A treatise on gout and rheumatic gout (rheumatoid arthritis)

Front matter

A TREATISE ON

GOUT

AND

Chapter I

IXTBODUCTOBY EeSIAEKS '.— KNOWLEDGE OF THE ANCIENT WRITERS XTPON THE SUBJECT OP GOUT— VIEWS OP HIPPOCRATES— CELSUS — GALEN— AEETiEUS—C^LIUS AURELIANUS— ALEXANDER TRALLIANUS

AETIUS— PAUXUS iEGINBTA — DEMETRIUS PEPAGOMENOS — THE

ARABIAN PHYSICIANS— THE PRINCIPAL AUTHORS OF THE 17TH AND 18th CENTXIRIES— CLASSIFICATION OF GOUT ADOPTED BY DIFFERENT AUTHORS — author's DIVISION

Chapter II

Acute Gout : — description of an early attack — premonitory symptoms — seat ant5 character of gouty inflammation — parts first affectet) — pain — oedema — desquamation — not followed by supplttation — apparent exceptions— febrile disturbance — temperature — progress of gout — illustrative cases — acute general gout — sequels of acute gout — is gout a salutary disease ?— gout simulating rheumatism — sydenham's description of acute gout

Chapter III

Chbonic Gout :— not a constant sequel to the acute affection— descbiition op — constitutional symptoms — alterations

OF STEUCTUEE produced by chronic GOUT — NATURE OF THE so-called CHALK-STONES OR TOPHACEOUS DEPOSITS — THEIR MICRO- SCOPIC AND CHEMICAL CHARACTERS — THEIR FREQUENT OCCURRENCE — SITUATION OF — UPON EARS — OFTEN USEFUL IN DIAGNOSIS— AROUND JOINT.S — WITHIN BURS^ — CAUSING MUCH DEFORMITY — ILLUSTRATIVE CASE.S — GOUTY ABSCESSES— MR. MOORE'S DESCRIPTION OP — CIRCUMSTANCES LEADING TO THE FORMATION OF EXTENSIVE CHALK-LIKE DEPOSIT.S— SYDENHAM'S DESCRIPTION OF CHRONIC GOUT -lo viii

CONTENTS.

Chapter IV. Page

Blood in Gout : — alteked condition of the blood in gout often assumed by the older weitees, not proved until very recently— composition of the blood in health— its alteration in gout — globules — fibrin — albumen — discovery of urate of soda in the blood— mode of separating uric acid and urate of soda from it — clinical method for determining the presence of ulilc acid in the blood— details and precautions — delicacy op the test — ready decomposition of uric acid in the blood— probable changes which ensue— table containing a short summary op cases op gout in which uric acid was proved to exist in the blood — discovery of uric acid in fluids artificially effused— use in diagnosis — small amount op urea in the blood in gout, also of oxalic acid — traces of uric acid aud urea in healthy blood— condition of the blood in the intervals between the attacks of gout — perspiration in gout— oxalic acid found in this secretion 80

Chapter V

Urine in Gout: — characters op healthy urine— table exhibiting THE composition OF LTJINE AND THE DAILY ELIMINATION OF ITS DIFFERENT CONSTITUENTS — URIC ACID — THE 3IANNER IN WHICH IT EXISTS IN THE URINE— RELATION BETWEEN THE ACIDITY OF URINE AND THE URIC ACID CONTAINED IN IT — CONDITION OF THE URINE IN ACUTE GOUT— NO EXCESSIVE EXCRETION OF URIC ACID IN MANY CASES- ELIMINATION OF THE' UREA BUT LITTLE IN- FLUENCED— URINE IN CHRONIC GOUT— DEFICIENT EXCRETION OF URIC ACID— NO MARKED DEFICIENCY IN THE EXCRETED UREA — FREQUENT PRESENCE OF SMALL AMOUNTS OP ALBUMEN — URINE OF GOUTY INDIVIDUALS IN THE INTERVALS OP THE FITS — PROBABLE EXPLANATION OP THE FREQUENT RETURNS OF GOUT — MICROSCOPIC CHARACTERS OF THE URINE IN DIFFERENT FORMS OP GOUT — MODE OF DETECTING ALBUMEN IN URINE OF GOUTY SUBJECTS . . Hit

Chapter VI

The Morbid Anatomy of Gout : — great importance of the subject — changes in the joints observed by portal, morgagni, dr.

