Gout

“ In like refrain, our own countryman Heberden deplores that people “are neither ashamed nor afraid of it; but solace themselves with the hope that they shall one day have the gout; or, if they have already suffered it, impute all their other ails, not to having had too much of that disease, but to wanting more. The gout, far from being blamed as the cause, is looked up to as the expected deliverer from these evils.” Such deluded views being prevalent, it is hardly a matter for surprise that misguided persons deliberately courted a “fit of the gout” by resorting to excess and intemperance. ”

“ I am well aware, that it is a common opinion, that the gout is as frequently owing to gluttony in eating, as to intemperance in drinking fermented or spirituous liquors. To this I answer, that I have seen no person afflicted with the gout, who has not drank freely of fermented liquor, as wine and water, or small beer; though as the disposition to all the diseases, which have originated from intoxication, is in some degree hereditary, a less quantity of spirituous potation will induce the gout in those, who inherit the disposition from their parents. ”

“ As a proof of the efficacy of active, or passive depletion, in preventing the gout, it has been found that persons who sweat freely, either generally or partially, or who make a great deal of water, are rarely affected by it.
An epitome of all that has been said upon the means of preventing a return of the gout, may be delivered in a few words. A man who has had one fit of it, should consider himself in the same state as a man who has received the seeds of a malignant fever into his blood. ”

“ That confounded gout is the chief of all diseases--in other words, it is the source of them all, and it proceeds from the gouty humour which is in the bones, and which simply tears one to pieces with the pain, and this gouty substance comes from the poisonous matter one has swallowed as food--for example kümmel or tobacco--or as medicine at the apothecary's. Now you must understand that any one who has gout must, if he wishes to be cured, be packed in damp sheets, till the water has drawn all the tobacco he has ever smoked, and all the kümmel he has ever drunk out of his constitution. ”

“ In the same way, I cannot help thinking that the growing infrequency and attenuation of gout is in part due to increasing appreciation by the laity and the profession of the vital importance of oral hygiene and timely and radical treatment of local foci of infection. The fact that in children, victims of so-called infantile gout, the purin metabolism may show those same derangements held typical of the subjects of gout, is surely an indication that the disorder begins betimes, and that we too must not tarry if we would prevent these evil potentialities coming later to fruition. ”

“ Many things will indeed shorten a fit of the gout, and some will drive it off altogether: but nothing has yet been found which will do this with safety to the patient. In pain we eagerly grasp at any thing that promises immediate ease, and even hazard life itself for a temporary relief. This is the true reason why so many infallible remedies have been proposed for the gout, and why such numbers have lost their lives by the use of them. ”

“ There are situations nevertheless in which a paroxysm of gout has been believed to be desirable, as relieving the patient from other disagreeable diseases, or debilities, or sensations. Thus when the liver is torpid, a perpetual uneasiness and depression of spirits occur; which a fit of gout is supposed to cure by a metastasis of the disease. Others have acquired epileptic fits, probably from the disagreeable sensation of a chronically inflamed liver; which they suppose the pain and inflammation of gout would relieve. ”

“ This leads me on to the further reflection that the favourable or unfavourable reaction in different cases depends on the varying nature of what I may term the “excitants” of gout. For the deviations from health that evoke the disorder are manifold and diverse, each carrying with it its own therapeutic indications. Something more is needed than what may be termed a blind or unintelligent “washing out” process. ”

“ It is no more necessary to produce the gout in the feet, in order to cure it, than it is to wait for, or encourage abscesses or natural hæmorrhages, to cure a fever. The practice originated at a time when morbific matter was supposed to be the cause of the gout, but it has unfortunately continued under the influence of theories which have placed the seat of the disease in the solids. ”

“ Despite the fact that heredity plays so dominant a rôle in the genesis of gout, how relatively scanty the attention paid to prophylactic measures! It is the second, never the initial, attack of gout that we endeavour to avert. Surely to inhibit the development rather than to prevent the recurrence of the malady is the better part. The idea is not wholly utopian, for such shrewd observers as Scudamore, Austin Flint, and others, were convinced that by timely and judicious intervention a threatened outbreak might be averted or at least its severity mitigated. ”

“ The assertion is unfounded, for bleeding in a fit of the gout has no such effect, provided the remedies to be mentioned hereafter are used to prevent it. But a fit of the gout is not singular in its disposition to recur after being once cured. The rheumatism, the pleurisy, and the intermitting fever are all equally disposed to return when persons are exposed to their remote and exciting causes, and yet we do not upon this account consider them as incurable diseases, nor do we abstain from the usual remedies which cure them. ”

“ We know not the proximate cause of gout, it is true, nor the exact modus operandi of those agents, infective or other, which bring to fruition the latent morbid potentialities of its victims. But, even if so handicapped, we should be quick to descry those portents of the coming storm, those minor backslidings from physiological righteousness, that doubtless foreshadow the outbreak of the disorder. ”

“ As to the axiom, generally accepted, that the earlier in life gout makes its début, the more unfavourable the outlook, there are exceptions. Where longevity marks the stock, they usually are true to type. Thus, even if the first outbreak occurs in the twenties, I have known them reach the allotted span and over. Nor if their urine show traces of albumen is this necessarily of grave import, for these gouty veterans may for many years, even to old age, exhibit traces of albumen without apparently developing genuine Bright’s disease. ”

“ With this view I feel much in accord, and if to the malign effects of gout be superadded the effects of alcohol or, haply, lead also, how incalculably greater the chances of fanning into flame any latent tendency to nephritis—a legacy, perhaps, of some long bygone infection.
Prognosis in Gout
Gout per se rarely, if ever, proves fatal. Certainly, as Sir Thomas Watson long since said, “gout in the extremities is not a mortal disease.” ”

