toes is affected in gouty persons has always been noted. In Scudamore's
tables the proportion of the first attacks in this joint was 72 per
cent., and in 66 per cent. one or both great joints were affected to
the exclusion of other joints. This frequency is due to the fact that
this joint is the most vulnerable one in the body, bearing as it does
the weight of the body and being exposed to most frequent shock. The
phalangeal joints of the hands and the wrist-joints are also often the
seat of acute gout, though these joints are more frequently affected by
the subacute form of the disease. The larger joints may also be the
seat of true gouty inflammation; indeed, no joint, not even the
intervertebral, can be said to enjoy immunity, and the hip and shoulder
are occasionally attacked to {117} the exclusion of others. The
cartilages of the ear and the arytenoid cartilages are sometimes the
seat of gouty deposits.
The great frequency of arterial sclerosis, and the subsequent fatty and
chalky metamorphosis in persons who have suffered from chronic gout,
are well recognized. Next to syphilis, gout seems to be the most common
cause of these arterial changes. The influence of these lesions in the
arteries and capillaries in determining cardiac hypertrophy and
cerebral hemorrhage is often seen in the accidents which terminate the
lives of gouty patients.
In the heart a gouty endocarditis is of not uncommon occurrence,
according to Ebstein, who cites Lancereaux as having found uric acid in
concretions on the valves. Garrod, however, after examining a number of
cases in which cardiac disease existed with gout, states that in his
opinion the valvular changes are not due to a gouty deposit, he never
having been able to demonstrate the presence of uric acid in them.
Some years ago Sir James Paget called attention to the frequency of
adhesive phlebitis as a gouty lesion. This is observed in connection
with articular gout, but may also occur independently of joint-lesion.
It is observed most frequently in the lower limbs, is generally
symmetrical, and shows a disposition to metastasis.
Neuritis and sclerotic lesions of the nerve-centres are not uncommon in
the history of acquired and inherited gout. The neuralgias and other
temporary dysæsthesias which constitute a considerable category in the
symptoms of gouty persons are doubtless due to transient central and
peripheral lesions.
The so-called gouty kidney is the most striking illustration of the
effect of the gouty dyscrasia in the production of a characteristic
visceral lesion. The changes which occur in the kidney as a result of
gout are--a contraction of the organ, the result of interstitial
inflammatory processes, and a deposition of uratic salts, occurring
mainly in the papillary portion. The views as to the exact locality
where these deposits occur still differ considerably. Garrod is of
opinion that it occurs in the fibrous interstitial tissue. Virchow, on
the other hand, regards the lumen of the tubuli as the seat of the
deposit, and in this he is supported by Charcot and Cornil and Ranvier,
Lancereaux and Wagner. Dickinson inclines to the view of Garrod, and
believes that it is the deposition of the urates in the interstitial
tissue which gives rise to the chronic inflammation which results in
cirrhosis of the kidney--the granular kidney of gout. Ebstein seems to
think that the interstitial connective tissue, having previously
undergone a state of necrosis, as in cartilage and other connective
tissues, is the seat of the deposit. As in cartilage, he regards this
necrotic state as typical of gouty deposits. About the necrotic area in
which the deposit has occurred a secondary inflammation takes place,
leading ultimately to contraction of the new fibrous tissue formed. He
calls attention to the fact that (1) the kidneys may be perfectly sound
in gout; (2) the kidneys may be the seat of chronic interstitial
inflammatory changes, with cirrhosis, without any urate deposits of any
kind being demonstrable; (3) there may be chronic interstitial
nephritis, with crystallized urates in the urinary tubules.
