Gout, with a section on ocular disease in the gouty
Gouty Arthritis.
Note large tuberous swellings on knuckle and metacarpo-phalangeal joints due to uratic deposits.
BY LLEWELLYN JONES LLEWELLYN, M.B. Lond.
GOVERNOR AND SENIOR PHYSICIAN, ROYAL MINERAL WATER HOSPITAL, BATH; FELLOW OF ROYAL SOCIETY OF MEDICINE; AUTHOR OF “ARTHRITIS DEFORMANS”; CO-AUTHOR OF “FIBROSITIS”; CO-AUTHOR OF “MALINGERING, OR THE SIMULATION OF DISEASE”; CO-AUTHOR OF “PENSIONS AND THE PRINCIPLES OF THEIR EVALUATION”; CONTRIBUTOR TO LATHAM AND ENGLISH’S “SYSTEM OF TREATMENT,” ALSO TO “OXFORD ENCYCLOPÆDIA OF TREATMENT” AND TO “STUDENT’S TEXT-BOOK OF SURGERY.”
WITH A SECTION ON OCULAR DISEASE IN THE GOUTY BY W. M. BEAUMONT
CONSULTING OPHTHALMIC SURGEON TO THE SOUTH-WESTERN REGION OF THE MINISTRY OF PENSIONS; AUTHOR OF “INJURIES OF THE EYES OF THE UNEMPLOYED, PROBLEMS IN PROGNOSIS,” ETC.
ST. LOUIS C. V. MOSBY COMPANY 1921
Printed in Great Britain.
Llewellyn J. Llewellyn
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GOUT
PREFACE
TABLE OF CONTENTS
The Antiquity of Gout
Prevalence of Gout in the Anglo-Saxon Period
Views of the Humoralists
The Aphorisms of Hippocrates
Introduction of the Word “Gout”
Early Views as to the Nature of Tophi
The “Honour of the Gout”
That Gout confers Immunity from other Disorders
Growing Infrequency and Attenuation of Gout
Isolation of Acute Articular Rheumatism From Gout
Tardy Dissociation of Chronic Gout From Chronic Rheumatism
Identification of Muscular Rheumatism
Differentiation of Chronic Gout From Arthritis Deformans
Cleavage of Arthritis Deformans into Two Types
Elimination of the Infective Arthritides
Garrod’s Theory
Antagonistic Views
Histogenous Theories
Antecedent Structural Changes
Hepatic Inadequacy
Hyperpyræmia
Nervous Theories
Growing Scepticism as to Garrod’s Pathogeny of Gout
Definition and Classification
Classification
Suggested Classification of Articular Gout
Etiology and Morbid Anatomy
Summary
Morbid Anatomy
Revelations of the Bio-Chemist
Protein Metabolism
The Formation of Urea
Fate of the Amino-Acids
Seat of Formation of Urea
Amino-Acids in Relation to Gout
The Glycocoll Theory of Gout
Urea Excretion in Gout
Creatine and Creatinine
Inborn Errors of Metabolism
The Isolation of Nucleic Acid
Researches on Spermatozoa
The Discovery of Purins
Uric Acid a Derivative of Nucleic Acid
The Chemistry of Uric Acid and the Purin Bodies
Chemical Constitution
Structural Formulæ
Properties of Uric Acid
Uric Acid in the Blood
Gudzent and Schade’s Theories
Organic Combinations
Complexity of the Problem
Exogenous Purins
Exogenous Uric Acid Excretion
Fate of the Unexcreted Purin
Endogenous Purins
Source of Endogenous Purins
Proteins and their Derivatives
Amino-Acids and Dicarboxylic Amino-Acids
Endogenous Uric Acid Excretion
Factors Influencing Endogenous Uric Acid Excretion
Physiological Conditions
Pathological States
Synthetic Formation of Uric Acid
Distribution of the Enzymes
Stages in Disruption of Nucleic Acid
Destruction of Uric Acid
Uric Acid Excretion in Gout
Uric Acid Variations in Acute Gout
Uric Acid Variations in Chronic Gout
Retarded Exogenous Uric Acid Output
Lowered Endogenous Uric Acid Output
Other Anomalies in Excretion in Gout
Purin Metabolism in other Disorders
Purin Metabolism in Chronic Alcoholism and Plumbism
Infantile Gout
Anomalies in Uric Acid Excretion in Gout
Uricæmia in Nephritis
Uric Acid, Urea N, and Creatinine of Blood in Gout and Early and Late Nephritis
The Relationship, if any, between the Amounts of Uric Acid and of Urea, and Total Non-Protein Nitrogen in Human Blood
Uricæmia not Necessarily Due To Renal Defect
Uricæmia not Peculiar to Nephritis
Uricæmia does not Necessarily Portend Gout
To what may be Ascribed the Deficient Eliminating Capacity of the Kidney for Uric Acid?