“ Gout never assails the husbandman who unites temperance with his labours; but he is not exempted from rheumatism in any of its forms. Gout is the disorder of peculiar constitutions, and of the adult age; but rheumatism occurs at every period of life, and to all constitutions.
On the assumption that gout is a gastro-enterite, with a developement of irritation in the joints, purgative medicines are prohibited, and the free application of leeches to the affected parts is recommended as the chief curative treatment. ”

“ Chalmers Watson’s final conclusion was that “the clinical features of gout—regular or irregular, acute or chronic—are more adequately explained by the light of our present knowledge of infections, relapses, and immunity than by any other theory. The distinctive feature of this infection in gout is that the toxin or toxins have a special property of disturbing nitrogenous metabolism in a manner favourable to the deposit of uric acid in certain tissues.” ”

“ In the history of gout it has ever been so, the changing, oftentimes contradictory, vogues in treatment, always the reflex of equally mutable and conflicting views as to its pathogeny. For who can doubt that the facts of pathology supply the indices of rational as opposed to empirical methods of therapy?
Albeit, much remains to be done before we can claim to fulfil the demands of ideal treatment of gout. For we are still ignorant of its exact etiology, cannot yet boast of our control of the morbid potentialities that constitute the pathological groundwork of the malady. ”

“ Distilled liquors, as brandy and whisky, are not so likely to occasion gout. "Poor man's gout" may arise in individuals who lead the most temperate lives, if they have a strong inherited tendency to the disease, or when digestion and assimilative disorders are present, as well as in the case of the poor who drink much beer and live in bad surroundings, and have improper and insufficient food. Workers in lead, as typesetters and house painters, are more liable to gout than others. ”

“ The gout is always induced by general predisposing debility.
6. The remote causes of the gout which induce this debility, are, indolence, great bodily labour, long protracted bodily exercise, intemperance in eating, and in venery, acid aliments and drinks, strong tea and coffee, public and domestic vexation, the violent, or long continued exercise of the understanding, imagination, and passions in study, business, or pleasure, and, lastly, the use of ardent, and fermented liquors. The last are absolutely necessary to produce that form of gout which appears in the ligaments and muscles. ”

“ In a word, it favours the onset of pre-senilism, with all that such connotes. So it is that in these subjects, too often past the meridian of life, we have not only gout to combat, but the grisly appanage of oncoming age.
It is this larger view of our responsibilities that we must cultivate if our treatment of chronic gout is to be in any sense rational, and not wholly haphazard. Also, if my contention be correct that the alimentary canal is the fons et origo mali, the major source of the provocatives of gout, then the basal and essential part of our [399] therapy must be diet and regimen. ”

“ Thus we cannot, on the basis of the variations in uric acid excretion, presume to diagnose gout; in other words, if we take urine analysis alone, it is extremely difficult to prove that the uric acid elimination in gout is really and truly abnormal. Our uncertainty, moreover, is the more pronounced when we realise that in some cases of rheumatoid arthritis, etc., there is a disturbance of purin metabolism which in some of its features is reminiscent of that obtaining in typical gout. ”

“ Hence the disease derives the general name gout (gutta) , from its resemblance to a drop (gutta) trickling or falling downward and flowing over the weaker organs, which receive the humor. For gout arises particularly from rheumatic causes. Now, as the humors are rather uncontrollable (male terminabiles) fluids, they flow towards the exterior and softer parts, like the flesh and skin, which receive their moisture and being soft, dilatable and extensible, there results some swelling. ”

“ Hence walking will bring on a fitt of the gout, without any other predisposition, for want of sufficient mucilage. The action heats the joints, and sollicits the lurking humor out of the blood, before its time. Hence it emaciates the limbs and burns up all their fat, as a sacrifice to its rage. And at best the podagric, when in health, is but a criple, the joints being defrauded of due unction. Hence the cure of the gout, by our artificial oyls, analogous and succedaneous to the natural. ”

“ Gout does not render patients immune from tuberculous, syphilitic or gonococcal disease, and when in such so-called diathetic stocks an iritis occurs, especially in gonorrhœa, years after the primary disease, it is probable that gout, rather than lues, will be assigned as the cause. ”

“ Robin holds that if visceral gout is present, or the urine contains much albumen, no colchicum should be given.
It is notorious that old persons stand colchicum badly. In their instance we need be the less ready to resort to heroic doses when we recall that acute gout is a self-delimited disease, and while it would be improper to do nothing in elderly subjects exhibiting visceral lesions, etc., it is well that we proceed cautiously, so as to avoid the induction of circulatory depression or the excitation of nausea or a diarrhœa which may be, and often is, difficult of control. ”

“ But for our encouragement it may be observed that not always does gout carry with it such a terrible Nemesis. “Gout is the disease of those who will have it,” said a wise physician, and though the inbred gouty tendency may be so strong as to cast defiance at abstinence, yet it is by no means always so. ”

“ The gout is a disease of the whole system. It affects the ligaments, blood-vessels, stomach, bowels, brain, liver, lymphatics, nerves, muscles, cartilages, bones, and skin.
2. The gout is a primary disease, only of the solids. Chalk-stones, abscesses, dropsical effusions into cavities, and cellular membrane, and eruptions on the skin, are all the effects of a morbid action in the blood-vessels. ”

“ Reviewing articular gout as a whole, one cannot but realise that it does in respect of the recurrence of gouty paroxysms exhibit inexplicable vagaries, inexplicable in that, as Sir William Roberts long since said, “in many instances they are dependent neither upon medical treatment nor upon altered dietetic habits, but are due to spontaneous changes in the constitution. They form part of the natural history of gout ”