MONRO, AND OTHERS — CRUVEILHIER'S OBSERVATIONS — THE AUTHOR'S INVESTIGATIONS — 1. CASES OF CHRONIC GOUT WITH EXTENSIVE CHALK-STONES AND DISTORTIONS— 2. SUBJECTS EXHIBITING POINTS OP DEPOSITION ON THE EARS ALONE— 3. CASES IN -ttTIICH NO DEPOSIT OR DEFORMITY EXISTED — 1. WHERE ONLY THE BALL OP ONE GREAT TOE HAD BEEN AFFECTED WITH GOUT— 0. WHERE A SINGLE ATTACK OF GOUT HAD OCCURRED MANY YEARS PREVIOUSLY 119

CONTENTS.

is

Chapter VII. Pauk

JIOEBiD Anatomy of Gout continued : — deductions drawn from

THE CASES RELATED IN THE LAST CHAPTER — PROOFS OP THE IN- VARIABLE DEPOSITION OP CHALKY MATTER IN THE INFLAMMATION OF TRUE GOUT — MICROSCOPIC AND CHEMICAL CHARACTERS OP GOUTY DEPOSITS IN DIFFERENT STRUCTURES — IN ARTICULAR CAB- TILAGE — SYNOVIAL MEMBRANE — FIBROUS TISSUE — ANCHYLOSIS OP GKELVT TOE — CH^VNGES IN THE KIDNEYS OF GOUTY^ SUBJECTS : 1. IN

THE CHRONIC FORMS OP THE MALADY ; 2. IN THE EARLY STAGES

DEPOSITS IN OTHER SITUATIONS — MORBID ANATOMY OP LOWER ANIMALS IN RELATION TO URIC ACID 183

CHAPTER VIII. Causes op Gout : — predisposing causes : hereditary influence

— sex — AGE — TEMPERAMENT OR CONSTITUTIONAL PECULIARITY

alcoholic liquors — DIFFERENCES IN THEIR POWER OP INDUCINa GOUT — INDIGESTION — ANIMAL DIET — ABSENCE OF EXERCISE — SEVERE STUDY — MENTAL ANXIETY — RACE — CLIMATE — SEASON — LEAD AS A PREDISPOSING CAUSE OF GOUT — GREAT FREQUENCY OP THE DISEASE AMONG PAINTERS AND PLUMBERS — INFLUENCE OP THE ABSORPTION OP LEAD UPON THE EXCRETION OP URIC ACID — EXCITING CAUSES : WINES, ETC. — DYSPEPSIA— COLD AND MOISTURE — MENTAL AND BODILY EXCITEMENT OR FATIGUE .... 208

CHAPTER IX. Pathology or Nature of Gout : — evidence of a close relation

BETWEEN gout AITO UEIC ACID — CHARACTERS AND COMPOSITION OP URIC ACID AJsD ITS SALTS— PRODUCTS OF ITS METAMORPHOSIS UNDER DIFFERENT CIRCUMSTANCES — ITS OCCURRENCE IN DIFFERENT CLASSES OP ANIMALS — ITS PHYSIOLOGICAL AND PATHOLOGICAL RELATIONS — OPINIONS OF THE ANCIENTS ON THE NATURE OP GOUT CULLEN'S OBJECTIONS TO THE DOCTRINE OF THE HUMORAL PATHO- LOGISTS, AND HIS OWN VIEWS ON THE SUBJECT — MURRAY FORBES'S THEORY — OPI^^ONS OF SIB C. SCUDAMORE, SIR H. HOLLAND, DR. BARLOW, DR. GAIHDNER, AND OTHERS — AUTHOR'S OWN VIEWS ON THE NATUBE OF GOUT — EXPL^VNATION OF THE GOUTY DIATHESIS AND PREMONITORY SYMPTOMS — EXPLANATION OP THE PAROXYSM AND VARIOUS PHENOMENA CONNECTED WITH THE DISEASE . . 241)

