Gout.
Synonym:—Podagra.
Definition:—A chronic disease resulting from abnormal metabolic changes, characterized by the deposit in the joints of the body and in the contiguous fibrous structures, of the sodium biurate, which results in arthritis, pain, and perhaps more or less permanent deformity.
Etiology:—Many theories have been advanced as to the cause of this well-known disorder. It occurs in patients of the higher classes who have but little regular physical exercise and are high livers, addicted to the excessive drinking of sweet wines and malt liquors. It occurs frequently, however, among the poorer classes, who indulge freely in beer and subsist on insufficient food of a poor quality, with unhygienic surroundings. Those who live in the open air and whose employment is actively physical and always out of doors, and who are temperate in their habits, are seldom attacked with this disease.
Occasional cases will be observed in children, but in these it is often ascribed to heredity, as statistics of some countries show that in nearly one-half of the cases the immediate ancestry were afflicted with this disease. I am inclined to think that this is due more to the adoption by the children of the same habits of living as those practiced by the ancestors, rather than to any transmitted tendency to the disease. It occurs more commonly between the ages of thirty and fifty, during the active period of early middle life, and because of the intemperate habits of males, these are more frequently attacked than females.
The constant overeating of highly seasoned foods is a prolific source of this disease. There is an inability on the part of the system to appropriate for the purposes of nutrition only a portion of the foods taken; excretion must dispose of the remainder. When there is overactivity or perversion of the metabolic processes, and where the elimination is insufficient or imperfect, this condition results. As stated, these factors, combined with insufficient physical exercise, and overexercise of the nervous system under constrained or unhygienic circumstances, are especially favorable. The condition is common among certain metal workers, and is a direct result of chronic lead poisoning.
Symptomatology:—There is considerable variety in the forms in which this disease manifests itself. Most commonly there are premonitory symptoms of imperfect or disordered tissue metabolism, which continue for weeks or perhaps months, resulting in the insidious development of gout, with its characteristic phenomena. But occasionally it is distinctly acute in its manifestations. There is disturbance of the digestion, with irritability of the nervous system, and insomnia, for a number of days; the tongue is heavily coated, there are eructations of gas and nausea, with some vomiting; occasionally there is a mild diarrhea. This is accompanied with a severe headache, similar to that which is described as sick-headache. There is scanty urine, of dark color and high specific gravity, which is passed with burning or urethral irritation. Occasionally the urine is heavily loaded with urates and uric acid, which may readily deposit upon cooling. There is at times muscular soreness, or cramps in the muscles, or transient, fleeting, but rather severe pains, both in the muscles and joints. In other cases there is asthmatic breathing of rather abrupt occurrence. Rarely, however, a patient will be taken abruptly with the full development of the disease, after having been in apparently excellent health for some time. Pain, sharp, intense and severe, of a cutting or stabbing character, increased with every jar or movement, occurs then in the ball of the great toe, or in the metatarso-phalangeal articulation. At the seat of pain the tissues swell very rapidly and become exceedingly sensitive; the skin becomes red and hot and pits upon pressure, and is of a shiny or polished appearance over the entire inflamed area. There is usually a slight chilliness with a development of a considerable temperature. It may rise as high as 103° F., but usually 102° or 102.5° F. is the limit. With the fever there is a paroxysm of especially excruciating pain of a crushing character, described as feeling as if the joints were in a vise. These intense symptoms, which usually occur in the early morning, will last perhaps two hours, when there is a rapid abatement of the pain, the fever declines, there is free perspiration, the appetite returns, and the patient is inclined to go about his usual avocation. On the following morning these symptoms will recur, with perhaps increased violence and additional involvement of the same toe on the opposite foot, or of the joints of the hand. The third or fourth attack, however, is hardly as severe as that of the preceding morning, and on subsequent daily recurrences will abate. The fever declines, the swelling abates, and there is a desquamation of the cuticle over the inflamed surface; the skin gradually assumes its normal color, and there is a gradual return to usual health. The health continues unimpaired as long as the patient preserves a strict oversight over his habits of living, and avoids alcoholics and all excesses in diet. But after any overindulgence symptoms of the disorder will reappear, and if the patient has grown careless in his habits the original attack in all its severity will recur. In no case is there suppuration of the joint.
In very rare cases uremia results from an acute attack, and cerebral symptoms, such as acute delirium, excitable mania, or coma, or perhaps apoplexy will result. In other cases, under circumstances in which this disorder is described as retrocedent, the pain and inflammatory symptoms are transfered to some one of the other vital organs, as to the stomach, when there is acute vomiting of a severe type, which greatly increases the almost agonizing pain in the epigastrium and is accompanied with sudden prostration which may be quite alarming. With the abatement of the symptoms in the great toe, the pain may attack the heart, when the pulse becomes small, rapid, feeble, very irregular, and there is dyspnea, anxiety and prostration. Or an acute pericarditis may develop which is likely to terminate fatally.
