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GOUT
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GOUT , the name rather vaguely given, in See also:medicine, to a constitutional disorder which manifests itself by inflammation of the See also:joints, with sometimes deposition of urates of soda, and also by morbid changes in various important See also:organs. The See also:term gout, which was first used about the end of the 13th See also:century, is derived through the Fr. goutte from the See also:Lat. See also:gutta, a drop, in allusion to the old pathological See also:doctrine of the dropping of a morbid material from the See also:blood within the joints. The disease was known and described by the See also:ancient See also:Greek physicians under various terms, which, however, appear to have been applied by them alike to See also:rheumatism and gout. The See also:general term See also:arthritis (apOpov, a See also:joint) was employed when many joints were the seat of inflammation; while in those instances where the disease was limited to one See also:part the terms used See also:bore reference to such locality; hence podagra (aoSaypa, from robs, the See also:foot, and try pa, a seizure), chiragra (xelp, the See also:hand), gonagra (yovu, the See also:knee), &c. See also:Hippocrates in his- Aphorisms speaks of gout as occurring most commonly in See also:spring and autumn, and mentions the fact that See also:women are less liable to it than men. He also gives directions as to treatment. See also:Celsus gives a similar See also:account of the disease. See also:Galen regarded gout• as an unnatural See also:accumulation of humours in a part, and the See also:chalk-stones as the concretions of these, and he attributed the disease to over-See also:indulgence and luxury. Gout is alluded to in the See also:works of See also:Ovid and See also:Pliny, and See also:Seneca, in his, 95th See also:epistle, mentions the prevalence of gout among the See also:Roman ladies of his See also:day as one of the results of their high living and debauchery. See also: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 See also:share of the See also:attention of physicians, from its wide prevalence and from the amount of suffering which it entails. See also:Sydenham, the famous See also:English physician of the 17th century, wrote an important See also:treatise on the subject, and his description of the gouty See also:paroxysm, all the more vivid from his having himself been afflicted with the disease for See also:thirty-four years, is still quoted by writers as the most graphic and exhaustive account of the symptomatology of gout. Subsequently See also:Cullen, recognizing gout as capable of manifesting itself in various ways, divided the disease into See also: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 See also:stomach and alimentary See also:canal; retrocedent gout, where the inflammatory attack suddenly disappears from an affected joint and serious disturbance takes See also:place in some See also:internal See also:organ, generally the stomach or See also: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 See also: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 fhe 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 See also:reverse is probably as frequently the See also:case, and the pre-monitory symptoms, especially in those who have previously suffered from the disease, may be sufficiently precise to indicate289 the impending seizure. Among the more See also:common of these may be mentioned marked disorders of the See also:digestive organs, with a feeble and capricious appetite, flatulence and See also:pain after eating, and uneasiness in the right See also:side in the region of the See also:liver. A remarkable tendency to gnashing of the See also:teeth is sometimes observed. This symptom was first noticed by Dr See also:Graves, who connected it with irritation in the urinary organs, which also is See also:present as one of the premonitory indications of the gouty attack. Various forms of See also:nervous disturbance also present themselves in the See also:form of general discomfort, extreme irritability of See also: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 See also:night of the attack the patient retires to See also:rest apparently well, but about two or three o'See also:clock in the See also:morning awakes with a painful feeling in the foot, most commonly in the See also:ball of the See also:great toe, but it may be in the instep or See also: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 See also: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 See also:bear the See also:weight of the bedclothes, nor the See also:jar of a See also:person walking in the See also:room." When the affected part is examined it is found to be swollen and of a deep red See also:hue. The superjacent skin is tense and glistening, and the surrounding See also:veins are more or less distended. After a few See also:hours there is a remission of the pain, slight See also: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 See also:abatement towards morning. These nocturnal exacerbations occur with greater or less severity during the continuance of the attack, which generally lasts for a See also: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 See also: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 See also:cramp in the limbs and from See also:dyspepsia, thirst and See also:constipation. The urine is scanty and high-coloured, with a copious See also: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 See also:long time before; hence the once popular notion that a See also:fit of the gout was capable of removing all other ailments. Any such See also: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 See also:apt to occur within a See also: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 See also: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