Uratic Deposits in Nephritis
Differentiation of Uratic Deposits in Gout and Nephritis
Clinical Associations of Gout and Granular Kidney
Folin and Denis’s Method
Uric Acid a Normal Constituent of Blood
Uric Acid, Total Non-Protein Nitrogen and Urea Nitrogen in Blood
Uric Acid, Total Non-Protein Nitrogen and Urea Nitrogen in Blood
Effect of Exogenous Purines
Uric Acid Content of Blood in Gout
Hyper-Uricæmia in Non-Gouty Arthritis
Variations in Uric Acid Content of Blood Independently of Diet
What Relation, if any, Exists between the Uric Acid Content of the Blood and Attacks of Gout?
Discussion of the Foregoing Data
Constitution of Tophi
Marchand’s Analysis
Lehmann’s Analysis
Ebstein and Sprague’s Analysis
Mode of Formation
Localisation of Uratic Deposits
The Causation of Tophi
Solubilities of Uric Acid
Tophi in Relation To Uricæmia
Tissue Affinities for Uric Acid
Retention Capacity of Tissues for Uric Acid
Table I.—Concentration of Uric Acid in Human Tissues and Fluids per 100 Grams of Material
Table II.—Concentration of Uric Acid in Miscellaneous Human Tissues per 100 Grams of Material
Clinical Evolution of Tophi
The Cause of the Inflammatory Phenomena
Non-Toxicity of Uric Acid
Are the Precursors of Uric Acid Toxic?
Suggestion of a Specific Infection
Local Foci of Infection
Summary
Analysis of the Acute Paroxysm
The Evolution and Life History of Gout
Analogies between Gout and the Specific Infective Arthritides
Correlation of the Metabolic Phenomena of Gout with the Postulated Infective Element
Acute Localised Gout
Prodromal Symptoms
The Acute Paroxysm
Detailed Consideration of Phenomena
Acute Generalised Gout
Collateral Phenomena of Gout
Incidence of Gouty Stigmata in Various Types of Fibrositis
Chronic Articular Gout
The Joint Deformities of Chronic Gout
Tophi: Their Evolution and Distribution
Other Sites of Tophi
Affinities Between Gout and Other Diseases
Gout in Relation to Glycosuria
Gout in Relation to Phlebitis
Cutaneous Disorders
Gout and Nephritis
Prognosis in Gout
Articular Gout
Etiological Diagnosis
Clinical Diagnosis
The Diagnostic Status of Tophi
Tophi in Relation to Arthritis
Frequency of Tophi in True Gouty Arthritis Underestimated
Difficulty of detecting Tophi
Acute Articular Gout—Localised Variety
Differential Diagnosis
Gout in the Big Toe
Static Foot Deformities
Gout in the Instep
Gout in the Heel
Local Sources of Fallacy
Gout in the Sole
Anomalous Sites for Initial Outbreaks
Acute Gouty Polyarthritis
Differential Diagnosis
Acute Articular Rheumatism
Acute Gonococcal Arthritis
Secondary Syphilitic Arthritis
Acute Rheumatoid or Atrophic Arthritis
Infective Arthritis of Undifferentiated Type
Chronic Articular Gout
Chronic Monarticular Gout
Monarticular Gout in Large Articulation a Rarity
Chronic Gout of Oligo-articular Distribution
Its Confusion with Chronic Villous Synovitis
Villous Synovitis Static and Non-gouty in Origin
Clinical Symptoms of Villous Synovitis
Chronic Gout of Polyarticular Distribution
Differential Diagnosis
Osteoarthritis
Local Characters of Joint Swellings
Rheumatoid Arthritis
Local Characters of Joint Swellings
Nerve Arthropathies
Hæmophilic Arthritis
Skiagraphy
Differential Diagnosis
Retrocedent Gout
Other Irregular Manifestations
Infantile Gout
Iritis.
Radical Treatment of Local Foci of Infection or Toxic Absorption
Diet
Regulation of Diet in the Gouty
The Individual Foodstuffs
Special Dietaries
Beverages in Gout
Alcohol in Gout
The Various Alcoholic Beverages
Medicinal Therapy
Acute Gout
Treatment in the Inter-paroxysmal Period
Chronic Articular Gout
Treatment of Associated Morbid Conditions
Climate and Residence
Exercise
General Massage
General Hydro-therapy
Methods of Application of General Hydro-therapy
Methods of Local Hydro-therapy
Treatment by Hyperæmia
Mineral Springs
Radio-active Waters
Influence on Uric Acid Metabolism
Therapeutic Action and Application
Choice of Spa
Associated Morbid Conditions
Concluding Remarks on Spa Treatment
Spas from a National Aspect
FOOTNOTES
INDEX
