Gout (Fr. goutte, from Lat. gutta, 'a drop'), a medieval term of uncertain date, derived from the humoral pathology (see RHEUMATISM), indicating a well-known form of disease, which occurs for the most part in persons of more or less luxurious habits, and past the middle period of life. In its most common and easily recognised form, it manifests itself by an acute inflammation in the neighbourhood of one of the joints, usually the ball of the great toe; and to such attacks only the name was once applied. But its use is now extended by most writers to include all injurious effects in any part of the body produced by the same condition of the system which leads to the inflammation of the joints. The name podagra (Gr. pod-, 'foot,' and agra, 'seizure') indicates the leading character of the disease as apprehended by all antiquity; and the very numerous references to the disorder so called, not only in the medical writings of Hippocrates, Galen, Aretæus, Cælius, Aurelianus, and the later Greek physicians, but in such purely literary works as those of Lucian, Seneca, Ovid, and Pliny, show not only the frequency, but the notoriety of the disease. The allusions, indeed, are of a kind which give ample proof that the essential characters of gout have not been changed in the lapse of centuries. It is caricatured by Lucian in his burlesque of Tragopodagra in language quite applicable to the disease as now observed; while the connection of it with the advance of luxury in Rome is recognised by Seneca (Epist. 95) in the remark that in his day even the women had become gouty, thus setting at naught the authority of physicians, which had asserted the little liability of women to gout. Pliny likewise (book xxvi. chap. 10) remarks upon the increase of gout, even within his own time, not to go back to that of his father and grandfather; he is of opinion, further, that the disease must have been imported, for if it had been native in Italy it would surely have had a Latin name. Ovid and Lucian represent gout as mostly incurable by medicine; from this view of it Pliny dissents. The list of quack remedies given by Lucian is one of the most curious relics of antiquity.
General Causes of Gout.—In more than half the cases gout can be traced to inheritance. There is in fact no disease in which hereditary transmission is more clearly established; in some families its recurrence is notorious. Professor Cantani of Naples even states that in his country 'the hereditary tendency has been handed down from the period of the Greek colonisation and the Roman empire.' Yet even in those strongly predisposed to it its actual occurrence may be avoided by strict regulation of the diet and habits. For, if it is certain that it may be inherited, it is no less certain that it may be acquired, though perhaps not, at all events not readily, by every one; and that the most important of the causes which lead to it are errors in diet. Of these popular opinion has seized upon excessive consumption of alcohol alone; and there is no doubt that alcohol, especially in the form of strong wine or beer, has a powerful effect. But complete abstinence from alcohol will not protect those predisposed to it from the development of gout, unless they are careful with regard to food as well; overeating, especially excessive indulgence in animal food and in rich and highly-seasoned dishes, is no less certain to be prejudicial. Too little exercise, especially when associated with too much food or drink, is also hurtful. Chronic lead-poisoning is frequently associated with the development of gout, though the reason of this is not yet understood. Gout is much more common in the male than in the female sex. It is said to be most common at the present day in England, especially in London, and in southern Italy.
Essential Nature of Gout.—It has long been known that the tophi or chalkstones deposited under the skin in most well-marked and severe cases of gout consist largely of urate of soda; and that Uric Acid (q.v.) and its salts are often excreted in large amount in the urine of gouty persons. But it was first shown by Dr (now Sir) A. Garrod that this substance is always present in considerable quantity in the blood in cases of gout; in chronic gout at all times, and in acute gout for some time before the occurrence of an attack. It is now agreed by all that the presence of this substance in excess in the system is an important factor in the production of gout; but authorities differ as to how its presence is to be explained. There are two main theories on the subject which it must suffice to mention: (1) that the processes of disintegration going on in the body, particularly in the liver, lead to its formation in excessive amount; (2) that there is not excessive formation, but defective elimination of it by the kidneys. There is, however, a third theory with regard to the origin of gout, which attributes its occurrence to a perverted condition of the nervous system, and regards the presence in excessive amount of urate of soda in the blood as a subordinate though still important feature of the disease.
Symptoms of Acute 'regular' Gout.—Sydenham's treatise on gout, written 200 years ago, is interesting not only as containing the well-considered views of a master in the medical art, but also as the faithful description of the disease by one of the victims of it. His account of the paroxysm of regular gout may be given here with some abbreviation. After some weeks of previous indigestion, attended with flatulent swelling and a feeling 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 dislocated 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 character, 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 unbearable. The next night is one of tossing and turning, the uneasy limb being constantly moved about to find a better position; till towards 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 peeling-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 sometimes extends over a period of weeks, or even months, before 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.