CHAPTER X. Treatment of Gout :— short review op the treatment adopted

BY THE ANCIENTS — IS GOUT A CURABLE DISEASE .' — CULLEN'S opinion— author's VIEWS ON THE VALUE OP REMEDIES IN THE DIFFERENT STAGES OP GOUT — TREATMENT OF ACUTE GOUT — DIET A.VD REGIMEN — THE VALUE OF PURGATIVES — MERCURIALS — THEIR I.VJUKIOUS EFFECTS IN MANY CASES— DIURETICS AND DIAPHORETICS — BLOOD-LETTING — COLCHICUM — LOCAL TREATMENT — LEECHE.S — BLISTERS— WARM APPLICATION.S— EVAPORATING LOTIONS— ANODYNES — SUMMARY OF THE TREATMENT OF THE GOUTY PAROXYSM . . 295

CONIENTS.

Chapter XI

Teeatment op Gout :— colchicum— impoetance op the study of'"^°" ITS mode op opeeation — the heemodactylus of the ancients

PROBABLY a SPECIES OF COLCHICUM— CHEMICAL COMPOSITION OF COLCHICUM — ITS PHYSIOLOGICAL ACTION — CUEATIVE EFFECTS NOT EXPLICABLE BY ITS PURGATIVE PEOPEETY — ITS INFLUENCE ON THE CIECULATING SYSTEM— ON THE UEINE— SIE E. CHEISTISON'S EXPEEl- MENTS— OBSEEVATIONS OP PEOPESSOE CHELIUS— AUTHOR'S ANALYSES EXHIBITING THE EFFECT OF COLCHICUM ON THE UEINE — DEDUC- TIONS THEEEPEOM — MODE OF EMPLOYING COLCHICUM IN THE TREAT- MENT OF GOUT — THE QUESTION DISCUSSED AS TO ITS LIABILITY TO CAUSE MISCHIEF — DIPPEEENT PEEPAEATIONS OF COLCHICUM — WHITE HELLEBORE IN GOUT — GEEEN HELLEBORE — LAVILLE'S TINCTlfEE . 31T

CHAPTEE XII.

Treatment of Gout :— importance of treatment in the chronic

STAGES — medicinal TREATMENT OP CHRONIC GOUT — GENERAL SKETCH OP— VALUE OF SPECIAL REMEDIES — ALKALIES AND SALINES — DILUENTS — LITHIA SALTS PROPOSED AS CURATIVE AGENTS — THEIE SPECIAL ACTION AKD ADVANTAGES — ASH LEAVES IN GOUT — TONICS — THEIR VALUE IN GOUTY CASES — PORTLAND POWDER — DISCUSSION OP THE LIABILITY OF TONICS TO PRODUCE INJURIOUS CONSEQUENCES — TREATMENT OF GOUT COMPLICATED WITH KIDNEY DISEASE — TREATMENT OF THE LOCAL AFFECTIONS — OEDEMA — STIFFNESS OF JOINTS— CHALK-STONES — GOUTY ABSCESSES — EXTERNAL APPLICA- TION OP LITHIA — ^DIET AND REGIMEN IN CHEONIC GOUT. . . 34T

CHAPTER XIII. •Treatment op Gout: — mineral waters — geiteeal eemaeks on

THEIR employment — ALKALINE WATERS OP VICHY — MODE OP action of— AUTH0E"S EXPEEIENCE op their value — SALINE WATERS OP WIESBADEN — THEIR VALUE IN GOUT — LITHIA SPRINGS OF BADEN-BADEN USED IN GOUTY OASES — VALUE OF THE WATERS OP CARLSBAD, HOMBURG, WILDBAD, TEPLITZ, BUXTON, AIX-LA- CHAPELLE, AIX-LES-BAINS, ETC.— SUMMARY OP THE TREATMENT OP GOUT BY MINERAL WATERS 40i>

