4*1 



GOUT. 



GOUT. 



in the middle of the night. The patient ii awakened at two or three 

 oVlivk in tin- uioming with acute pain in the ball of the great toe, 

 accompanied with a feeling of heat and stiffness* of the part : chillim -- 

 and fever come on, which gradually abate u the pain increases, \sl.i. !i 

 become* more violent every hour, having a burning or gnawing cha- 

 racter. Thi generally continues till the middle of the following night, 

 though in alight case* it may remit after a few hours' duration. A 

 iwrspiration then break* out, and tho patient falls asleep. The 

 next morning the toe U shining, red, and Dwelled ; the veins of tin- 

 foot are very much distended, and the joint is excessively tender. 

 Exacerbation*, ' becoming leas violent each time, recur for several 

 nights, and then the attack declines. The joint remains swelled 

 and weak for some days, and there is violent itching, followed 

 iy desquamation of the cuticle; after which nil disease ceases, 

 :u"i.l the patient feels better, both in body and mind, than before 

 the attack. 



Such are the hi.-tory and course of a simple fit of gout, as it gene- 

 rally occurs on its first attack. In subsequent seizures, the inflam- 

 mation, on subsiding in one joint, frequently attacks another, and 

 eventually several joints may be attacked in succession, or two or more 

 at the same time, as the fingers, wrists, and knees. Generally the 

 intervals between the attacks grow shorter, the patient has more and 

 more frequent fits, and they last longer ; but this will depend in a 

 great measure on the treatment pursued, and the mode of life of the 

 at The fits are more liable to occur in the spring and autumn 

 than at other seasons, owing perhaps to the greater variableness of the 

 weather at those times of the year. After repeated attacks the joints 

 may become stiff and rigid : deposits of whitish matter, called chalk- 

 clones [CALCULI] (which principally consist of urate of soda), will take 

 place beneath the skin, so that the joints of the fingers and toes become 

 enlarged and swollen. 



It is very common, when persons have hod gout for a length of 

 tiin,'. for various internal organs to become diseased. The inflamma- 

 tion may suddenly disappear from a joint, and some seripus internal 

 affection, as apoplexy or gastritis, unexpectedly make its appearance. 

 This is called retrocedent or displaced gout. The internal affections 

 which thus arise ore often caused by the patient's imprudence, and 

 sometimes by injudicious treatment, as the application of cold to the 

 inflamed joint. 



We have mentioned among the precursory symptoms of an attack ol 

 gout, that the urine is frequently turbid, and deposits a lateritious 

 sediment. There seems to be a tendency to throw off morbid matter 

 from the overloaded system by this outlet. It has been said that gout 

 favours the formation of urinary calculi, and numerous cases are 

 related where stone in the bladder, or gravel, has occurred in con 

 nection with this disease. Irritation of the urinary organs is certainly 

 vi-ry common in gouty persons. 



( ;.'iit is more frequently met with hi persons of vigorous and robust 

 constitutions, than in those of spare habit ; and is more common in 

 men than in women : this comparative immunity of the female sex 

 seems to be owing in a great measure to their more temperate habits o 

 life. Persons of advanced and middle age are more liable to gout than 

 those of early life. It does not commonly appear till after the age of 

 thirty-five, though where the predisposition is strong it may occui 

 i-cfore puberty. Hereditary predisposition is doubtless a cause o 

 gout, and where this tendency exists the disease may take place unde 

 circumstances which would not otherwise have power to produce it 

 Hence persons who are conscious of an hereditary taint should guarc 

 with particular care against the causes which excite gouty action. Tli 

 most active of these is a plethoric or inflammatory state of constitution 

 arising from luxurious living, indolence, and sedentary habits; whicl 

 also give rise to that disordered state of the digestive organs whicl 



constantly precedes on attack of gout. 

 Where the predisposition, bot 



t both hereditary and acquired, strong! 



exists, a very slight cause may excite the paroxysm. A fit of intern 

 perance, or excessive indulgence in eating, may bring it on. Excite- 

 ment of mind from anxiety or intense study will sometimes cause a fi 

 of gout ; and it has been known to follow violent exercise, particular! 

 walking. An accident or injury of a joint, occurring in a gout 

 subject, instead of causing simple inflammation, may give rise to a 

 attack nf gout. Gout lionesses considerable resemblance in man 

 of its characters to rheumatism, and these affections are in sou 

 instances confounded together. There are even modifications wliic 

 partake so much of the characters of both, that they go by the nam 

 of rheumatic gout. Gout however may generally be known ni 

 rheumatism, by its 'attacking persons later advanced in life and a 

 a full habit ; liy its affecting principally tho smaller joints, and bein 

 commonly confined to one, at least in its earlier seizure* ; the attic 

 of gout alo declines more quickly, is preceded in most cases b 

 disorder of the digestive organs, and is not brought on by any e: 

 temal exciting cause, as cold and damp, which is mostly the oaf ' 

 rheumatism. 



With regard to the cause of gout, and the state of the system in 

 which it comes on, considerable light has been thrown upon thbm b 

 the researches of Dr. Garrod, He has shown that the retention < 

 uric acid in the blood is the first of a series of changes, which resul 

 in the deposition of urate of soda in the joint* or other part* affect* 

 . with the gouty inflammation. The following are the conclusions a 



hich Dr. Garrod has arrived and which he has published in his 

 ork 'On the Nature and Treatment nf Cunt.' 



