THE DIAGNOSIS AND TREATMENT OF GOUT. 
BY 
LOUIS F. BISHOP, M.D., 
OF NEW YORK. 
FROM 
THE MEDICAL NEWS, 
January i8, 1896. [Reprinted from The Medical News, January 18, 1896.] 
THE DIAGNOSIS ANDJREATMENT OF GOUT. 
LOUIS F. BISHOP, M.D., 
OF NEW YORK. 
In a previous paper we dwelt very extensively 
upon the theory and distribution of gout. Inter- 
esting though it may be to theorize as to its cause, 
the practical outcome of such study should be the 
recognition of the disease in its various forms and 
the application of a proper plan of management. 
The subject naturally divides itself into the diag- 
nosis of acute attacks of gout and of the gouty 
diathesis, constitution, habit, or whatever else we 
choose to call it. 
Acute gout arising for the first time in a com- 
paratively young person can very easily be over- 
looked by us in this country because it is not at all 
common in our experience. The points to be con- 
sidered are the time of the attack, the location of 
the pain, its character, the nature of the inflamma- 
tion, and the fact that the inflammation is followed 
by desquamation of the cuticle. The attack usually 
occurs without previous foreboding in the early 
hours of the morning. The pain, located, as a 
rule, in the metatarso-phalangeal joint of the great 
toe, is very severe in character. The tissues of the 
joint will be acutely inflamed, swollen, and intensely 
congested. Accompanying the attack there will 
be a slight rise in temperature, which increases 2 
slightly after the attack has lasted a while. Toward 
the afternoon of the following day the fever subsides 
and the pain is a good deal relieved, but the symp- 
toms recur the next night, and the attack goes on 
in this way often from five to eight days, gradually 
wearing off. The inflammation may involve the 
great toe of the opposite foot or other joints. 
Now there occurs what will confirm our diagnosis, 
and that is the desquamation of the epidermis of 
the part inflamed. The term " suppressed gout " 
is applied to a series of symptoms not typical of 
gout, but which occur in a person subject to gout, 
and which from strong negative and positive evi- 
dence we suppose to be gouty in origin. These 
attacks of suppressed gout are worthy our close 
study because they must occur sometimes in our 
practice, and can so easily be overlooked. They 
may immediately follow an attack of acute gout, 
or replace an attack. The patient may have severe 
vomiting, pain, diarrhoea, and profound depression, 
or there may be cardiac failure, manifested by 
dyspnoea, irregular action of the heart, and pain 
referred to the heart or to the left shoulder. We 
should remember that these attacks of so-called 
suppressed gout may occur independently or re- 
place an attack of acute articular gout. Here it is 
that a great difficulty of diagnosis occurs, and the 
best that we can do is to keep this in mind as the 
possible cause when we see obscure, severe, and 
often fatal cardiac attacks accompanied by extreme 
dyspnoea, with failure of the heart's action in force 
and rhythm. Our training in this country leads 
us to attribute all these cases to uraemia, and we go 3 
so far as to classify cases in which there is an ab- 
sence of albumin in the urine and many other of 
the typical signs of kidney-disease. It would seem 
that at least a few of these cases were cases of sup- 
pressed gout. 
Nor is the diagnosis of the gouty diathesis easy 
or one upon which all observers will agree in every 
individual case. Just what the condition is from is 
also a matter of discussion, but that there is such a 
condition is not a matter of dispute. 
Dr. William Draper said, in a discussion on gout 
occasioned by a previous paper, that the " gouty 
habit is a constitutional vice, a vice of nutrition." 
We say that a man has gout because he has too 
much uric acid in his blood; but the close rela- 
tion between diabetes and gout suggests the idea 
that the former is a condition of imperfect com- 
bustion of carbohydrates, and the latter of proteids. 
This seems to give a good working hypothesis for 
the understanding of these diseases. In the same 
discussion Dr. F. P. Kinnicutt said : " I believe 
that gout exists in America to-day to a very large 
extent, and I should say that probably it exists 
more frequently in the irregular than in the typical 
form. We do not see so much in the hospital as 
in private practice. What I see in private practice 
perhaps more frequently than any other manifesta- 
tion of it is both the typical and irregular forms in 
women, particularly as they approach the climac- 
teric. I think that about the approach of this 
period you will find in very many women all the 
manifestations of gouty trouble." 