Chapter XIV

Ireegulae Forms op Gout : preliminary observations— difficulties IN THE investigation OF IREEGULAE POEMS OF GOUT — MODE OP ASCERTAINING THE TRUE NATURE OF DIFFICULT AND ANOMALOUS CASES — EETROCEDENT OR METASTATIC GOUT — IMPLI- CATING THE STOMACH, INTESTINES, HEART, AND HEAD— OTHER FORMS OP ABAETICULAR GOUT — IMPLICATING THE DIGESTIVE ORGANS — THE HEART — THE EESPIHATORY ORGANS — THE URINARY ORGANS— THE EYE— THE EAR— THE LARYNX — THE SKIN — THE MUS- CULAR AND NERVOUS SYSTEMS— TREATMENT OF THE DIFFERENT POEMS OP IRREGULAR GOUT 4!'2

CONTENTS.

xi

Chapter XV. Pace

Diseases to which gouty persons ahe paeticulaely liable — gbavel and calculus— sciatica and lumbago— phlebitis — kidney disease, and the secondaey consequences op— degekebation of the tissues op the heaet and bones — gout and diabetes— gout and scorbutus or true scurvy— liability of gouty patients to be affected by lead— pyaemia in gouty subjects— prophylactic treatment op gout — influence of colonial life— prognosis op gout 4g&

Chapter XVI

liHEUMATic Gout : — remarks on the use of the name— confusion

ARISING from the EMPLOYMENT OF THE TERM — DIFFERENT DISEASES INCLUDED UNDER THE HEAD OF RHEUMATIC GOUT — CASES TO WHICH THE TITLE IS GIVEN — SEPARATION OP GOUT PEOM RHEUMATISM— RHEUMATOID ARTHRITIS— HISTORY AND DEFINITION — DESCRIPTION — NODOSITIES OP FINGERS — MORBID ANATOMY OP RHEUMATOID ARTHRITIS — CONDITION OP BLOOD, ETC. — CAUSES — lEEEGULAR FORMS OF RHEUMATOID ARTHRITIS — RHEUMATOID AETHEITIS IN CONNECTION WITH OTHER DISEASES — PATHOLOGY , 489'

CHAPTER XVII. Eheum^vtic Gout continued : — treatment op rheumatoid arthritis

— OP the ACUTE FORM — OP THE CHRONIC VARIETIES — VALUE OF SPECIAL 3IEDICINES IN THIS DISEASE— VALUE OP MINERAL WATERS IN — TURKISH BATHS IN — LOCAL TREATMENT OP RHEUMATOID AETHEITIS— DIET— REGIMEN— CASES ILLUSTRATING TREATMENT — DLiGNOSIS OF— TABLE GIVING THE DIFFERENTIAL DIAGNOSIS OP GOUT, RHEUMATISM, AND EHEUMATOID ARTHRITIS— ILLUSTRATIVE CASES OP BHEU3LA.T0ID ARTHRITIS — PROGNOSIS OP . . . . 52S-

EXPLANATION OF THE PLATES.

Plate I. (To face page 58.) Fig. 1. — a. The ear of a gouty subject, exliibiting one small nodule of urate of soda upon the edge of the helix, the only external e'N'idence of chalk-stones visible throughout the body. b. The ear of another gouty subject, with several deposits on the helix.

rig. 2. — Right hand of a gouty subject, 69 years of age, with a large concretion on the dorsal surface of the metacarpo-phalangeal joint of the index linger, and a smaller one near the base of the middle finger ; the former a veiy common position for the concretion (fi'om French edition).

Fig. 3. — The great toe of a gouty patient, considerable deposits of urate of soda seen approaching the surface, the veins in their neighbourhood enlai'ged, and the whole toe inflamed.

Plate II. (To face page 152.) — The arm of a gouty man, in which chalk-stones had become developed to an extreme degree ; the bursa over the olecranon enormously distended with chalk -like matter.

Plate III. (To face page 206.) Fig. 1. — The section of a thumb, showing the thin layer of deposit on the articular cartilages, also on the ligaments, causing anchylosis, and extending towards the surface.

Fig. 2. — The section of a finger, exhibiting the same phenomena as Fig. 1, in addition to which the urate of soda has jiressed upon the phalangeal bones and caused partial absoi-ption ; some of the same matter is seen penetrating the bone itself.