Fir it. In true pmt, uric acid is invariably present in the blood in 

 anormal quantities in the form of urate of soda. 

 Secondly. True gouty inflammation is always accompanied with a 

 eposition of urate of soda in the inflamed part. 



T/iinlli. The deposit of urate of soda is crystalline and interstitial, 

 and when once the cartilages and ligamentary structures become 

 ifiltrated, such deposition remains for a lengthened time, perhaps 

 tiring life. 



rihli/. These deposits are the cause and not the effect of gouty 

 ifl animation. 



h'ifMii. The attack of gouty inflammation tends to destroy the 

 .rate of soda in the blood of the part, and in the system generally. 



/>'/'..'/(///. The kidneys are early implicated in gout, and this all- 

 s not only functional, but eventually becomes structural. The urine in 

 gout is always altered in composition. 



Sercnlkly. The presence of urate of soda in the blood, is probably 

 he cause of the premonitory symptoms of an attack of the gout 

 f the anomalous symptoms which are known to present themselves in 

 gouty subjects. 



Big/My. The causes known to predispose to the gouty attack are 

 uch as produce an increased formation of uric acid in the system, or 

 hich leads to its retention in the blood. 



.\inililii. The causes exciting a fit of the gout are those which 

 reduce the alkalinity of the blood, or augment the formation of uric 

 acid, or temporarily check the power of the kidneys hi eliminating this 

 >riuciple. 



Dr. Garrod's theory has certainly the merit of explaining the anonm- 

 ies presented in the history of gout. It shows that the tendency 

 of the kidneys to refuse the elimination of uric acid i litiry, 



ind it also explains that in poor systems, as well as plethoric ones, 

 .his tendency of the kidneys may serve to bring on an attack of (: 



The occurrence of a paroxysm of gout often seems to relieve the 

 jeneral health for a time ; and it is a common idea that an attack 

 sxpels the morbid matter from the system. Although ;n to a 



certain extent, it is a dangerous doctrine to put in practice. It has 

 often led to very improper and even dangerous proceedings. On tho 

 contrary, the judicious plan of treatment in gout is to moderate tho 

 aaroxysm and prevent its recurrence. It would be out of place here 

 ~M enter into any detail of the numerous plans of treatment and the 

 remedies which have been adopted in gout. With regard to the pre- 

 ventive treatment, we need only recommend temperance and exercise, 

 wliii-li will generally succeed in keeping off a recurrence of the disease, 

 and if strictly adopted will be a sufficient guidance to the gouty patient. 

 There is an old Scotch proverb, and a very true one, " that a man 

 might cure himself of gout by living on sixpence a day, and working 

 for it." The treatment of the paroxysm is very simple. The inflam- 

 mation should be subdued in this case by the same means as would be 

 requisite in inflammation from any other cause. If the patient be 

 plethoric, and there is active fever, we must bleed, purge, and starve 

 him. Should there be less constitutional disturbance, we may safely 

 leave the fit to run its course ; for gouty inflammation has a natural 

 tendency to subside spontaneously, without terminating in suppura- 

 tion. Alkalies and saline medicines which act as purgatives and diu- 

 retics are also to be recommended. Dr. Garrod also recommends the 

 salts of lithia. 



Topical remedies are of little use in gout. Warm .applications do 

 no good, and cold ones may do serious harm by suddenly checking the 

 inflammation, and bringing on dangerous affections of internal organs. 

 If anything be applied to the part, a warm evaporating lotion is perhaps 

 the best thing. 



In addition to the general antiphlogistic treatment which we have 

 mentioned, we possess a remedy which certainly i* highly valuable in 

 gout, namely, colchicum. This medicine, when given in a sufficient 

 quantity, generally purges the bowels, and lowers the pulse. A large 

 dose of this drug, given when the occurrence of a paroxysm is threat- 

 ened, will often avert it altogether, but the prudence of this mode of 

 proceeding is very questionable; it only suppresses the )>aroxysm, 

 without removing the constitutional disorders on which the disease 

 depend* Colchicum may be given with safety during a fit of gout, 

 and it certainly seems to shorten its duration. The colcliku 

 which the wine of the seeds is one of the best preparations) m 

 .iid repeated in moderate doses three or four times a day. 

 alone, or combined with purgatives. As soon as free purging is pro- 

 duced, the symptoms are generally relieved. Some authors arc of 

 11 that the colchicum does no good without it acts upon tlie 

 bowels ; but in many instances, before this effect is produced, it will 

 allay the pain, bring down the pulse, and stop the progress of the 

 paroxysm. Colchicum U said to increase the secretion of uric acid by 

 the kidneys, but this is denied by Dr. Garrod, who has carefully in- 

 vestigated the subject This drug is the active ingredient in the cau 

 mfdicinale and other quack medicines which arc in general use as 

 specifics for the cure of gout 



With respect to the treatment of the complex conditions and 

 different varieties of gout, it must be directed to the improvement of 

 that disordered state of constitution upon which they depend. 



Persons of a gouty habit are liable to certain inflammatory affections 