The diagnosis of chronic gout following a series 4 
of acute attacks and gradually settling down to a 
permanent condition is easy enough, but this is not 
the beginning that we usually find. Like Bright's 
disease, a very large number of cases are gradual in 
onset, and it is hard to say just where they began. 
This is especially true of the cases in which the 
articular symptoms are not very marked. In artic- 
ular gout the picture of a chronic case is very 
typical. We have the deposits of concretions 
about the joints with the skin over the tophi be- 
coming stretched and often discharging so-called 
chalkstones. The subject of such a condition is 
usually anaemic, poorly nourished, and in addition 
has those signs which follow in endarteritis, namely, 
high-tension pulse, an increased quantity of urine 
of low gravity and containing a trace of albumin. 
In studying hospital reports some years ago I was 
struck by the extreme rarity of diagnosis of gout 
and the frequency of the diagnosis of chronic 
diffuse nephritis. It would seem that the micro- 
scope had concentrated our gaze too much upon 
kidney-pathology. It is a teaching of some, or at 
least the impression given students, that many of 
these cases are primarily cases of nephritis, and 
that scleriasis of the vessels with the accompanying 
condition is secondary. Certainly a good many 
of these cases are cases of gout, or at least of the 
gouty diathesis, and should be treated, especially at 
the beginning, as cases of lithsemia. The impor- 
tance of early diagnosis is that the avoidance of 
sclerotic conditions depending upon gout depends 
upon a proper management of the underlying vice 
of nutrition. 5 
The discussion of the diagnosis of gout would not 
be complete without a consideration of some of the 
more irregular manifestations. These may be ner- 
vous, gastric, cutaneous, pulmonary, or may affect 
the organs of special sense. Their irregular mani- 
festations are as often due to hereditary tendencies 
as to acquired gout, hence we see them often in 
very young people. The gouty habit or lithsemic 
state may even appear in infants. Infantile eczema 
may sometimes be due to hereditary gout when it 
is unusually obstinate to treatment. In older peo- 
ple cutaneous affections are very closely allied to 
this constitutional vice. So firmly is this belief 
held in these days, that no one would think of 
treating chronic psoriasis without attention to diet; 
but skin-affections are not always gouty, and the 
effect of diet and the modification of other condi- 
tions of the system upon the course of the disease 
should be studied before arriving at the conclu- 
sions that any particular skin-disease is due to gout. 
While writing this there comes through the mail 
a pamphlet on psoriasis, in which Dr. L. Duncan 
Bulkley, in speaking of the relation between gout 
and these very troublesome skin-affections, says: 
" It is often very difficult to determine with certainty 
the underlying causes which operate to produce the 
eruption, for it is observed in those presenting widely 
diverse conditions of life and under the greatest variety 
of circumstances. It develops with about equal fre- 
quency among the poor and the rich. Not only will it 
appear after exhaustive diseases, after pregnancy, and 
in those debilitated by various excesses, but it comes 
also in subjects who are apparently in the best of health 
and enjoying the surroundings of a healthy and appar- 
ently proper life. No single cause or element, or any 6 
combination of causes or elements, can be traced in 
every case. 
" The evidence increases, however, that it is more or 
less closely allied to the blood-states which are known 
as the gouty and rheumatic.'' 
The gout-factor in the production of pulmonary 
affections and affections of the organs of circula- 
tion is also pretty clear, for gout is certainly often 
a factor in the production of chronic bronchitis 
and in the sclerosis of vessels and valves, which is 
so familiar as the cause of those diseases of the 
heart and bloodvessels which are of gradual onset. 
