Gout

Gout, the name rather vaguely given, in medicine, to a constitutional disorder which manifests itself by inflammation of the joints, with sometimes deposition of urates of soda, and also by morbid changes in various important organs. The term gout, which was first used about the end of the 13th century, is derived through the Fr. goutte from the Lat. gutta, a drop, in allusion to the old pathological doctrine of the dropping of a morbid material from the blood within the joints. The disease was known and described by the ancient Greek physicians under various terms, which, however, appear to have been applied by them alike to rheumatism and gout. The general term arthritis (ἄρθρον, a joint) was employed when many joints were the seat of inflammation; while in those instances where the disease was limited to one part the terms used bore reference to such locality; hence podagra (ποδάγρα, from πούς, the foot, and ἅγρα, a seizure), chiragra (χείρ, the hand), gonagra (γόνυ, the knee), &c.

Hippocrates in his Aphorisms speaks of gout as occurring most commonly in spring and autumn, and mentions the fact that women are less liable to it than men. He also gives directions as to treatment. Celsus gives a similar account of the disease. Galen regarded gout as an unnatural accumulation of humours in a part, and the chalk-stones as the concretions of these, and he attributed the disease to over-indulgence and luxury. Gout is alluded to in the works of Ovid and Pliny, and Seneca, in his 95th epistle, mentions the prevalence of gout among the Roman ladies of his day as one of the results of their high living and debauchery. Lucian, in his Tragopodagra, gives an amusing account of the remedies employed for the cure of gout.

In all times this disease has engaged a large share of the attention of physicians, from its wide prevalence and from the amount of suffering which it entails. Sydenham, the famous English physician of the 17th century, wrote an important treatise on the subject, and his description of the gouty paroxysm, all the more vivid from his having himself been afflicted with the disease for thirty-four years, is still quoted by writers as the most graphic and exhaustive account of the symptomatology of gout. Subsequently Cullen, recognizing gout as capable of manifesting itself in various ways, divided the disease into regular gout, which affects the joints only, and irregular gout, where the gouty disposition exhibits itself in other forms; and the latter variety he subdivided into atonic gout, where the most prominent symptoms are throughout referable to the stomach and alimentary canal; retrocedent gout, where the inflammatory attack suddenly disappears from an affected joint and serious disturbance takes place in some internal organ, generally the stomach or heart; and misplaced gout, where from the first the disease does not appear externally, but reveals itself by an inflammatory attack of some internal part. Dr Garrod, one of the most eminent authorities on gout, adopted a division somewhat similar to, though simpler than that of Cullen, namely, regular gout, which affects the joints alone, and is either acute or chronic, and irregular gout, affecting non-articular tissues, or disturbing the functions of various organs.

It is often stated that the attack of gout comes on without any previous warning; but, while this is true in many instances, the reverse is probably as frequently the case, and the premonitory symptoms, especially in those who have previously suffered from the disease, may be sufficiently precise to indicate the impending seizure. Among the more common of these may be mentioned marked disorders of the digestive organs, with a feeble and capricious appetite, flatulence and pain after eating, and uneasiness in the right side in the region of the liver. A remarkable tendency to gnashing of the teeth is sometimes observed. This symptom was first noticed by Dr Graves, who connected it with irritation in the urinary organs, which also is present as one of the premonitory indications of the gouty attack. Various forms of nervous disturbance also present themselves in the form of general discomfort, extreme irritability of temper, and various perverted sensations, such as that of numbness and coldness in the limbs. These symptoms may persist for many days and then undergo amelioration immediately before the impending paroxysm. On the night of the attack the patient retires to rest apparently well, but about two or three o’clock in the morning awakes with a painful feeling in the foot, most commonly in the ball of the great toe, but it may be in the instep or heel, or in the thumb. With the pain there often occurs a distinct shivering followed by feverishness. The pain soon becomes of the most agonizing character: in the words of Sydenham, “now it is a violent stretching and tearing of the ligaments, now it is a gnawing pain, and now a pressure and tightening; so exquisite and lively meanwhile is the part affected that it cannot bear the weight of the bedclothes, nor the jar of a person walking in the room.”