Fig. 3. — a, b, c. The knee-joint of a gouty man, recently opened, and exhibiting the white plaster-like layer of urate of soda in the articular cartilage on the heads of the femur, tibia, and patella.

Fig. 4. — Section of the contracted kidney of a goutj' subject, exhibiting white streaks of urate of soda in the direction of the tubidi luiniferi, and points of the same matter at the end of the pyramids.

Plate IV. (To face page 288.)— Fig. 1. The hand of a woman in the early .stage of rheumatoid arthritis, or rheumatic gout, showing enlargements, chiefly of the first phalangeal joints.

Fig. 2.— A hand showing one kind of deformity which occurs in advanced rheumatoid arthritis. The " type d'extension " of Charcot (from French edition).

3.— A hand showing another kind of deformity which occurs in advanced rheumatoid arthritis. The "type do flexion" of Charcot (from French edition).

xiv

EXPLANATION OF THE PLATES.

Plate V. (To fuce page 432.) Fig. 1.— A tliin vertical section of articnlaicartilage affected mtli gouty deposit, exhibiting the cry.stalline charactciiof the lU'ato of soda, dense towards the free edges of the cartilage, and gradually becoming thinner ; external to this deposit a tliin layer of organic matter is seen. Linear magnifying power, 220.

Fig. 2. — A. thin horizontal section of articular cartilage, taken from a specimen obtained from a limb amputated by Mr. Listen, in 1847. The arrangement of the crystals in stellar groups is well shown. Linear power, 220.

Fig. 3. — Crystals of urate of soda from a semi-fluid chalky concretion. Linear power, 220.

rig. 4. — Crystallised nrate of soda, obtained by evaporatmg the watery solution of the blood in gout. Linear- power, 220.

Kg. 5. — Uric acid, crystallised ou fibres from the blood in gout, by the urie acid thread experiment. Linear power, 100 and 220.

Fig. 6. — Oxalate of lime, crystallised on a fibre obtained from the perspii-ation of a gouty subject. Linear power, 220.

Plate VI. (To face page 512.) Fig. 1. — Eight hand of a child, about 4 years old, suffering from rheumatoid arthritis, showing enlargement of the wiist-joint and many of the digital articulations.

Fig. 2. — Eight foot of the same cliild, showing similar enlargements.

Fig. 3. — The left temporo-maxillary articulation of a man whose case is related at iJage 520, showing the entire removal of the inter-articirlar fibro-cartilage, also of the articular cartilage from the surface of the temporal and infra-maxiUary bones ; also the growth of osseous processes from the denuded surfaces of the bone, which form a kind of sutiu'e and cause anchylosis.

Fig. 4. — a. Eepresents the exti-eme phalangeal joint of a finger enlarged by rheumatoid arthritis (Heberden's nodosities). h. A view of the bone of same, enlarged with osteoiihytes.

c. A side view of the same.

d. The bones of the corresponding finger of a hand in a normal

condition (from French edition).

DESCRIPTION OF THE WOODCUTS.

PAGE

Fig. 1. — The appearance presented by a drop of the cream-like fluid obtained by puncturing a recently formed mate of soda deposit. Tliat in the di-awing was obtained from the knuckle of a patient whose case is described in chap. iii. Linear magnifying power 220, polarised light . 49

Fig. 2. — A drawing fi-om the hand of a patient suffering from chronic gout of many years' dm-ation, and representing a condition not unfrequently met with ............ Si

Fig. 3. — A di-awing of the hand of a patient in which the first phalangeal joint of the fourth finger of right hand is shown extremely enlarged from the deposition of urate of soda . . . . . . , . 6i

Fig. 4. — A di-awing of the left hand of a woman suffering from extreme chalkstones in nearly every limb . . . . . . . . .73

Fig. 5. — A dra^\'ing of the right foot of the same woman from whom the delineation of the hand (fig. 4. ) was obtained . . . . . .74

Fig. 6. — A fibre of thread with rhombs of uric acid adheiiug to it, as seen under polarized light with a linear magnifying power of 60, formed ^vith an inch object-glass and low eye-piece ....... 87

Fig. 7. — Casts of tubes, some granular, some waxy or fibrinous in character.