That chronic bronchitis is often due to gout might 
be inferred from the fact that it occurs so often in 
gouty people, and that it is sometimes ameliorated 
by a course of treatment for the underlying consti- 
tutional state when more direct methods have had 
but little effect. Gastro-intestinal disorders are 
often of a gouty origin. This is especially true of 
attacks of biliousness in which the tongue is dirty, 
the bowels constipated; headache and all the other 
usual symptoms are not only present, but rather 
persistent. When these bilious attacks occur with 
unwonted frequency and are not modified by ordi- 
nary treatment, it is well to investigate for other 
evidences as to the gouty diathesis. To some of 
the nervous manifestations we have already alluded 
in quoting some remarks of Dr. Kinnicutt. 
The nervous manifestations of gout may be divided 
into two classes, the immediate and the remote. 
The immediate are such as are due to the effect of 
sodium urate circulating in the blood and coming 
in contact with nervous elements or being de- 
posited in them; the secondary effects are due to 7 
the gouty ravages upon tissues in the neighborhood 
of nerves or upon the bloodvessels by which the 
large nervous centres are nourished. Perhaps the 
commonest manifestation of gouty state in its re- 
current form is a migraine. The investigations of 
Haig caused him to come to certain conclusions 
after elaborate clinical and chemical investigations. 
After trying a great variety of alternations of diet, 
he gave up all butcher's meat and replaced it by 
milk and fish. On this diet the headaches disap- 
peared by the intervals becoming longer, until 
finally he went eighteen months without an attack 
of notable severity. In searching for the cause of 
this phenomena he discovered the relation between 
his headache and the excretion of uric acid, and 
means by which he could control the excretion of 
uric acid from day to day, or from hour to hour, 
and that in altering the uric acid he could alter the 
symptoms relating to it. He noticed that when he 
produced the headache, mental depression, etc., 
there was an increased excretion, and when he 
stopped the plus excretion with an acid he removed 
all these symptoms. But he noticed that in curing 
the headache by giving the acid he produced a cer- 
tain amount of shooting-pain in the joints, the 
meaning of which probably was that the uric acid 
which failed to appear in the urine must have been 
held back in the joints and produced pains. The 
headache depended upon the absolute quantity of 
uric acid circulating in the blood. 
Haig's interpretation of the phenomenon is as 
follows: He supposes that gouty symptoms are due 
to an accumulation in the body of uric acid de- 8 
pending upon a diminished excretion. He points 
out that if excretion falls behind secretion by a 
minute quantity, in the course of time there will be 
an accumulation. He supposes that so long as this 
accumulation is quietly stored up in the tissues there 
are no constitutional symptoms, but when for any 
reason this is liberated and circulates in the blood 
the symptoms appear, and naturally enough an ex- 
cess appears in the urine. This theory certainly 
explains very well the increased excretion that he 
observed at the time when symptoms were present 
or imminent. This also explains the periodicity of 
attacks. He believes that in persons in whom the 
balance of secretion and excretion is but very 
slightly deranged there is a very gradual accumula- 
tion, and that such persons will suffer from gout 
in some of its more obscure forms after years have 
elapsed. 
In practice, however, we would not wish it to be 
thought that gout is by any means the cause of all 
or even the majority of cases of migraine. This 
most interesting affection, in all probability, has a 
number of very different origins. Neuralgia affect- 
ing the sciatic nerves, the intercostal nerves, the 
fifth nerves, or, more rarely, other nerves, are often 
gouty in origin. The gouty subjects are also liable 
to neuralgic pains of a shooting, drawing character, 
lasting a moment and then disappearing in almost 
any part of the body. They also suffer from visceral 
pains of a neuralgic character. A true neuritis most 
commonly affecting the sciatic nerve is common in 
gouty subjects, especially if alcoholic. In speaking 
of the more or less indefinite nervous symptoms of 9 
gout, Gowers says "that cases which may be re- 
garded as functional are those in which symptoms, 
commonly subjective in character, result from some 
morbid blood-state." 