As regards changes in the liver, few satisfactory accounts exist. {118}
Portal originally called attention to the fact that in gout and
rheumatism indurations of the liver caused by the deposit of a
phosphatic earth occurred, and Charcot has recently referred to the
fact. Ebstein cites a case in which in a gouty patient he was able to
make a diagnosis of moderate hypertrophic hepatic cirrhosis, but so far
he had not been able to confirm it by post-mortem examination.[6]
[Footnote 6: Gout in Animals.--Of the occurrence of gout in animals not
many reliable reports exist; Ebstein has collected a few. Thus, he
cites a case where in an old hunting-dog uratic concretions were found
in the articular ligaments and in the periosteum of the epiphyses of
many joints, but especially those connecting the ribs with their
cartilages. In the toes of falcons and of parrots kept in confinement
deposits of urates have been observed, and in an alligator dying in
captivity deposits were found in the muscles as well as the joints
which consisted of free uric acid together with sodium urate.
Experimentally, Ebstein was able to produce gouty lesions having all
the characteristics of those occurring spontaneously in man by
injecting subcutaneously small quantities of the neutral chromate of
potash into the blood of cocks for a considerable period of time. By
this method changes in the epithelial elements of the kidney were
produced, preventing the elimination of the urates from the blood and
causing their consequent accumulation in the system. He obtained in
this way typical deposits of urates in the joints, tendons, muscular
sheaths, heart, and other organs, while the birds emaciated and finally
died. But these experiments, which are extremely valuable and
interesting, still need confirmation.
The experiment of tying the ureters of fowls is an old one. Galvani who
was perhaps the first to perform it, employed it in his investigations
on the kidney, and since then Zalesky, Pawlinoff, Von Schroeder,
Colosanti, and others have made use of it in their experimented studies
on the site of origin of uric acid. As a result of this operation
deposits of urates occur in various organs. Ebstein, however, does not
regard them as analogous to the gouty deposit in human beings, as they
lack the feature of necrosis, which, as mentioned above, he considers
as alone characteristic of the true gouty lesion.]
SYMPTOMATOLOGY.--The development of true gouty lesions, whether of the
acute or subacute form, is usually preceded by a period, more or less
protracted, in which characteristic derangements of the health present
themselves. These derangements may be conveniently classified as
disturbances of primary digestion and as manifestations of
malnutrition.
The disturbances of primary digestion are repeated attacks of flatulent
dyspepsia, with pyrosis, colicky pains, alternate constipation and
diarrhoea, and a scanty, high-colored, and heavy urine with uratic
sediments. This dyspepsia may be accompanied with a variety of reflex
nervous symptoms, such as pain in the nape of the neck and occiput,
insomnia, palpitation, sighing respiration, singultus, and nausea.
These symptoms are commonly described as due to biliousness, and are
provoked by excesses in diet, and not unfrequently by moderate
indulgence in certain common articles of food, such as sweets, fruits,
farinaceous foods, and the fermented preparations of alcohol.
Derangements of nutrition are shown by a disposition to erythematous
and catarrhal affections of the skin and mucous membranes, to
affections of the sebaceous glands, and to premature falling of the
hair. There is often a more or less marked tendency to obesity.
Accompanying these derangements there may be a loss of energy, both
physical and mental, manifesting itself in indolence and fatigue on
slight exertion, in irritability of temper, with diminished
intellectual activity and hypochondriasis. Neither the primary
indigestion nor the nutritive derangements invariably precede the
development of acute gouty lesions, nor are they necessarily followed
when they exist by the articular signs {119} of gout; but they are so
commonly associated with the evolution of what are regarded as the
specific lesions of gout that they may fairly be described as
constituting its prodromal period.
ACUTE ARTICULAR GOUT.--A typical attack of acute gout is usually
sudden. It seizes its victim without warning, and often rouses him from
sleep with a vicious agonizing pain in the joint assailed. Examination
will reveal a slight redness, heat, and puffiness of the part affected
altogether disproportioned to the intensity of the pain; the tenderness
is exquisite, and the torture is often aggravated by the occurrence of
reflex spasms of neighboring muscles. There is usually moderate fever,
and if the surface be exposed there may be a chill. Sleep is impossible
and the restlessness uncontrollable. As the morning advances slight
perspiration occurs, and sleep may become possible. With the abatement
of pain there is coincident increase in the signs of inflammation: the
joint swells, the skin becomes red and oedematous around the joint, and
the superficial veins are distended. But, though the pain subsides with
the occurrence of swelling, and usually in proportion to its degree,
the tenderness and pain on any attempt to move the joint continue to be
extreme. The day is passed in comparative ease, but the evening
generally brings an exacerbation of pain and fever, and the night
another paroxysm of agony--not as severe as the first, but severe
enough to make the daylight a benison. The progress of the disease
after the second day, provided it is confined to one joint, is usually
marked by a steady and regular decline in the severity of the symptoms.
