Definition.—An abnormal metabolism, attended by an excessive formation of uric acid, and characterized clinically by polyarthritis, affecting mostly the small articulations, and by the gradual deposit of sodium urate in and about the joints, and attended by various systemic disturbances.
Etiology.—Various theories have been advanced as to the cause and nature of gout. Among the predisposing or contributing causes may be mentioned:
- Heredity.—Statistics show that in more than fifty per cent of all cases reported, the disease existed in the parents or grandparents.
- Age.—Gout is mostly found between the ages of thirty and fifty, though, when the hereditary taint is very strong, it may occur before puberty, and in very rare cases it is found in infancy.
- Sex.—Males are more often affected than females, no doubt on account of males being addicted to the drink habit.
- Diet and Social Condition.—Indulging the appetite in rich foods, sweet wines, and malt liquors, with defective muscular exercise, is a prolific source of the disease, and occurs more frequently among the wealthy classes. It is not rare, however, to find gout among the poorer classes, who drink large quantities of malt liquors, and whose food is insufficient in quantity and quality. This is known as "poor man's" gout. The consumption of a large quantity of malt liquors by either rich or poor is a contributing cause.
Chronic lead-poisoning also predisposes to the disease.
These various contributing causes result in a disordered metabolism, in which uric acid is found in excess, but the exact nature of the disease has not yet been proven.
Pathology.—The characteristic anatomical changes consist in the deposit of urate of sodium in and about the joints, the ligaments, and the synovial membrane. In rare cases the deposits are found in the cartilages of the ear, nose, eyelids, and larynx.
The kidneys are the most frequently involved of the internal organs.
In the early stage the acid and sodium salts are in a fluid state, but soon "small, chalky-white dots or lines beneath the surface of the articular cartilage appear, and progressively increase in size, coalesce into larger coherent surfaces, and give rise to destruction and deformity of the articular surfaces." These white, chalky deposits are known as chalk-stones or tophi.
The joint first attacked is usually the great toe, the articulation farthest from the center of circulation; then the ankles, knees, and small joints of the hands and wrists follow in the order mentioned. Not infrequently the skin covering these chalky masses gives way, and the deposits appear externally through the ulcerated opening.
These chalky deposits excite secondary inflammatory changes, which result in fibrous overgrowths, leaving marked deformities of the joints and ankylosis.
In the kidneys the uratic deposits are principally in the papillae, though to some extent throughout the organ.
Arteriosclerosis is always present in the blood-vessels of advanced cases, and this in turn gives rise to cardiac hypertrophy. especially of the left ventricle. Uratic deposits have been noted on the valves.
Symptoms.—Gout is generally a chronic disease, coming on insidiously after months of disturbed metabolism, though it frequently begins as an acute articular gout, gradually assuming the chronic form.
Acute Form.—This form is usually preceded by prodromal symptoms for several days. The patient complains of a bad taste, coated tongue, acrid eructations, pain in the head, vomiting and diarrhea; or asthmatic seizures may disturb the patient's rest. Again there are mental disturbances, the patient being restless and irritable; his sleep is disturbed, followed by great depression of spirits.
Muscular pains and cramps, with fugitive pains in the articulations, are not uncommon. The urine is scanty, high-colored, and there may be albumin present, while traces of sugar may be found—gouty glycosuria. In rare cases the patient feels better than usual the day preceding the attack.
The attack usually begins after midnight, the patient being wakened by intense pain in the metatarso-phalangeal articulation of the great toe. The pain is excruciating, and is described as burning, boring, or crushing in character, as though the toe was in a vise. The toe rapidly becomes swollen, red, and shiny, and the least motion causes exquisite pain. With these local symptoms the temperature rises to 101°, 102°, or 103°. The paroxysm lasts two, three, or four hours, when the temperature falls, the pain subsides, the patient freely perspires, and the suffering is temporarily at an end. The toe remains puffy and swollen, and is somewhat edematous.
During the early hours of the following morning there is a recurrence of the symptoms of the preceding night. Sometimes other joints are involved at the same time, notably the opposite toe and the small joints of the hand or wrist. These attacks occur nightly for from three to eight days, gradually becoming less severe after the second night. The swelling slowly subsides, desquamation of the skin follows, and during the quiet that follows the storm, the health seems improved.
