Pathologically, gout is characterized by the presence of an excessive amount of uric acid in the blood and the deposition of uric-acid salts in the tissues. The most common seat of deposits is the articular cartilage of the first joint of the great toe, but other articular cartilages may also be involved, as may also the cartilages of the eyelids, larynx, and ears, and the ligaments of joints. The deposit incrusts or infiltrates the cartilage, and if ulceration of the overlying skin takes place, may appear on the surface as the so called `chalk-stones.' According to Ehstein, the primary changes in the joints are those of a local necrosis due to the excess of urates in the blood. Sclerotic conditions in the arteries and kidneys are quite common, and deposits of urates in the latter may occur. Hypertrophy of the heart is often associated with the arterial changes. As to the cause of the accumulation of urates in the system in gout we are uncertain. It may he due to defective elimination of urates or to local conditions which favor their deposition. A typi cal attack of acute gout presents the following symptoms: After some weeks of previous indiges tion, attended with flatulent swelling and a feel ing 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 he is awakened by a pain in the great toe. or sometimes in the heel, the ankle, or the calf of the leg. The pain resembles that of a dis located bone, and is accompanied 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 feverishness, 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 char acter, 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 unbear able. The next night is one of tossing and turn ing, the uneasy limb being constantly moved about to find a better position; till toward 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 peel ing-off of the cuticle. This individual attack may be repeated many times in the course of what is termed 'a fit of the gout,' which commonly ex tends over a period of weeks, or even months, be fore 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. In this form, acute gout might almost be called a local disease; although the connection of the at tacks with deranged digestion, or with the other morbid affinities already described, and the ob vious relief obtained after a sharp attack, from the symptoms of constitutional suffering, point to a cause of the disease operating over a larger range of functions than those included in the ordinary local manifestations at this period. Regular gout, accordingly, forms only part of a nosological picture, in which the so-called ir regular forms have to be included before it can be said to be at all complete.
The joints which have been repeatedly the seat of the regular paroxysm become more or less permanently crippled and distorted. The patient is laid up more or less permanently in his arm chair; and exercise, the great natural specific remedy of the gouty, is denied by the very con ditions of the diseased state. Then follow aggra vations of all the constitutional troubles. In digestion continues or becomes constant, assum ing the form chiefly of acidity after meals; the liver becomes torpid, the abdomen corpulent, the bowels disposed to costiveness; the kidney fails to perform its functions satisfactorily, and not unfrequently there is a tendency to gravel and calculus (q.v.) ; the heart is affected with palpi
tations, or fainting occurs, sometimes with spas modic attacks of pain; the arteries become the seat of calcareous deposits, and the veins are varicose in the limbs and in the neighborhood of the rectum (see PILES) ; the temper is singularly irritable, and often morose; then, sooner or later, the appetite fails or is only kept up by very stimulating and unwholesome diet, with an excess of wine or of alcoholic liquors; in the end, the body emaciates, the organs and viscera func tionate feebly, and premature old age rapidly supervenes. Sometimes the end is sudden, as by cerebral hemorrhage, uremia, dropsy from the heart condition, or gouty kidney (interstitial nephritis). Uric acid in a certain excess has been shown by Garrod, and subsequently by Alex ander Haig, to be characteristic of the blood of the gouty, although a minute amount of this substance is probably present even in perfect health. The most recent speculations, according ly, tend to connect the gouty predisposition either with an excessive formation or a checked excre tion of this important substance, the product, as physiology teaches, of the vital disintegration of flesh and other food, after these have subserved the daily wants of the system. The cure of gout demands the careful consideration of all its pre disposing causes in the individual, and the strict regulation of the whole life and habits according ly, from the earliest possible period. The amount of meat food and sugar must be lessened, and milk and vegetables must constitute the diet. In old people, fruit acids must be avoided, wine and malt liquors must be absolutely prohibited, and large quantities of pure water must be imbibed. In some cases very small quantities of distilled spirits do not harm a patient who is taking no nitrogenous food but milk. Tea, coffee, and cocoa must be forbidden. The following diet list has been prepared by Haig, frorii whom it is quoted, with slight abridgment: "Breakfast.—A large soup plate half full of porridge, eaten with milk and salted. A few mouthfuls of eggs, prepared in various ways; or some mushrooms, tomatoes, or other vege tables, and occasionally fish. One or two rounds of bread, or its equivalent in toast or scones, with plenty of butter. A cup of milk, previously boiled, and flavored with tea, coffee, or cocoa. Finish with a small quantity of any fruit that is in season.
"Lunch.—Potato and one other vegetable, cooked in various ways, eaten with butter, fat, or various sauces. Pudding; tart or stewed fruit. Biscuit and butter, with cheese in con siderable quantity. A little fruit as at breakfast. For drink, a little milk, which in winter is often warm; or water, often taken in summer, with a little fruit syrup, such as lime-juice cordial.
"Afternoon Tca.—Bread and butter and cake of various kinds. A little milk and water fla vored with tea.
"Dinner.—Soup made without meat stock. Fish, or an egg, or a small bit of meat, is occasionally substituted for it. Two vegetables, with sauces, butter, or fat. Any ordinary pud ding, tart, or stewed fruit. Biscuit and butter, and perhaps cheese, if the quantity of fish or egg has been small. A good supply of various fruits for dessert. For drink, water with fruit syrup, aerated waters, or a little milk, warm in winter. A tumbler of water, aerated water, or, in winter, hot water, at bedtime." Exercise in the open air facilitates inter stitial oxidation, and improves excretion. Moun tain-climbing benefits many. Cold sponge baths, with brisk friction from a rough towel thereafter, are desirable, unless reaction be feeble. In the latter case warm baths are indicated. The bath should be taken in the morning and the patient should return to bed for an hour at least. For certain patients dry, hot-air baths, Turkish or Russian baths are desirable; to others, sea baths are beneficial.
Medicinal treatment consists in the intelligent and discriminate use of alkalies, salicylates, and benzoates, mineral acids, purgatives, mineral waters, colchicum, lithium salts, piperazine, mer curials, iodides, quinine, antipyrin, guaiae, and certain other drugs. There is no routine treat ment for the disease; the patient must be stud ied and treated according to the nature of the case. Consult Haig, Uric Acid in the Causation of Disease (London, 1894).