Repeated recurrences of the acute form of this disease develop a permanency of character which terminates in chronic gout. The joints become more or less permanently stiffened with continued soreness in the surrounding tissues. There is an occasional recurrence of paroxysms of pain, which are not as severe as those of the acute attacks. Deposits of the sodium biurate in the diseased joints result in deformity and in actual dislocation. Finally there is a subsidence or an entire disappearance of the acute attack, with a slow increase in the abnormal deposits. These invade the fingers and the wrists, as well as the joints of the foot. In the fingers the phalanges are sometimes displaced laterally or otherwise, and become anchylosed; in other cases the deposits are made in the larger joints, such as the hip, knee or shoulder, for a short period, but there is seldom deformity or permanent stiffness. While suppuration does not occur, ulceration of the skin—a necrosis of the covering tissues of these diseased joints—will occur, from which may exude particles of a chalky substance with which the joint is enveloped. In these chronic cases, changes are apt to occur also in the urine. It may still continue scanty and high colored, but will contain albumin and tube casts, but the disorder is apt to produce an interstitial nephritis, especially in patients advanced in life, in which there will be a large quantity of pale urine of low specific gravity, and a considerable quantity of albumin.
These patients, when the disease is permanently established, are liable to acute exacerbations, in which fever develops and constitutional involvement is pronounced. During these exacerbations there may be acute pharyngitis, laryngitis, pneumonia or pleurisy, or the conditions may occur which we have described as occurring during the retrocedent form of the disease.
Nearly all writers recognize a form of gout which is described as irregular gout. Sir Dyce Duckworth defined it as a manifestation of gout anywhere else but in a joint.
Those who possess a gouty diathesis exhibit a great variety of symptoms, which although attributed to the uric acid diathesis, are not due to the presence of this substance, but differ from the uric acid disorder both in the development of the cause and in the manifestation of the symptoms. It may be difficult to determine which of the two conditions is the cause, and in common practice they are often carelessly classed together as resulting from an excess of uric acid. These patients often suffer from intractable nasal catarrh, or from pharyngitis, tonsilitis, or laryngitis, which occurs in an acute form, often from no apparent cause, or peritonitis may occur. Bronchitis and persistently recurring asthmatic attacks are attributed to it. There is at times persistent acid gastritis with anorexia and nausea, and perhaps a disgust for food. There is diarrhea, with severe colic at times, which fails to yield to the usual treatment.
Myalgia may be classed under this head. There is muscular stiffness, soreness and more or less pain in the deep cervical and lumbar muscles, in the muscles of the thighs and calves and in the chest muscles. This may be especially severe upon waking in the morning, but may disappear in the early part of the day, to recur on the following day. Neuralgic pains are common, and other nervous manifestations, especially migraine. Eczema is a frequent result of gout, and pruritus of the genitals of an exceedingly aggravating character, or pruritus of the skin in any locality, and especially in the palms of the hands and in the soles of the feet, is not uncommon. It also induces itching of the eyeballs or of the inner ear, and keratitis, conjunctivitis, iritis and other eye disorders may occur.
There is no doubt that gout is a direct cause of albuminuria with casts, and of the ultimate development of interstitial nephritis. Its persistent presence in the system induces gravel, and renal and vesicle calculi, which, acting as an irritant to the kidneys, induces renal colic, pyuria, or cystitis, and the entire train of symptoms common to those conditions. It may also cause glycosuria, or remotely, diabetes mellitus.
Diagnosis:—The classic appearance of acute gout in the joint of the big toe cannot be mistaken. There is usually a history of high living, dissipation, and but little physical activity. In this form it is quite readily distinguished from acute rheumatism, but when several joints are attacked simultaneously, and fever and other constitutional manifestations appear, then a differential diagnosis is much more difficult. Rheumatism attacks individuals of all ages and of all classes, and the attacks may occur at any time. Thompson has stated that in rheumatism there is a diffused tenderness in the skin and in the tissues surrounding the joints, and in the tendons, while in gout the greatest tenderness in the large joints is elicited upon transverse pressure directly over the condyles. In chronic rheumatism the larger joints rather than the small joints of the hands and feet are affected.
Prognosis:—The disease does not readily yield to treatment. The prognosis depends largely upon the conditions; those who have a history of heredity, and who themselves persist in high living, are seldom benefited by treatment, and die in early middle life. When the attacks occur after the age of forty-five the prognosis is better than in earlier life. Alcoholic beverages must be entirely prohibited if relief from any treatment is permanent. Complications of any kind render the prognosis less favorable.
Treatment:—The treatment of this disease resolves itself into the treatment of the acute attacks, and ultimately into the treatment of the general condition. So severe is the pain and the local inflammatory symptoms that it is often necessary, for immediate relief, to administer an opiate. Hot fomentations are productive of comfort, and the use of labradol or antiphlogistine, surrounded by dry heat, will not only give immediate relief, but will do much toward preventing as severe an attack on the following day. The administration of a single large dose of salicin or salicylic acid will produce some amelioration. Smaller doses may be repeated during the day, in anticipation of the attack on the following morning.