When the affected part is examined it is found to be swollen and of a deep red hue. The superjacent skin is tense and glistening, and the surrounding veins are more or less distended. After a few hours there is a remission of the pain, slight perspiration takes place, and the patient may fall asleep. The pain may continue moderate during the day but returns as night advances, and the patient goes through a similar experience of suffering to that of the previous night, followed with a like abatement towards morning. These nocturnal exacerbations occur with greater or less severity during the continuance of the attack, which generally lasts for a week or ten days. As the symptoms decline the swelling and tenderness of the affected joint abate, but the skin over it pits on pressure for a time, and with this there is often associated slight desquamation of the cuticle. During the attacks there is much constitutional disturbance. The patient is restless and extremely irritable, and suffers from cramp in the limbs and from dyspepsia, thirst and constipation. The urine is scanty and high-coloured, with a copious deposit, consisting chiefly of urates. During the continuance of the symptoms the inflammation may leave the one foot and affect the other, or both may suffer at the same time. After the attack is over the patient feels quite well and fancies himself better than he had been for a long time before; hence the once popular notion that a fit of the gout was capable of removing all other ailments. Any such idea, however, is sadly belied in the experience of most sufferers from this disease. It is rare that the first is the only attack of gout, and another is apt to occur within a year, although by care and treatment it may be warded off. The disease, however, undoubtedly tends to take a firmer hold on the constitution and to return. In the earlier recurrences the same joints as were formerly the seat of the gouty inflammation suffer again, but in course of time others become implicated, until in advanced cases scarcely any articulation escapes, and the disease thus becomes chronic. It is to be noticed that when gout assumes this form the frequently recurring attacks are usually attended with less pain than the earlier ones, but their disastrous effects are evidenced alike by the disturbance of various important organs, especially the stomach, liver, kidneys and heart, and by the remarkable changes which take place in the joints from the formation of the so-called chalk-stones or tophi. These deposits, which are highly characteristic of gout, appear at first to take place in the form of a semifluid material, consisting for the most part of urate of soda, which gradually becomes more dense, and ultimately quite hard. When any quantity of this is deposited in the structures of a joint the effect is to produce stiffening, and, as deposits appear to take place to a greater or less amount in connexion with every attack, permanent thickening and deformity of the parts is apt to be the consequence. The extent of this depends, of course, on the amount of the deposits, which, however, would seem to be in no necessary relation to the severity of the attack, being in some cases even of chronic gout so slight as to be barely appreciable externally, but on the other hand occasionally causing great enlargement of the joints, and fixing them in a flexed or extended position which renders them entirely useless. Dr Garrod describes the appearance of a hand in an extreme case of this kind, and likens its shape to a bundle of French carrots with their heads forward, the nails corresponding to the stalks. Any of the joints may be thus affected, but most commonly those of the hands and feet. The deposits take place in other structures besides those of joints, such as along the course of tendons, underneath the skin and periosteum, in the sclerotic coat of the eye, and especially on the cartilages of the external ear. When largely deposited in joints an abscess sometimes forms, the skin gives way, and the concretion is exposed. Sir Thomas Watson quotes a case of this kind where the patient when playing at cards was accustomed to chalk the score of the game upon the table with his gouty knuckles.

The recognition of what is termed irregular gout is less easy than that form above described, where the disease gives abundant external evidence of its presence; but that other parts than joints suffer from gouty attacks is beyond question. The diagnosis may often be made in cases where in an attack of ordinary gout the disease suddenly leaves the affected joints and some new series of symptoms arises. It has been often observed when cold has been applied to an inflamed joint that the pain and inflammation in the part ceased, but that some sudden and alarming seizure referable to the stomach, brain, heart or lungs supervened. Such attacks, which correspond to what is termed by Cullen retrocedent gout, often terminate favourably, more especially if the disease again returns to the joints. Further, the gouty nature of some long-continued internal or cutaneous disorder may be rendered apparent by its disappearance on the outbreak of the paroxysm in the joints. Gout, when of long standing, is often found associated with degenerative changes in the heart and large arteries, the liver, and especially the kidneys, which are apt to assume the contracted granular condition characteristic of one of the forms of Bright’s disease. A variety of urinary calculus—the uric acid—formed by concretions of this substance in the kidneys is a not unfrequent occurrence in connexion with gout; hence the well-known association of this disease and gravel.

The pathology of gout is discussed in the article on Metabolic Diseases. Many points, however, still remain unexplained. As remarked by Trousseau, “the production in excess of uric acid and urates is a pathological phenomenon inherent like all others in the disease; and like all the others it is dominated by a specific cause, which we know only by its effects, and which we term the gouty diathesis.” This subject of diathesis (habit, or organic predisposition of individuals), which is regarded as an essential element in the pathology of gout, naturally suggests the question as to whether, besides being inherited, such a peculiarity may also be acquired, and this leads to a consideration of the causes which are recognized as influential in favouring the occurrence of this disease.

