GOUT. 86 GOUT. affected limb ; to this succeeds chilliness, with shiverin<r. and a trace of feverishness, these last sjinptouis diiuinisliing as the pain increases. From hour to hour, until the next evening, the patient suffers eveiy 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, tc 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 cveu, in some cases, b^' 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 fvmctions satisfactorily, and not linfrequently 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 Pfles) ; 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, ura'mia, 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 physiolog}- teaches, of the vital disintegration of flesh anil other food, after these have sub-icrved the daily wants ol 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, from 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 fiiiit syrup, such as lime-juice cordial. "Afternoon Tea. — 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. watx;-r ^vith 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 diy, hot-air baths, Turkish or Russian baths are desirable; to others, sea baths are beneficial. Medicinal treatment consists in the intelligent and discriminate >ise of alkalies, salicylates, and benzoates, mineral acids, purgatives, mineral