If the attack is confined to a single joint, a week may elapse before
the inflammatory signs subside, and it may be a fortnight before
pressure can be borne or the mobility of the joint is restored.
Occasionally the sufferings of an acute attack of gout may be
protracted by successive seizures for several weeks. The fever during
the attack is distinctly remittent, the evening exacerbation rarely
exceeding 103° F.
The urinary symptoms before, during, and after an acute paroxysm of
gout are interesting and important in their bearing upon the uric-acid
theory of the disease. Garrod's statements upon this point are
generally accepted, and have been confirmed by other observers. He says
that previous to the attack the amount of uric acid in the urine is
below the average--that during the paroxysm the proportion grows
smaller, and only rises to the normal standard with the termination of
the seizure. The reaction of the urine is strongly acid during the
paroxysm. This is due probably to the increased excretion of acid
phosphates. The quantity of the urine is generally diminished, the
specific gravity increased, and the color deepened.
Attacks of acute gout are generally followed by improved health and
capacity for physical and mental work and enjoyment. The blood seems to
be purified, the processes of digestion and assimilation are once more
normally performed, the equilibrium of the nervous centres is restored,
and the evolution of all the vital energies proceeds with ease and
vigor. This state of well-being may continue for a year or two years,
or even a longer period, after the first attack, the immunity varying
according to the intensity of the inheritance or the habits of life.
The subsequent attacks are apt to occur at increasingly shorter
intervals, and, as a rule, the acuteness of them tends to diminish.
Gradually the dyscrasia becomes more {120} profound, and the
constitutional symptoms and structural changes which belong to the
atonic and irregular forms of the disease are developed.
ATONIC GOUT.--Though subacute, irregular, or atonic gout is often the
sequence of repeated attacks of the acute disease, it is not
necessarily preceded by them, nor is acute gout invariably followed by
a marked gouty dyscrasia. It is not uncommon for a well-characterized
gouty habit to exist, manifesting itself by many and varied gouty
phenomena, without the occurrence of any acute lesions, and repeated
attacks of acute articular gout may occur without the development of
the progressive impairment of health and the tissue-changes which
distinguish the chronic malady. The recognition of this fact is
important, inasmuch as the occurrence of acute gout is commonly
regarded as an essential element in the diagnosis of the gouty
dyscrasia. Acute articular attacks, as already noted, are very rare in
women, in whom the subacute and irregular forms of the disease are by
no means infrequent. So far as acute articular gout is of value in the
diagnosis of the constitutional vice, it is perhaps as significant if
established in the history of a near relative as in the individual in
whom the disease is suspected.
The general symptoms of atonic gout--or, as it may more properly be
called, the gouty dyscrasia--are similar to those which sometimes
precede the development of the acute form. The difference lies in their
persistence, in the subacute character of the local lesions, and in the
absence of the relief to the constitutional symptoms which follows
acute attacks.
The dyspeptic symptoms are perhaps the most pronounced and uniform in
the history of the evolution of chronic gout. These symptoms have been
already described, but the fact which seems especially to distinguish
them is that they are chiefly provoked by the acid fermentation of the
carbohydric elements of the food, the sugar and starches, and
especially by the fermented preparations of alcohol; the ability to
digest these articles of diet appears to be deficient in the gouty
dyspeptic.