Occasionally there is definite failure of power, 
lasting for a few days or weeks, without objective 
symptoms, and passing. But the most common 
symptoms from this cause are sensory and subjective, 
feelings of tingling and formication in the legs, dull 
aching, and sometimes actual pain ; this is usually 
transient, but occasionally continues for some days 
or weeks, varies in position, but in gouty cases often 
felt in the heels. Symptoms due to morbid blood- 
states, like other symptoms of the same class, are 
especially common in persons who inherit a ten- 
dency to gout, but have not suffered from attacks 
of definite arthritis. Indirectly due to gout are the 
effects of the interruptions of circulation which go 
with gouty endarteritis. The thickening of the 
cerebral arteries may give rise to attacks of dizzi- 
ness, temporary loss of consciousness, and even im- 
paired mental conditions. When a condition of 
endarteritis sufficient to cause these symptoms is 
present, there is, of course, great danger of throm- 
bosis and an accompanying destruction of brain- 
matter, with symptoms corresponding to its location. 
Of the effects on the special senses, due to gout, 
we will speak briefly. It may attack almost any of 
the tissues of the eye. As a cause of conjunctival 
irritation it seems to be quite frequent. Iritis, 
though perhaps more commonly rheumatic, may 
still be due to gout. Even glaucoma has been 
attributed to it, but the evidence is not very strong. 10 
Gout as a cause of deafness is sometimes due to 
urates being deposited between the layers of the 
membrana tympani. Gouty subjects are especially 
liable to inflammations of the throat and larynx, 
and to catarrhal conditions generally, but there is 
no direct evidence that it is more than the increased 
liability which would come with the depressed 
vitality of a constitutional disorder. 
The manifestations of gout have not by any 
means been covered by this enumeration, but we 
must pass now to a brief consideration of the man- 
agement. The word management, as a name given 
to our efforts to bring about a cure of gout, is better 
than the word treatment, because treatment carries 
with it a trace of an idea of a specific plan of medi- 
cation. It is a trite remark that the management of 
gout is chiefly a question of hygiene, and that 
though the value of drugs cannot be disputed when 
applied to proper cases at the proper time, still no 
one drug is always available. To a condition like 
this we are apt to apply the statement that its man- 
agement is chiefly a question of hygiene. A good 
many persons, both laymen and physicians, fall into 
the error of supposing that a hygienic treatment is 
easy of accomplishment. This is a deep error. The 
cure of a disease by the modification of patient's 
surroundings and the habits of action of his organs 
may well tax the patience, knowledge, and ingenuity 
of his doctor. Hygienic treatment includes not 
only the modification of air, mode of life, food and 
drink, but the skilful use of drugs, which are directed 
to the improvement of the physical action of the 
organs. It does not seem quite philosophical to 11 
include tonics, blood-foods, and laxatives under 
the head of a drug-treatment of the disease. 
The first question that arises is that of food. We 
must modify the popular notion in regard to dif- 
ferent classes of food. We are not in a position to 
draw a line between carbohydrates and proteids. 
Clinical evidence is brought forward by Dr. 
William H. Draper and others that some gouty 
patients do well on animal-diet, controverting the 
theoretical conclusion that meat is to be avoided. 
The safest hypothesis upon which we can work is 
that in gout there is an impairment of the chemical 
powers of the body, which in different patients 
affects somewhat different processes. Some hold 
that it is a question of deficient oxygenation, so, of 
course, we think immediately of remedying the 
defect by supplying more oxygen. This we attempt, 
but we must also take pains that the amount of 
these foods, concerning which there is a failure of 
chemical action on the part of the body, shall be 
in as small a quantity as possible. 
In discussing the previous paper already alluded 
to at the New York Academy of Medicine, Dr. 
William H. Draper said : 
" Shall he confine himself to starchy foods and take 
as little proteid food as possible, or shall he take pro- 
teid food with the proper proportion of starchy food ? 
My own experience leads me to think that a gouty per- 
son does best upon a diet in which there is a good pro- 
portion of proteid food, but that he should have a fair 
amount of starchy food as well. Gouty persons digest 
proteids freely, but the carbohydrates are exceedingly 
difficult of digestion. 
