
suddenly, often during the night. In many cases the patient has
retired in his usual health, though in others there may be certain pre­
monitory symptoms, such as pain in the region of the heart, belch­
ing of gas from the stomach, and mental depression or irritability.
These symptoms so frequently precede an attack of gout that many,
who have already experienced one attack, recognize in these symp­
toms the onset of another. The attack itself begins by extreme
pain in one of the joints, usually that between the great toe and the
foot. This pain is variously described by patients as like that of
the gnawing of an animal, the dislocation of the bone, or like tear­
ing the flesh with pincers. A feeling of throbbing accompanies
the pain, and there is usually considerable fever, sometimes pre­
ceded by a chill. These features continue for several hours before
subsiding; at the end of this time the patient is reasonably com­
fortable, and usually falls asleep.

This attack is usually followed on succeeding nights by repeti­
tions of a similar nature; either during these repetitions, or perhaps
during the first attack, the painful joint becomes swollen, reddened
and exquisitely tender. The local affection may be limited to the
joint originally affected, but often attacks also the corresponding
joint of the other foot, or spreads to the instep and hollow of the
foot. Indeed, in individuals who have repeatedly suffered from this
disease, numerous joints in different parts of the body, even of the
hands, may become similarly affected. In many cases the pain
lasts but a few hours, and returns again on the following night.
There are instances, however, in which the pain merely decreases
in intensity during the day without entirely ceasing. Cramp may
affect the muscles of the legs, the thigh, and even other parts of
the body, though this is a somewhat unusual symptom. These
attacks may return nightly for a week or for several weeks. The
long continued attacks are usually less severe than the brief ones;
the result may be entire recovery or continuation as the chronic
form of the disease. Chronic gout may be the result of a series
of acute attacks of gout, or may begin in a very mild manner. In
either case the symptoms which characterize the acute affection are
present in but slight degree. The disorder is rather a constitu­
tional one, that is to say, the symptoms manifested in the foot are
so slight that attention is directed to the constitutional derange­
ment. There are usually disorders of indigestion — dyspepsia,
pain in the stomach, derangement of the bowels. In many cases
these derangements have caused serious impairment of the general
health.

Sooner or later there occurs in the chronic cases of gout a con­
dition quite characteristic of this affection : masses resembling chalk
are formed in and around the small joints, and, indeed, some of the
large ones ; the joint of the great toe is especially apt to exhibit
this appearance. As a result, the joints become deformed, stiffened
and even incapable of any movement. Sometimes collections of
this chalk-like matter can be felt just under the skin, and if opened
this matter can be pressed out. Sometimes matter forms around
these masses and makes its way through the skin, resulting in the
formation of openings, called fistulæ. The result of all these
changes is that both hands and feet become strangely deformed,
presenting apprearances which have been likened to a bunch of
parsnips. Similar formations of chalk-like matter have been known
to occur in various parts of the skin, on the eyelids and in the ear.
There has long been an impression among medical men, which
has become a popular belief among the people, that gout may be
manifested, not merely in the joints, but also in the internal organs,
such as the stomach, heart and brain. Disorders which affect these
organs during an attack of gout are supposed to be due to the
gouty influence ; the gout has “ struck in. “ This expression is par­
ticularly applicable to those attacks of gout during which the affec­
tion of the joints suddenly ceases, and symptoms indicating some
derangement of some internal organ follow. There is, doubtless,
some connection between the local attack and the affection of the
internal organs. This is amply shown in the fact that remedies
addressed to the gout relieve these symptoms.

Those who have long been subject to gout usually present
certain disorders which constitute the dangers of the disease ; for
the local affection of the feet, or of the hands, however painful and
unsightly, contains no element of danger to the patient. One of
the most serious complications occurring in gouty patients is a dis­
ordered action of the heart. This disorder occasions not only pal­
pitation, shortness of breath, sense of suffocation and pain in the
region of the heart, but may even cause sudden death, in conse­
quence of the sudden stoppage of the heart’s action. Various
affections of the lungs also are popularly, and doubtless properly,
attributed to the gout. Among these are persistent cough, bron­
chitis and asthma. The explanation of many an intractable case of
asthma has been found in the gouty condition of the patient, and
relief from the asthma has followed remedies addressed to the gout.
So, too, various pains designated as neuralgia,— particularly neu
ralgia of the face and of the hip (sciatica)—periodical headache
and even hysteria, seem to be promoted by the gouty condition of
the patient.

Another most serious complication of the gout is a disease of
the kidney, one form of the so-called “ Bright’s disease.” This dis­
ease is so common among those affected with gout that the small,
hard kidneys characteristic of this affection are called “ gouty kid­
neys.” This form of Bright’s disease is not indicated by the symp­
toms characteristic of the ordinary acute Bright’s disease ; there is
no dropsy, no fever, in fact none of the usual signs. The most
characteristic feature, at least the one most readily recognized by
the non-professional observer, is the fact that the patient passes an
unusually large quantity of urine. These patients are almost always
advanced in years.