The patient, now truly penitent, observes better habits, and is more careful of his diet, eschews fermented drinks, and for a time there is really an improvement in the general health. After several months, however, the patient grows careless, there is a return to the same conditions that brought about the first attack, and in from a few months to a year or more he again suffers an attack, to be repeated at more frequent intervals, while more joints become affected. One characteristic feature of the tense, swollen joint is that suppuration never takes place.
Retrocedent Gout.—These paroxysms sometimes terminate differently, the pain being transferred to some internal organ, when it is termed retrocedent gout. The pain quickly subsides from the affected joint, to appear with great intensity in some internal viscus. When the stomach is the seat of the metastasis, there is intense pain in the epigastrium, vomiting, diarrhea, and great prostration, sometimes terminating in death.
When the heart is the organ attacked, there is intense pain, dyspnea, irregular pulse, anxious countenance, with great mental distress, the patient fearing early dissolution. Acute pericarditis has followed such metastasis, terminating fatally.
At other times the head receives the force of the attack, and cerebral disturbances are most marked, as shown by delirium, coma, and apoplexy.
Chronic Gout.—As the attacks become more frequent, more joints are affected and the paroxysms last longer, though not of such a severe character. The deposits progressively increase, first in the cartilages, to be followed by deposits in the ligaments and capsular tissues. This is followed by unsightly deformities and loss "of articular motion.
Where the chalky deposits are near the surface, as in the knuckles, the skin sometimes gives way, the chalk-stones being exposed. The fingers are deflected to the ulnar side, the one overlapping, as may be seen so often in arthritis deformans.
Although the patient may display great mental and bodily vigor, there is usually more or less disturbance of the stomach and bowels, while the stiffened blood-vessels, hypertrophied heart, and tensive character of the pulse, proclaim arterio-sclerosis.
The urine, plentiful, but of low specific gravity and containing traces of albumin and tube-casts, proclaims degenerative changes in the kidney.
Irregular Gout.—Whenever gout manifests itself in other parts than the articulations, it has been termed irregular gout. The subjects of this form are usually the offspring of gouty parents, though the condition may be acquired. The uratic deposits occur in the various tissues in sufficient quantities to give rise to a multitude of unpleasant symptoms.
Myalgia.—It is not uncommon to find patients of a gouty diathesis to suffer with muscular soreness in the cervical and lumbar regions. A favorite location for the pain is also in the abductors of the leg. These pains are more severe on waking in the morning, and disappear as the day progresses.
Nervous Manifestations.—Headache is one of the common heritages of the gouty subject, while neuralgias are often found, especially of the sciatic nerve. The itching, tingling, and burning sensation so often experienced in the palms of the hand, soles of the feet, and eyeballs, are always suggestive of gout.
Gastro-Intestinal Disorders.—Disturbance of the digestive apparatus is quite common, and is manifested by frequent attacks of vomiting, cramps, diarrhea, and abdominal pain.
Cardio-Vascular Symptoms.—The increased amount of uric acid always makes more or less impression on the vascular system. This may be shown by increased arterial tension, by renal degeneration, or cardiac disturbance. Albuminuria and dropsical effusion would point to lesion of the kidneys, while an irregular pulse, dyspnea, and palpitation would show cardiac disturbance.
Cutaneous Eruptions.—The various forms of eczema are quite often associated with the gouty habit, and are more intractable than when appearing at other times.
Urinary Disorders.—Among the more frequent complications are renal disorders. The urine is excessively acid, and not infrequently contains albumin and tube-casts, while glycosuria is not rare. Renal colic frequently occurs, while disturbances of the bladder and urethra are found, and calculi, both renal and vesical, are common.
Pulmonary Affections.—Chronic bronchitis, asthma, and emphysema are frequent complications of a gouty constitution.
Eye Affections.—Conjunctivitis, iritis, keratitis, hemorrhagic retinitis, and glaucoma, are lesions of the eye, found in gout.