Such are the principal features of the 'regular gout.' In this form it might almost be called a local disease; although the connection of the attacks with deranged digestion, or with a variety of other minor ailments too complex to be described here, and the obvious relief obtained through the 'fit' 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 irregular, atonic, metastatic, or retrocedent forms have to be included before it can be said to be at all complete.
These, indeed, form almost all the darker shadows of the picture; for regular gout, though a very painful disorder, can hardly be said to be dangerous to life, or even to the limb affected, at least until after many attacks.
It is the tendency, however, of gout to fall into irregular forms; and herein lies its danger. One source of local aggravation is, indeed, soon apparent, and it leads rapidly to other evils. The joints which have been repeatedly the seat of the regular paroxysm become, more or less permanently, crippled and distorted. A white, friable, chalk-like material is gradually deposited around the cartilages and ligaments, and sometimes in the cellular tissue and under the skin (tophi or chalk-stones). Sometimes this material is discharged externally by ulceration, and then usually with relief. At other times it accumulates into irregular masses, or 'nodosities,' which entirely destroy, or at least greatly impair, the movement of the limb. 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 conditions of the diseased state itself.
Other Manifestations of Gout.—With regard to what should be included under the term irregular gout there is much difference of opinion. It is sometimes no doubt used as a refuge for ignorance, when no other cause can be discovered to explain symptoms of ill-health. It is certain, however, that regular gout often alternates with a morbid condition in some other part of the body, and that many diseases occurring in those whose family history or habits of life may be considered to predispose to gout, whether they themselves have suffered from regular gout or not, are benefited by hygienic and medicinal measures similar to those which do good in undoubted cases of gout; and most physicians agree in speaking of such as forms of gout. The most important of these we shall here enumerate, in connection with the organs affected. Heart and blood-vessels—palpitation, irregularity of heart action, angina pectoris, and atheroma with its consequence, phlebitis. Lungs—asthma, bronchitis. Nervous system—neuralgia, headache, epilepsy, mental disorder. Skin—eczema. Digestive organs—inflammation of throat, various forms of indigestion, cramp or inflammation of stomach, jaundice. Urinary organs—irritability of bladder; stone, especially the uric acid form (see CALCULUS); diabetes; above all, chronic Bright's disease. It is impossible within the limits of such an article as the present to give any description of the various manifestations of the gouty tendency; the above list of ailments (most of them treated separately) will give some idea of their complexity and importance.
Treatment of Gout.—The cure of gout, in the highest sense of the word, demands the careful consideration of all its predisposing causes in the individual, and the strict regulation of the whole life and habits accordingly, from the earliest possible period. It is the difficulty of accomplishing this which makes gout a disease proverbially intractable; for the regular attacks of the disease seldom occur till pretty late in life, long after the habits have been fully formed which are most adverse to the cure. Rigid temperance in eating and drinking, with daily exercise proportionate to the strength and condition of the individual, in reality constitutes the only radical cure of the gout, the lesson of ages of experience as read to the gouty by the light of science. But the lesson is not learned, or only learned when too late. It should never be forgotten that a man of gouty family, or individually much exposed to the causes of the disease, can only hope to escape it in his old age by habits of life formed at an early period, and by a careful avoidance of most of the common dissipations of youth. That the disease may be warded off in this way there is ample evidence; and it is not less certain that there is no other way of living secure from gout. The treatment of the fit, in so far as it does not resolve itself into the celebrated prescription of 'patience and flannel,' must be a subject of medical prescription. Blisters, leeches, and especially cold applications, though they may give temporary relief, are studiously to be avoided; the last sometimes even lead to a fatal result. The well-known virtues of Colchicum (q.v.) are perhaps somewhat overrated by the public; and its dangers are not less striking than its virtues. It is certain, however, that in cautious medical hands colchicum is a remedy of great value in the gouty paroxysm; and of equal value perhaps are certain natural mineral waters, as those of Vichy and Carlsbad. Alkalies and their salts, especially potash and lithia waters, as prepared artificially, with minute doses of iodine and bromine, have likewise been much recommended for the cure of gouty deposits. For the distinctions of gout and rheumatism, and the presumed relation between them in some cases, see RHEUMATISM. See Sir Dyce Duckworth's Treatise on Gout (1889).
Goutweed. See BISHOPWEED.