The changes in the urine in the gouty dyscrasia are especially
important. In the formative stages of the gouty vice the amount of
urine may not vary much from the normal quantity, but the proportion of
solid constituents, especially of the urea, is increased, so that the
specific gravity may rise to 1.030 or 1.035. The acid reaction is
intensified by the excess of the acid urates and phosphates upon which
the normal acidity depends. Sometimes crystalline deposits of uric
acid, urates, and oxalates take place in the tubuli of the kidney and
in the bladder, and lead to the nephritic and vesical irritations which
are often the source of much inconvenience and pain. Where the urine is
free from these crystalline constituents as it comes from the bladder
it may deposit them within a few hours after its passage. At a later
stage in the development of the gouty dyscrasia the quantity and
quality of the urine undergo marked changes. The quantity is increased;
the color is pale, partly in consequence of dilution and partly through
a diminution in the amount of coloring-matter. The quantity may be so
considerable as to constitute a polyuria. The reaction is neutral or
only feebly acid; crystalline sediments of uric acid and calcium
oxalate may occasionally appear, and the specific gravity may be so low
as to indicate not only a relative but an absolute diminution in the
daily excretion of urinary solids. Traces of albumen and of sugar are
not infrequently observed.
{121} The articular symptoms of chronic gout are subacute. They affect
the joints, as a rule, which are most exposed to strain and injury, and
hence are most common in the hands and feet, but they may involve the
knee and the hips, the elbow and the shoulder, and even the
intervertebral joints. The pain is less severe, because the tension is
never so considerable; the tenderness is often a source of great
discomfort; the swelling varies with the acuteness of the inflammatory
process, the joints being more or less permanently enlarged by
hypertrophic changes affecting the articular structures and by tophous
deposits. The deformities are increased by ankylosis, by contractions,
by absorption of the cartilages, by partial luxations, and by the
atrophy of disused muscles. Crepitations are often observed in the
affected joints. Exacerbations of the local symptoms are often provoked
by movements, by imprudence in diet, by changes in temperature or in
barometric and hygrometric conditions, and not infrequently by
psychical disturbances.
The frequency with which tegumentary affections, mucous as well as
cutaneous, are observed as correlative phenomena of arthritic lesions
in gouty persons and in gouty families justifies the inference that the
same lithæmic vice which determines articular inflammations is often
responsible for derangements of nutrition in the skin and mucous
membranes. The French school of dermatology, which has always
maintained the humoral origin of many cutaneous diseases, has long
recognized the arthritic nature of a large class of affections of the
skin. Bazin[7] has given the most precise description of the
arthritides, as he terms them. He insists upon certain functional
derangements of the skin as characteristic of the gouty diathesis, such
as excessive perspiration, especially in certain regions, as the head,
the axillæ, the hands and feet, and the sexual organs, and also
affections of the sebaceous glands, causing the different forms of
seborrhoea and the premature falling of the hair. He notes the
liability in gouty persons to certain neurotic affections, such as
pruritus, general or localized, about the arms and genital organs.
Erythematous affections, especially urticaria, erythema nodosum, and
the fugitive erythema which occurs about the face, causing sudden and
evanescent swelling of the eyelids, cheeks, lips, and even the tongue
and soft palate, are recognized by him and other observers as arthritic
in their origin. Among the erythemata which are observed in gouty
persons the peliosis rheumatica should be mentioned.
[Footnote 7: _Affections génériques de la Peau_, Paris, 1862.]
The more persistent inflammatory lesions of the skin, such as eczema
and psoriasis, which are characterized by long-continued hyperæmia with
hyperplasia, are now recognized as among the possible transformations
of gout. They are certainly often observed alternating with arthritic
lesions, and associated with all the characteristic derangements of
nutrition which belong to the gouty habit. The frequency of the various
forms of acne, the inflammatory, as well as those which result from
excessive function of the glands, in persons having a strong gouty
inheritance, is recognized by many dermatologists. I have noticed these
lesions especially in young women belonging to gouty families. They are
generally accompanied by marked dyspeptic symptoms, and not
infrequently by neurotic derangements.