Linear magnifying power, 220 ... ..... 147

Fig. 8. — The head of the femur of a man, showing the deposition of urate of

soda in the cartilage and spots of the same in the ligamentum teres . 157

Fig. 9. — Represents the end of the femur, showing the deposition of urate of soda in streaks upon the surface of the condyles. In this case no chalkstones were visible e.xtemally, except two or three small spots on the cartilage of one ear . 165

Fig. 10. — Represents the appearance of the articulating surfaces of the bones of the ball of the left great toe of a man in whom only eight attacks of gout liail ever occurred ; no trace of deposits was seen externally, and no appreciable stiffness of the joints or deformity existed .... 174

Fig. 11.— A knee-joint, showing tlie deposition of urate of soda resulting from

one slight attack of gout in that joint 177

Fig. 12.— (1.) Drawn from the ball of tlie right great toe of a man who only experienced two sliglit attacks of gout, botli confined to the joint in question. (2.) Kepre.sents the apjiearance of the end of phalangeal bono of the corresponding joint of the left gi'eat toe, in which no trace of urate of soda existed 180 xvi DESCBIFTION OF THE WOODCUTS.

Fig. 13. — A draAving from the right groat toe of a man who had hut a single attack of gout 13 years before death 181

Fig. 14. — The metatarso-phalaiigeal joint of left great toe from tlie same man

from whom fig. 13 was di'awn 181

Kg. 15. — The aijpearance presented by a very thin vertical section of gouty cartilage ; the matter is seen to be most dense at the free surface, and gradually to become thinner as it penetrates into the structure. From a specimen preserved in Canada balsam. Linear magnifying power 220. Polarised light 190

Kg. 16. — Represents the crystallisation of urate of soda from the watery solution in which gouty cartilage had been digested, seen under polarised light. Linear magnifying power 220 190

Fig. 17. — Represents the ends of two metacarpal bones, one encrusted with urate of soda, the other freed from the deposit by the action of warm water, and exhibiting the cartilage apparently healthy in structure . 191

Fig. 18. — A drawing from a small piece of sjmovial membrane from the knee-joint, under polarised light. (1.) Shows the appearance with, a magnifying power of 60 linear. (2.) One of the smaller points with a magnifying power of 220 linear, exhibiting the crystalline structure . . .193

Fig. 19. — Represents a perpendicular section of the first joint of a great toe

which had become anchylosed after a few attacks of gout . . . 194

Fig. 20. — Represents the crystals of urate of soda in the pyramidal portion of

a gouty kidney. Linear magnifying power 220, and polarised light . 197

Fig. 21. — Represents the condition of the kidney in gout, and some fonns of albmninuria (chronic desquamative nephritis). To the right and below the tubes are filled with disintegrated epithelial cells ; the cystic appearance in the other parts is produced by the denuding of the tubes and removal of the epithelium. Linear magnifying power 100 . . 202

Fig. 22. — From a section of a kidney in advanced gout, exhibiting, to the right, the tubes in an ati-ophied and shrivelled state, and to the left the clustering together of Malpighian bodies. Linear magnifying power 100 203

Fig. 23. — Represents the hypertrophy of the Malpighian arteries ; the muscular fibres are seen to be much enlarged, more especially the circular, in the drawing. Linear magnifying power, 100 .... 203

Fig. 24.— Represents the cup of the iii'st phalan-x of the great toe containing

a speck of urate of soda ; fi'om a man who died of deliriiun ti'emens. . 285

Fig. 25. — The left ear of a gouty subject, in which the urate deposits were

especially prominent. ......... 451

Fig. 26. — ^A di'awing from a plaster cast of a hand much distorted from rheumatoid arthritis. .......... 502

Fig. 27. — Hand of a lady with nodules and distortions produced by rheumatoid arthritis ; she was sufi'ering from a chronic affection of one hip joint of a similar nature . 504

ON GOUT:

ITS

NATURE AND TEEATMENT.