VI. GOUT (Podagra)

Definition. A nutritional disorder, associated with an excessive formation of uric acid, and characterized clinically by attacks of acute brltis, by the gradual deposition of urate of soda in and about the joints, and by the occurrence of irregular constitutional symptoms. 

Etiology. — It is now generally recognized that the disease depends upon disturbed metabolism ; most probably upon defective oxidation of nitrogenous food-stuffs. 

Among important etiological factors in gout are the following: 

(a) Hereditary Influences — Statistics show that in from fifty to sixty per cent of all cases the disease existed in the parents or grandparents. The transmission is supposed to be more marked from the male side. Cases with a strong hereditary taint have been known to develop before puberty. The disease has been seen even in infants at the breast. Males are more subject to the disease than females. It rarely develops before the thirtieth year; and in large majority of the cases the first manifestions appear before the age of fifty, 

(b) Alcohol is the most potent factor in the etiology of the disease. Fermented liquors favor its development much more than distilled spirits, and it prevails most extensively in countries like England and Gennany, which consume the most beer and ale. Probably the greater tendency of malt liquors to induce gout is associated with the production of an acid dyspepsia. The lighter beers used in this country are much less liable to produce gout than the heavier English and Scotch ales, 

(c) Food plays a role equal in importance to that of alcohol. From the time of Hippocrates overeating has been regarded as a special predisposing cause. The excessive use of food, particularly of meats, disturbs gastric digestion and leads to the formation of lactic and volatile fatty acids. It is held by Garrod and others that these tend to decrease the alkalinity of the blood and to reduce its power of holding urates in solution. A special form of gouty dyspepsia has been described. A robust and active digestion is, however, often met in gouty persons. Gout is by no means confined to the rich. In England the combination of poor food, defective hygiene, and an excessive consumption of malt liquor makes the "poor man's gout" a common affection.

(d) Lead. Garrod has shown that workers In lead are specially prone to gout. In thirty per cent of his hospital cases the patients had been painters or workers in lead. The association is probably to be sought in the production by the poison of arteriosclerosis and chronic nephritis. Something in addition is necessary, or certainly in this country we should more frequently see cases of this kind so common in London hospitals. Chronic lead-poisoning here frequently associated with arteriosclerosis and contracted kidneys, but acute arthritis is rare. Gouty deposits are, however, to be found, in the big-toe joint and in the kidneys in those cases. 

There are three theories with reference to gout :

(1) The Uric-acid Theory. — Sir Alfred Garrod, to whom the profession is indebted for so many careful studies in this disease, showed that there was an increase in the uric acid in the blood, due either to increased production or to diminished elimination ; and that the alkalinity of the blood was also lessened. He attributes the deposition of the urate of soda the diminished alkalinity of the plasma, which is unable to hold it in solution. An increase in the quantity of the uric acid produced, or any interference with elimination through the kidneys, may cause a sudden outbreak. The acute paroxysm is due to an accumulation of the urates the blood, which he believes are responsible also for the preliminary dyspepaia, the coated tongue, the irritability of temper, and the general feelings of malaise. The sudden deposit of the cryst;itline urates about thf joint leads to inflammation. {H) The 

Nervous Theory. — The view of Cullen that gout was primarily an affection of the nervous system has been modified into a neuro-humoral view which has been advocated particularly by Sir Dyce Duckworth. On this theory there is a basic, arthritic stock-a diathetic habit, of which gout and rheumatism are two distinct branches. The gouty diathesis is expressed in a neurosis of the nerve-centres, which may be inherited acquired; and (b) "a peculiar incapacity for normal elaboration within the whole body, not merely in the liver or in one or two organs, of food, whereby uric acid is formed at times in excess, or is incapable of being duly transformed iuto more soluble and less noxious product. (Duckworth). The explosive neuroses and the influence of depressing circumstances, physical or mental, point strongly to the part played by the nervous system in the disease.

(3) Ebstein's Theory. — A nutritive tissue disturbance is the priflii change leading to necrosis, and in the necrotic areas the urates are posited. This is not unlike the view of Ord, who holds that there a tendency, inherited or acquired, to a special form of tissue degent tion. 

Morbid Anatomy. — The hold shows an excces of uric acid, as proved originally by Garrod. The uric acid may be obtained from the blood-serum by the method known as uric-acid thread experiment, or from the serum obtained from a blister....The primary change, according to Ebstein, is a local necrosis, due to the presence of an excess of urates in the blood. This is seen in the cartilage and other articular tissues tissues in which the nutritional currents are slow. 

Symptoms.--Gout is usually divided into acute, chronic, and irregular forms.

Treatment-- Individuals who have inherited a tendency to gout, or who have shown any manifestions of it, should live temperately, abstain from alcohol, and eat moderately. An open-air life, with plenty of exercise and regular hours, does much to counteract an inborn tendency to the disease.

Diet--Experience has shown that a modified nitrogenous diet is the most suitable. Starchy and saccharine articles of food are to be taken in very limited quantities; as "the conversion of anatized food is more complete with a minimum of carbohydrates than it is with an excess of them-in other words, one of the best means of avoiding the accumulation of lithic acid in the blood is to diminish the carbohdyrates rather than the anotized foods" (Draper).

Meats of all kinds, except perhaps the coarser sorts, such as pork and veal, and salted provisions, may be used. Eggs, oysters, and f ish may be taken. Lobsters and crabs, particulary when made into salaids, are to be eschewed. The sugar should be reduced to a minimum. The sweeter fruits should not be taken. L Oranges and lemons may be allowed. Strawberries, bananas, and melons should not be eaten. If necessary, saccharin may be substituted. for cane sugar. Potatoes should be sparingly used. The fresh vegetables, such as lettuce, cucumbers, tomatoes, and cauliflower, may be taken freely. Hot rolls and cakes of all sorts, hominy, grits, and the more starchy forms of prepared foods are not suitable. The various articles of diet prepared from corn should be avoided. Fats are easily digested and may be taken freely. In obstinate cases great benefit is derived with an exclusively milk diet. 

Persons with a gouty tendency should be encourage to drink freely of such mineral waters as they prefer. They kep the interstitial circulation active and so favor elimination. Milk and potash-water form a pleasant and wholesome drink for a lithamic patient. Alcohol in all forms should be avoided. When from any cause a stimulant is indicated, claret, dry sherry, or good whisky is preferable. Champagne is particularly pernicious. Persons with a marked tendency to lithaemia should be urged to restrict the appetite and to take only a moderate amount of food. Overeating is not far behind excessive drinking in its injurious effects. Indeed, a majority of people over forty years of age take more food than is required to maintain the equilibrium of health. Gout, in many cases, is evidence of an overfed, overworked, and consequently clogged machine.

In the chronic and irregular forms of gout the treatment by hygiene and diet is most suitable.