It is beyond dispute that gout is in a marked degree hereditary, fully more than half the number of cases being, according to Sir C. Scudamore and Dr Garrod, of this character. But it is no less certain that there are habits and modes of life the observance of which may induce the disease even where no hereditary tendencies can be traced, and the avoidance of which may, on the other hand, go far towards weakening or neutralizing the influence of inherited liability. Gout is said to affect the sedentary more readily than the active. If, however, inadequate exercise be combined with a luxurious manner of living, with habitual over-indulgence in animal food and rich dishes, and especially in alcoholic beverages, then undoubtedly the chief factors in the production of the disease are present.

Much has been written upon the relative influence of various forms of alcoholic drinks in promoting the development of gout. It is generally stated that fermented are more injurious than distilled liquors, and that, in particular, the stronger wines, such as port, sherry and madeira, are much more potent in their gout-producing action than the lighter class of wines, such as hock, moselle, &c., while malt liquors are fully as hurtful as strong wines. It seems quite as probable, however, that over-indulgence in any form of alcohol, when associated with the other conditions already adverted to, will have very much the same effect in developing gout. The comparative absence of gout in countries where spirituous liquors are chiefly used, such as Scotland, is cited as showing their relatively slight effect in encouraging that disease; but it is to be noticed that in such countries there is on the whole a less marked tendency to excess in the other pleasures of the table, which in no degree less than alcohol are chargeable with inducing the gouty habit. Gout is not a common disease among the poor and labouring classes, and when it does occur may often be connected even in them with errors in living. It is not very rare to meet gout in butlers, coachmen, &c., who are apt to live luxuriously while leading comparatively easy lives.

Gout, it must ever be borne in mind, may also affect persons who observe the strictest temperance in living, and whose only excesses are in the direction of over-work, either physical or intellectual. Many of the great names in history in all times have had their existence embittered by this malady, and have died from its effects. The influence of hereditary tendency may often be traced in such instances, and is doubtless called into activity by the depressing consequences of over-work. It may, notwithstanding, be affirmed as generally true that those who lead regular lives, and are moderate in the use of animal food and alcoholic drinks, or still better abstain from the latter altogether, are less likely to be the victims of gout even where an undoubted inherited tendency exists.

Gout is more common in mature age than in the earlier years of life, the greatest number of cases in one decennial period being between the ages of thirty and forty, next between twenty and thirty, and thirdly between forty and fifty. It may occasionally affect very young persons; such cases are generally regarded as hereditary, but, so far as diet is concerned, it has to be remembered that their home life has probably been a predisposing cause. After middle life gout rarely appears for the first time. Women are much less the subjects of gout than men, apparently from their less exposure to the influences (excepting, of course, that of heredity) which tend to develop the disease, and doubtless also from the differing circumstances of their physical constitution. It most frequently appears in females after the cessation of the menses. Persons exposed to the influence of lead poisoning, such as plumbers, painters, &c., are apt to suffer from gout; and it would seem that impregnation of the system with this metal markedly interferes with the uric acid excreting function of the kidneys.

Attacks of gout are readily excited in those predisposed to the disease. Exposure to cold, disorders of digestion, fatigue, and irritation or injuries of particular joints will often precipitate the gouty paroxysm.