Cause,—Gout, like rheumatism, is a disease occurring with
especial frequency in certain families. It is, indeed, largely the
result of a hereditary taint, which may be transmitted through sev­
eral generations ; yet it is not always so inherited, since it may be
as readily acquired by errors in diet and the mode of life. Nor does
it follow that the children of gouty parents will themselves necessa­
rily suffer from gout. The tendency to the disease varies also with
the age ; it rarely occurs at an age under fifteen years, and then
only in the children of gouty parents. It affects most frequently
middle life, thirty to fifty years. Sex, too, exerts a marked influ­
ence over the disease, since women are very rarely affected with
gout. But the most direct and powerful influences leading to the
acquirement of gout seem to be the habitual use of over-stimulating
food, and of wine or malt liquor. The disease is proverbially fre­
quent among the wealthier classes of society, who are addicted to
luxurious habits of life, so that gout is regarded generally as one of
the penalties of wealth. It is impossible to ascribe accurately and
definitely the exact influence exerted by each one of the factors
which enter into a luxurious life ; it is, however, certain that over-
indulgence in the pleasures of the table, even without the use of
liquors, promotes the production of this disease. As a matter of
fact, gout is by no means a monopoly of the wealthy, since it is
quite common among the London laborers who drink porter and
stout to excess.

Treatment.—One of the most important measures in the
treatment of gout consists in the regulation of the diet; the avoid­
ance of excesses at the table and in the use of liquors is an evident
necessity. Among the remedies used during the attack, reliance is
chiefly placed upon colchicum and alkalies. Instead of the latter,
various mineral waters have been highly recommended by different
authors; perhaps the most noted and universally used of these is
the so-called “ Lithia Water,” which may be obtained at the drug­
gist^. This is, in reality, not a natural mineral water, but an artificial
solution made by dissolving the citrate of lithia. If this be not
procurable, a solution of magnesia and colchicum may be em­
ployed as follows:

Wine of colchicum root, ... One drachm.
Magnesia, ------ One drachm.
Peppermint water, -                                Four ounces.
Mix; take a tablespoonful three times a day.

It may be necessary also to protect the inflamed joint; this may
be accomplished by the means prescribed in treating of rheuma­
tism— by enveloping the joint in cotton, or by wrapping it with
cloths which have been saturated with the tincture of belladonna or
with the tincture of aconite. The chloroform liniment will also be
found advantageous for local use in this affection. During the par­
oxysms it may be necessary to relieve pain by the use of opiates;
for this purpose twenty drops of laudanum, or ten grains of Dover’s
powder may be employed. If the opiate cause unpleasant effects,
such as nausea and headache, we may substitute ten drops of the
tincture of belladonna, which may be repeated in two or three
hours. In the intervals between the attacks the diet must also be
restricted—should embrace no wines or malt liquors, and but
little, if any, meat; a simple, unstimulating diet of milk, eggs, fish
and vegetables will materially assist in preventing the return of the
attack. So, too, the remedies useful in treating the paroxysm —
especially the colchicum — may be continued during the intervals
between the attacks. If the indications, such as dyspeptic symp­
toms, render the patient suspicious of an approaching attack, it will
be well to employ the colchicum and the alkalies in advance. For
there is reason to believe that impending attacks can be in this way
warded off.

The local affections of the joints may sometimes require atten­
tion after the severity of the paroxysm has subsided, for, as already
said, the joints are often rendered permanently stiff and deformed by
the deposit in and around them of chalk-like masses. This stiff­
ness can be sometimes partially relieved by systematic gentle
friction, and by the arrangement of the shoes so as to afford the
parts ample room. The swelling can be sometimes diminished
before the deposit of chalk is apparent, by the use of repeated
blisters, not allowed to remain long enough to produce excessive
blistering. After this chalk-like matter has been deposited in
abundance no measures can be successfully applied for its removal.
With reference to the use of mineral waters, Dr. Garrod, the
most eminent authority on this subject, says : “ They should be
altogether prohibited when there is considerable structural disease in
any important organs, especially in the heart or kidneys ; and even
when the organic mischief is slight, the greatest caution is necessary
in their use. They should be avoided when an acute attack is
either present or threatening.

“ The waters should be selected according to the nature of the
case. When the patient is robust and of a full habit, the alkaline-
saline springs; when torpidity of the bowels predominates, the
purgative waters ; when there is a want of vascular action, the
saline water ; when the skin is inactive, the sulphur springs ; lastly,
when debility prevails, then the more simple warm waters should
be chosen. In all cases the use of the waters should be cautiously
commenced, and care taken not to oppress the stomach by giving
too much liquid, nor to induce debility or any other injurious
effects by allowing a too long sojourn in the bath. “

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