Garrod, in a paper read at the International Medical Congress in 1881
{122} on "Eczema and Albuminuria in Relation to Gout," affirms that
each year strengthens his conviction that gout and eczema are most
closely allied. Since his attention was first called to this relation
in 1860, he has found a gradually increasing percentage of eczema in
the cases of gout that have come under his observation. Dividing all
the cases from 1860 to 1881 into ten groups, he found the percentage
rose from 10 in the first group to 47 in the tenth. He accounts for
this rapid increase in the percentage in the fact that in the first few
years the eczema was only observed when it was very patent; during the
past two or three years he has had made more careful inquiries as to
the presence of eczema or other skin eruption in every case of gout,
and by these means has frequently discovered its presence when it might
otherwise have been overlooked. Garrod believes that eczema is the
special skin-lesion of gouty subjects, and does not regard psoriasis as
having anything more than an accidental connection with gout. He admits
that the latter is often associated with rheumatoid arthritis. It must
be remembered, however, that Garrod does not admit that gout ever
exists without lithatic deposits.
In regard to the location of gouty eczema, it appears to affect by
preference the more tender and vascular regions of the skin. The
eyelids, ears, the scalp, and back of the neck, the fingers and toes,
particularly the dorsal and lateral surfaces, and in old people the
legs, are especially liable to be attacked. The subjective symptoms of
gouty eczema are often the source of great suffering; the burning and
itching are sometimes intolerable. This is especially true of persons
of highly neurotic constitution.
It is not possible to affirm that there are lesions of the mucous
membranes which are strictly analogous in their transient character to
the erythematous affections of the skin, but it is not unreasonable to
suppose that many of the temporary disturbances of indigestion to which
gouty patients are subject are caused by an evanescent hyperæmia
corresponding to the vaso-motor derangements which are observed in the
external integument. In regard, however, to the more persistent
catarrhal lesions, there can be no question as to their analogy with
those which affect the skin. The continuity of these lesions at the
orifices of the mucous tracts, and the frequent association of external
eczemas with catarrhs of mucous membranes, are facts of common
experience. Greenhow[8] of London first called attention to the
frequency with which chronic bronchitis is associated with the gouty
dyscrasia. In an analysis of 96 cases of chronic bronchitis he elicited
the fact that in 34 out of the 96 a distinct gouty history attached
either to the patients themselves or to some of their immediate
relatives. In 14 of the cases the patients were subject to attacks of
acute regular gout as well as to bronchitis. He also noted the
association in a number of cases of bronchitis and psoriasis with
gravel and gout. My own experience confirms these observations, and
also the alternations of catarrhal and parenchymatous tonsillitis, of
pharyngeal and laryngeal catarrh, and of asthma and chronic bronchitis,
with the more common manifestations of regular and irregular gout.
[Footnote 8: _On Chronic Bronchitis_, E. Headlam Greenhow, M.D.,
London, 1869.]
The occurrence of subacute gastro-duodenal and intestinal catarrhs
{123} with hemorrhoidal complications is even more common that the
catarrhal affections of the respiratory tract. The lesion, in fact,
which gives rise to the manifold dyspeptic symptoms in gouty subjects
is doubtless a catarrhal one.
The genito-urinary tract exhibits also the tendency to catarrhal
affections in sufferers from the gouty dyscrasia. It is certain that
gouty persons are especially liable to vesical catarrh, and it is
generally admitted that rheumatic and gouty persons are particularly
susceptible to gonorrhoea. My own experience leads me to suspect that
chronic urethral discharge resulting from acute urethritis is more
common in rheumatic persons than in those not having this taint. The
etiological relations of gonorrhoeal rheumatism and kerato-iritis are
still involved in obscurity, though I am inclined to believe that a
careful examination of the personal and family history in cases of
these diseases would establish the opinion that has been maintained as
to their gouty origin.
The presence of albumen in the urine of persons suffering from acute
gout is occasionally observed. Under these circumstances it is
transient, and has probably no more significance than is usually
attached to this symptom in the course of any acute febrile disease. In
chronic gout it is by no means infrequently observed as a more or less
persistent symptom. It is associated under these circumstances with a
copious discharge of urine of pale color and low density, and with the
general signs of what Rayer first described as the néphrite goutteuse.