" Now, in regard to sugars, sweets of all kinds, in 
gouty persons, what has been your experience ? There 12 
is an inability in gouty persons to digest a large amount 
of sweets; often they have to forswear sweets. They 
may indulge in spirituous drinks and suffer no inconve- 
nience, but if they take fermented wines they suffer, and 
how ? They have eructations of wind and are made 
very uncomfortable by it. Or they may suffer some of 
the nervous symptoms of gout as a consequence of a 
glass of wine or beer. Many gouty persons learn to 
shun the fermented preparations of alcohol. The gouty 
person may take distilled liquor, while he cannot take 
it as a fermented preparation. This is, I think, a very 
striking fact in the history of gouty people and one that 
complicates very much a uric-acid theory of the disease. 
" Now, in regard to starches. It is a very curious 
feature-but it is one which experience confirms-that 
there are persons who cannot take much starch, who 
are made uncomfortable thereby by nervous troubles as 
well as by the physical distresses to which they render 
themselves liable. This is especially true of potatoes. 
The simple injunction, ' Don't use potatoes,' is often of 
great value to the sufferer from gout. There is something 
in the vice of nutrition from which gouty people suffer, 
which is above and beyond the question of ingestion of 
food. What this is we do not now understand; but I 
believe that some day we shall understand why it is that 
gouty people, who ought to eat starchy food, cannot eat 
f it, and can eat proteid food." 
After all, the diet which Dr. Draper has found by 
his long experience to be best can be brought 
within a line of theory by considering that by not 
overtaxing the digestion with carbohydrates its 
forces are more at liberty to take care of the proteids. 
We will not attempt at this time to give a dietary, 
because in truth that must to a large extent be 
worked out for the individual case. We must study 
food from the theoretic side, but in the presence of 
the disease each patient must be studied by himself. 
The drug-treatment of gout is not a specific treat- 
ment. After we have controlled as far as possible 13 
the supply of foods to be taken care of, we attempt 
to modify favorably the chemistry of the body, and 
here the probable philosophy of mineral-waters be- 
comes plain. Nearly all chemical operations are 
carried on with water as the vehicle for the chemical 
agents and reagents. Every chemist knows that in 
seeking a chemical result the reaction of the fluids- 
that is, its degree of acidity or alkalinity-must be 
right. Now by supplying to the system fluids in 
abundant quantities, especially if these fluids tend to 
modify favorably the reaction of the system, we are 
certainly benefiting the chemistry of the body. 
Lithia seems to have vindicated its right to a place 
among useful drugs in gout. Its action is probably 
not, as was formerly supposed, principally by increas- 
ing the solubility of sodium urate, but it seems to 
have also a catalytic action ; that is, by its presence 
it favors the action and reaction of the fluids of the 
body to a degree out of proportion to its amount. 
In giving lithium, and this remark may be applied 
also to other drugs, it should be given in definite 
amount. There is no magic in native mineral-waters. 
Artificial waters are just as good, and have the ad- 
vantage of a definite formula and safety from pos- 
sible infection in rural neighborhoods. We would 
not think it necessary to unfold this doctrine to a 
patient to whom we thought the surroundings, the 
mode of life, and mental effect of a watering-place 
were necessary, but scientific truth is not modified 
by popular beliefs. And the verdict of the labora- 
tory upon the absence of any magic combination in 
native waters is positive. 
Colchicum has been shown by clinical experience 14 
to be of great value in controlling the symptoms of 
gout. It relieves the pain of acute attacks and 
modifies the course of chronic cases. It is an Eng- 
lish tradition, still held, that the suppression of 
acute gout by colchicum is liable to the production 
of dangerous internal diseases. Between the par- 
oxysm colchicum can be given from day to day 
with apparent benefit. Piperazine is a drug that is 
attracting so much attention that it cannot be passed 
without mention, but conclusions are not yet positive. 
Besides these drugs iodide of potassium in chronic 
gout is the only one well established. The drug- 
treatment of gout is so much a question of adapt- 
ing the well-known therapeutic agents to particular 
conditions that details are best left to individual 
judgment. Thus we see that gout is a disease which 
may manifest itself in a great many different ways, 
and the recognition and management of which must 
always be of great interest to physicians in every 
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