With respect to the treatment of gout the greatest variety of opinion has prevailed and practice been pursued, from the numerous quaint nostrums detailed by Lucian to the “expectant” or do-nothing system recommended by Sydenham. But gout, although, as has been shown, a malady of a most severe and intractable character, may nevertheless be successfully dealt with by appropriate medicinal and hygienic measures. The general plan of treatment can be here only briefly indicated. During the acute attack the affected part should be kept at perfect rest, and have applied to it warm opiate fomentations or poultices, or, what answers quite as well, be enveloped in cotton wool covered in with oil silk. The diet of the patient should be light, without animal food or stimulants. The administration of some simple laxative will be of service, as well as the free use of alkaline diuretics, such as the bicarbonate or acetate of potash. The medicinal agent most relied on for the relief of pain is colchicum, which manifestly exercises a powerful action on the disease. This drug (Colchicum autumnale), which is believed to correspond to the hermodactyl of the ancients, has proved of such efficacy in modifying the attacks that, as observed by Dr Garrod, “we may safely assert that colchicum possesses as specific a control over the gouty inflammation as cinchona barks or their alkaloids over intermittent fever.” It is usually administered in the form of the wine in doses of 10 to 30 drops every four or six hours, or in pill as the acetous extract (gr. ½-gr. i.). The effect of colchicum in subduing the pain of gout is generally so prompt and marked that it is unnecessary to have recourse to opiates; but its action requires to be carefully watched by the physician from its well-known nauseating and depressing consequences, which, should they appear, render the suspension of the drug necessary. Otherwise the remedy may be continued in gradually diminishing doses for some days after the disappearance of the gouty inflammation. Should gout give evidence of its presence in an irregular form by attacking internal organs, besides the medicinal treatment above mentioned, the use of frictions and mustard applications to the joints is indicated with the view of exciting its appearance there. When gout has become chronic, colchicum, although of less service than in acute gout, is yet valuable, particularly when the inflammatory attacks recur. More benefit, however, appears to be derived from potassium iodide, guaiacum, the alkalis potash and lithia, and from the administration of aspirin and sodium salicylate. Salicylate of menthol is an effective local application, painted on and covered with a gutta-percha bandage. Lithia was strongly recommended by Dr Garrod from its solvent action upon the urates. It is usually administered in the form of the carbonate (gr. v., freely diluted).

The treatment and regimen to be employed in the intervals of the gouty attacks are of the highest importance. These bear reference for the most part to the habits and mode of life of the patient. Restriction must be laid upon the amount and quality of the food, and equally, or still more, upon the alcoholic stimulants. “The instances,” says Sir Thomas Watson, “are not few of men of good sense, and masters of themselves, who, being warned by one visitation of the gout, have thenceforward resolutely abstained from rich living and from wine and strong drinks of all kinds, and who have been rewarded for their prudence and self-denial by complete immunity from any return of the disease, or upon whom, at any rate, its future assaults have been few and feeble.” The same eminent authority adds: “I am sure it is worth any young man’s while, who has had the gout, to become a teetotaller.” By those more advanced in life who, from long continued habit, are unable entirely to relinquish the use of stimulants, the strictest possible temperance must be observed. Regular but moderate exercise in the form of walking or riding, in the case of those who lead sedentary lives, is of great advantage, and all over-work, either physical or mental, should be avoided. Fatiguez la bête, et reposez la tête is the maxim of an experienced French doctor (Dr Debout d’Estrées of Contrexéville). Unfortunately the complete carrying out of such directions, even by those who feel their importance, is too often rendered difficult or impossible by circumstances of occupation and otherwise, and at most only an approximation can be made. Certain mineral waters and baths (such as those of Vichy, Royat, Contrexéville, &c.) are of undoubted value in cases of gout and arthritis. The particular place must in each case be determined by the physician, and special caution must be observed in recommending this plan of treatment in persons whose gout is complicated by organic disease of any kind.

Dr Alexander Haig’s “uric acid free diet” has found many adherents. His view as regards the pathology is that in gouty persons the blood is less alkaline than in normal, and therefore less able to hold in solution uric acid or its salts, which are retained in the joints. Assuming gout to be a poisoning by animal food (meat, fish, eggs), and by tea, coffee, cocoa and other vegetable alkaloid-containing substances, he recommends an average daily diet excluding these, and containing 24 oz. of breadstuffs (toast, bread, biscuits and puddings) together with 24 oz. of fruit and vegetables (excluding peas, beans, lentils, mushrooms and asparagus); 8 oz. of the breadstuffs may be replaced by 21 oz. of milk or 2 oz. of cheese, butter and oil being taken as required, so that it is not strictly a vegetarian diet.

Precisely the opposite view as to diet has recently been put forward by Professor A. Robin of the Hôpital Beaujon, who says serious mistakes are made in ordering patients to abstain from red meats and take light food, fish, eggs, &c. The common object in view is the diminished output of uric acid. This output is chiefly obtained from food rich in nucleins and in collagenous matters, i.e. young white meats, eggs, &c. Consequently the gouty subject ought to restrict himself to the consumption of red meat, beef and mutton, and leave out of his dietary all white meat and internal organs. He should take little hydrocarbons and sugars, and be moderate in fats. Vegetarian diet he regards as a mistake, likewise milk diet, as they tend to weaken the patient. To prevent the formation of uric acid Robin prescribes quinic acid combined with formine or urotropine.

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