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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 See also:appearance of a hand in an extreme case of this See also:kind, and likens its shape to a bundle of See also: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 See also:eye, and especially on the cartilages of the See also:external See also:ear. When largely deposited in joints an See also:abscess sometimes forms, the skin gives way, and the See also:concretion is exposed. See also:Sir See also: It has been often observed when See also: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, See also: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 See also:standing, is often found associated with degenerative changes in the heart and large See also:arteries, the liver, and especially the kidneys, which are apt to assume the contracted granular See also:condition characteristic of one of the forms of See also:Bright's disease. A variety of urinary calculus—the uric See also: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 See also:gravel. The See also:pathology of gout is discussed in the See also:article on METABOLIC DISEASES. Many points, however, still remain unexplained. As remarked by Trousseau, " the See also: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 (See also:habit, or organic predisposition of individuals), which is regarded as an essential See also: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 See also: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 See also: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 See also: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 See also: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 See also:animal See also:food and See also:rich dishes, and especially in alcoholic beverages, then undoubtedly the See also:chief factors in the production of the disease are present. Much has been written upon the relative influence of variousforms 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 See also:port, See also:sherry and See also:madeira, are much more potent in their gout-producing See also:action than the lighter class of wines, such as hock, moselle, &c., while See also:malt liquors are fully as hurtful as strong wines. It seems quite as probable, however,that over-indulgence in any form of See also:alcohol, when associated with the other conditions already adverted to, will have very much the same effect in developing gout. The See also:comparative See also:absence of gout in countries where spirituous liquors are chiefly used, such as See also: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 See also:borne in mind, may also affect persons who observe the strictest See also:temperance in living, and whose only excesses are in the direction of over-See also:work, either See also:physical or intellectual. Many of the great names in See also: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 See also: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 See also:age than in the earlier years of life, the greatest number of cases in one decennial See also:period being between the ages of thirty and See also:forty, next between twenty and thirty, and thirdly between forty and fifty. It may occasionally affect very See also:young persons; such cases are generally regarded as hereditary, but, so far as See also:diet is concerned, it has to be remembered that their See also:home life has probably been a predisposing cause. After See also: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 See also:heredity) which tend to develop the disease, and doubtless also from the differing circumstances of their physical constitution. It most frequently appears in See also: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 See also:system with this See also:metal markedly interferes with the uric acid excreting See also: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 See also:opinion has prevailed and practice been pursued, from the numerous See also: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 See also:measures. The general See also: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 See also:cotton See also:wool covered in with oil See also:silk. The diet of the patient should be See also:light, without animal food or stimulants. The See also:administration of some See also:simple laxative will be of service, as well as the See also:free use of alkaline diuretics, such as the bicarbonate or acetate of potash. The medicinal See also:agent most relied on for the See also:relief of pain is See also:colchicum, which manifestly exercises a powerful action on the disease. This See also: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 See also:control over the gouty inflammation as See also:cinchona barks or their alkaloids over intermittent See also:fever." It is usually administered in the form of the See also:wine in doses of to to 3o drops every four or six hours, or in pill as the acetous See also:extract (gr. i-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 ieregular form by attacking internal organs, besides the medicinal treatment above mentioned, the use of frictions and See also: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 See also:potassium iodide, See also:guaiacum, the alkalis potash and lithia, and from the administration of aspirin and See also:sodium salicylate. Salicylate of menthol is an effective See also: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 See also: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 See also:complete See also:immunity from any return of the disease, or upon whom, at any See also:rate, its future assaults have been few and feeble." The same eminent authority adds: " I am sure it is See also:worth any young See also: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 See also:riding, in the case of those who lead sedentary lives, is of great See also:advantage, and all over-work, either physical or See also:mental, should be avoided. Fatigues k bete, et reposez la teete is the See also:maxim of an experienced French See also:doctor (Dr• Debout d'See also:Estrees of See also:Contrexeville). 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 See also:mineral See also:waters and See also:baths (such as those of See also:Vichy, See also:Royat, Contrexeville, &c.) are of undoubted value in cases of gout and arthritis. The particular place must in each case be determined by the physician, and See also:special caution must be observed in recommending this plan of treatment in persons whose gout is complicated by organic disease of any kind.
Dr See also: See also:Robin of the Hopital Beaujon, who says serious mistakes are made in ordering patients to abstain from red meats and take light food, fish, eggs, &c. The common See also: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 See also: Additional information and CommentsThere are no comments yet for this article.
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