(JOl'T 



329 



time before the occurrence of an attack. It 

 i- MIIW agreed by all that the presence of this sub- 

 B in excess in the system IB an importent 

 r in the production of gout; lnit authorities 

 dill'er ,i- t-i h<>\\- its presence is to be explained. 

 There un- two main theories on the subject which 

 it mu>t suflice to mention : ( 1 ) that the processes 

 oi' disintegration going on in the body, particularly 

 in the liver, lead to its formation in excessive 

 amount; ('2) that there is not excessive formation, 

 l>ut defective elimination of it by the kidneys. 

 There is, however, a third theory with regard to the 

 origin of gout, which attributes its occurrence to 

 a perverted condition of the nervous system, and 

 regards the presence in excessive amount of urate 

 <>f -'"la in the blood as a subordinate though still 

 i in I MM taut feature of the disease. 



Symptoms of Acute 'regular' Gout. Sydenham's 

 treatise on gout, written 200 years ago, is interest- 

 ing not only as containing the well-considered 

 \i<>\vs of a master in the medical art, but also as 

 th' 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 abbrevi- 

 ation. 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 lie is awakened 

 by a pain in the great toe, or sometimes in the heel, 

 the ankle, or the calf of the leg. The pain re- 

 sembles that of a dislocated bone, and is accom- 

 panied 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 feverish- 

 in'-s 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 bedclothes, 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 he wakes refreshed, to find the limb swollen; 

 the venous 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 indi- 

 vidual attack may be repeated many times in the 

 course of what is termed ' a fit of the gout,' which 

 sometimes 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 descnl>ed here, 

 and the obvious relief obtained through the 'fit' 

 from the symptoms of constitutional suffering, 

 jMiint to a cause of the disease operating over a 

 larger range of functions than those included in 

 tin- ordinary local manifestations at this period. 

 Regular gout, accordingly, forms only part of a 

 noRologica) 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 shadow* 

 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 goat to fall 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 joint * 

 which have been rejieatedly the seat of the regular 

 paroxysm become, more or less permanently, 

 crippled and distorted. A white, friable, chalk- 

 like material is gradually dejK>sitd around the 

 cartilages and ligaments, and sometimes in t In- 

 cellular tissue and under the skin (tophi or chalk- 

 stones). Sometimes this material is discharged 

 externally by ulceration, and then usually with 

 relief. At other times it accumulates into irregu- 

 lar masses, or ' nodosities,' which entirely destroy, 

 or at least greatly impair, the movement of the 

 limb. The patient is laid up more or less perman- 

 ently 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. 



Other Manifestations of Gout. With regard to 

 what should be included under the term irregular 

 gout there is much difference of opinion. It is 

 sometimes no doubt used as a refuge for ignorance, 

 when no other cause can be discovered to explain 

 symptoms of ill-health. It is certain, however, that 

 regular gout often alternates with a morbid con- 

 dition in some other part of the body, and that 

 many diseases occurring in those whose family 

 history or habits of life may be considered to pre- 

 dispose to gout, whether they themselves have 

 suffered from regular gout or not, are benefited by 

 hygienic and medicinal measures similar to those 

 which do good in undoubted cases of gout ; and 

 most physicians agree in speaking of such as forms 

 of gout. The most important of these we shall 

 here enumerate, in connection with the organs 

 affected. Heart and blood-vessels palpitation, 

 irregularity of heart action, angina pectoris, 

 and atheroma with its consequence, phlebitis. 

 Lungs asthma, bronchitis. Nervous system neur- 

 algia, headache, epilepsy, mental disorder. Skin 

 eczema. Digestive organs inflammation of throat, 

 various forms of indigestion, cramp or inflamma- 

 tion of stomach, jaundice. Urinary organs irri- 

 tability of bladder; stone, especially the uric acid 

 form (see CALCULUS); diabetes ; above all, chronic 

 Bright's disease. It is impossible within the limits 

 of such an article as the present to give any de- 

 scription of the various manifestations of the gouty 

 tendency ; the above list of ailments ( most of them 

 treated separately) will give some idea of theii 

 complexity and importance. 



Treatment of Gout. The cure of gout, in the 

 highest sense of the word, demands the carefui 

 consideration of all its predisposing causes in the 

 individual, and the strict regulation of the whole 

 life and habits accordingly, from the earliest pos- 

 sible period. It is the difficulty of accomplishing 

 this which makes gout a disease proverbially in- 

 tractable ; 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 constitutes the only radical cure of the 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 his old age by 

 habite of life formed at an early period, and by a 