Diagnosis.—When we get a family history of gout in a patient who is addicted to high living, who consumes large quantities of fermented liquors, who leads a sedentary life, and who is attacked after midnight with excruciating pain in the great toe, which rapidly becomes red and swollen, and which, after two to four hours of pain, subsides, to be repeated again the following midnight, the diagnosis is very readily made.
When, however, other joints than the toe are affected, especially before the chalky deposits can be recognized, the diagnosis is not so easily made; even here, however, the family history and habits of the patient will be of assistance in the diagnosis. If we remember that acute rheumatism, the only disease that could be mistaken for gout, attacks the young, is usually attended by active fever, and does not come on so suddenly nor select the early hours of the morning for its invasion, we will not often be mistaken in our diagnosis. In old cases, the marked deformity and chalk-stones render the disease unmistakable.
Prognosis.—This depends upon several conditions,—the stage of the disease, the complications existing, and the ability of the physician to change the habits and environments of the patient. When albumin and tube-casts are found in the urine, the prognosis is decidedly unfavorable. While gout does not rapidly prove fatal, the life is shortened by some of the more serious visceral complications.
Treatment.—This may be divided into hygienic, dietetic, and medicinal.
Hygienic.—A temperate and dry climate is desirable, and residence in the country or suburbs preferable. The sleeping-room should be large, well ventilated, free from draughts, and with a sunny exposure. Flannels should be worn with the first chilly weather.
Since oxidation of the nitrogenized tissues can be greatly increased by appropriate exercise, the patient should be instructed to take, though not severe, daily well-regulated exercise. Not only is oxidation increased, but the excretory organs are stimulated and the detritis is eliminated in this way. The daily bath is quite essential, but should be suited to each individual case. Thus a young and vigorous patient would be benefited by a cold bath, with brisk friction, while a feeble or elderly patient would need a warm bath, after which he should remain in bed for several hours. The Turkish bath should only be taken by robust patients.
Dietetic.—Since gout is a lesion of nutrition, we can readily appreciate the value of a restricted diet. We are to remember that much care and attention must be paid to this subject, for the same diet will not do for every gouty patient; and while there are some general rules and restrictions to all patients, we are not to forget that one patient may eat with impunity what would be very harmful to another. As a rule, the amount of food should be lessened, and should be taken at regular intervals. Nearly every one eats more than is necessary after the age of forty.
Red meats in particular should be restricted, and malt liquors and sweet wines absolutely prohibited. A vegetable and fruit diet, with the free use of milk, is to be recommended. Sugar, unless in very small quantities, should also be forbidden. Vegetables of an acid character, and fruits rich in sugar, are to be taken sparingly, or not at all. While many would restrict fat, Ebstein strongly advocates good fresh butter to the amount of two and a half to three and a half ounces per day. Roberts would have gouty patients use as little salt as possible, since the sodium biurate crystallizes in the tissues with an excess of sodium salts. Most patients, however, may have a mixed diet, if taken in small quantities, slowly and thoroughly masticated, and followed by well-regulated exercise. A diet largely of milk, however, is preferable.
The patient should take freely of pure water, and where the habit is to take but little fluid, he should be instructed to cultivate taking water freely and often. Although customary to recommend some alkaline mineral springs, and though thousands yearly pay visits to some of these famous resorts, as much, if not more, benefit will be derived from a pure water devoid of any alkali.
Medicinal.—During an attack, either the tincture or wine of colchicum should be given in from ten to twenty drop doses every three hours, which v/ill favorably influence the inflammation, and also tend to relieve the pain. When the pain is excruciating, a hypodermic of morphia is permissible. The foot should be elevated and wrapped in cotton-wool.
As a local application, we may use menthol three parts, camphor two parts, well rubbed together; or menthol dissolved in chloroform. After an attack is over, the patient should be placed on the citrate of lithium or potassium, or potassium acetate may be used. Whichever salt is used, the patient must be instructed tc drink large quantities of water. Piperazin is highly recommended, and should be given in five-grain doses four times a day. The salicylates, especially salicylate of sodium, have been highly extolled in the chronic form. Following an attack, the patient should be placed on a milk diet, to which may soon be added eggs, fish, and fruits, bananas excepted. As soon as able, the hygienic measures already mentioned, should be carried out.