In adjusting conditions to a patient suffering from this disease he should spend much time in the open air and must avoid a damp and changeable climate. A dry, temperate climate is of much assistance in an ultimate cure. The patient should wear light flannels even in the summer time, and in cold weather he should be at all times warmly clothed. Physical exercise, short of exhaustion, is always desirable. This may be accomplished by horseback riding or by light regular out of door work, whichever is preferable.
Patients of naturally robust constitution, devoid of heart complications, obtain benefit by taking a course of hot baths. The baths at Hot Springs, Arkansas, are reputed to be of much service in ridding the system of an excess of tissue waste and of the earthy salts which cause this disease. Turkish baths are of much advantage, and should be taken regularly, but not too frequently. Hot air baths, or the alcohol vapor bath, is also beneficial. Feeble patients will seldom be benefited by so rigorous an eliminative treatment. These patients should drink freely of water. A carefully selected mineral water is sometimes of much efficacy. In our locality we have access to the Waukesha waters, which are devoid of any earthy salts, are pre-eminently pure, and exercise a simple influence in flushing the emunctories of the system, especially the kidneys. The use of distilled water has been advised, but its superiority has not been proven.
The course of diet of these patients must be selected with the utmost care and rigidly enforced. It is a good plan to deprive them for a time of all nitrogenous food, permitting the use of a well selected vegetable diet; however, milk is always permissible, and butter and cream are by no means objectionable. If the stomach is in a normal condition, the patient may take freely of even the coarse vegetables; I believe that cabbage, turnips, lettuce and celery are especially beneficial. Fruits may be eaten in season, excepting bananas, which I have found reason to exclude. The patient may partake freely of sweet potatoes, stale bread and toast, baked potatoes, hominy, rice, macaroni, sago, tapioca, and of the most of the prepared breakfast foods. Tea and coffee are always objectionable in gout, much more so than in lithemia or in stomach disorders. When it is thought best to permit meat to be added to the diet, the patient should be allowed eggs and oysters, and occasionally a meal of fresh fish. He may eat of fresh beef or mutton two or three times a week; but all cured, salted or canned meats and fish must be rigidly and persistently excluded from the diet. Other articles which should be excluded are fresh bread, hot biscuit or griddle cakes, all pastry, all dishes and fruits which contain an excess of sugar, and cheese. The use of condiments, pickles, sauces and flavoring extracts should be forbidden.
For beverages the patient must be satisfied with milk, water and a little cocoa. These may all be taken hot. Hot water seasoned with cream and sugar is sometimes quite palatable. I have only one word to say concerning the use of alcoholics in any form. While some patients might be able to take a little without apparent detriment, they are always in danger of increasing the conditions which induce the disease. There is no absolute safety in any course except absolute prohibition of everything that contains alcohol.
Medicinal Treatment:—No depleting measures of any kind should be adopted in the treatment of gout. We have but few remedies that exercise a specific influence on the disease. The pain may be controlled to excellent advantage by a preparation of sodium bromid three drams, sodium iodid one dram, morphin two grains, tincture of capsicum one-half dram, syrup of orange peel sufficient to make three ounces. Of this a teaspoonful may be given every half hour or hour. Colchicum is considered by the profession at large to be as near a specific in this disease as any remedy we possess. From fifteen to twenty drops of the wine of colchicum may be given during the attacks every three hours, and between the attacks ten drops may be given every four hours. The use of macrotys and acetate of potassium will facilitate the action of this remedy. The salicylates may be continued as long as there is no irritation of the stomach. Because of the possibility of this irritation occurring it is well to select the salicylate of strontium in preference to the potassium or sodium salts. Ten grains may be given every three or four hours. Occasionally the iodids are advised. If the urine is excessively acid, and an acid diathesis prevails within the system, good results may obtain from the use of the potassium or sodium iodid in reasonable doses. In another group of cases the acidity is not conspicuous, the urine may be neutral or alkaline, and there may be a tendency toward a deficiency of the acids of the gastrointestinal tract. Under these circumstances the hydriodic acid will be in every way preferable. It has accomplished excellent results, and is best given in the form of the syrup of hydriodic acid.
The excessive acidity which usually predominates in this condition has been treated to good advantage by the carbonate of potassium or the bicarbonate of potassium or sodium. I have succeeded with considerable satisfaction in relieving many of the untoward symptoms and in materially reducing the specific gravity of the urine, by the use of piperazin, in from seven to ten grain doses, four times daily. The dose should be administered in a glass of water.
I have read some excellent articles from physicians in whom I have confidence advocating the use of sulphur externally over the diseased joints in gout. The remedy is sprinkled freely over a piece of soft flannel and it is also rubbed well over the diseased part, which is then covered closely with the flannel and enveloped in sufficient other flannels to keep the part very warm. This should be continued for several hours at a time every day, or as in the judgment of the physician it will prove most beneficial.
