Sugar

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.

 

Among Eskimos, Europeanization has been longest delayed in the Canadian eastern Arctic, that great region which begins on the mainland about 500 miles east of the Mackenzie at Dolphin and Union Strait and extends to Hudson Bay. There, in Coronation Gulf and Victoria Island, our second expedition, the one of 1908-12, found more than 500 of what are now called Copper Eskimos, most of whom had never seen a white man. A decade later, in the 1920's, the Danish explorer Knud Rasmussen found on the eastern edge of the Copper Eskimo district about twenty who had missed seeing us, and who told him he was the first white man they had ever seen.

The Copper Eskimos, so named because many of their weapons and tools were of native copper, had never dealt with any traders before 1910. They did not even know tea, used no salt, and lived exclusively on flesh foods, eating roots and such only in time of famine. In 1910, they for the first time tasted sugar, given them by the first trader to reach Coronation Gulf, Joseph Bernard. They disliked it. Ten years later they were beginning to use material amounts of European foods, including both sugar and salt. Farther east, in the same section of arctic Canada, are people who first met whites long ago; but, even including them, the Eskimos of this section still are, with respect to food, the least Europeanized of all North Americans.

On the way south we happened to pick up a polar bear that was wandering about on shore. A day or two before that Palaiyak and Mangilanna had secured a young grizzly bear, and a day or two after Palaiyak got another one in the Melvill Mountains south of Langton Bay. In general, however, at this time we lived on the meat of the bearded seal, which the boys Palaiyak and Mangilanna secured by paddling out to sea in their kayaks and shooting the seals as they slept on floating cakes of ice. 

July 27th Ilavinirk, Natkusiak, and Mangilanna with our umiak started west to the Baillie Islands, while I remained behind doing archæological work around Langton Bay with the intermittent assistance of Palaiyak, Mamayauk, and Nogasak. In general, as I have had many occasions to point out, Nogasak was a very lazy and useless sort of person; but scratching around in the ground with the prospect of finding spear points or knives was something that appealed to her, and she really was my most valuable assistant throughout the entire summer in the work of excavating. I am inclined to think the main reason may have been that I discouraged her from the first, for fear that she might damage through carelessness some important find that she made. She was therefore very careful, and whenever she found a sign of anything she would come to me and tell me about it before she finally dug it up. It would no doubt have been more desirable had I had the means of employing expert diggers who would have done everything according to the book, but as it was it seemed to be much more useful that Nogasak should find things in the wrong way than that they should remain buried and probably unfound forever. 

The time had now come when the caribou might be expected to have a little fat on their backs and the skins were becoming suitable for clothing. Altogether, myself and various members of our party had killed only half a dozen or so caribou since we came back to Langton Bay, and the skins of all of them had been of little use, for they were full of large holes made by the escaping grubs of the bot-fly which had been growing under the hides of the poor animals' backs all winter and which had now just come out of their warm quarters and taken wing. The hair also is rather too short until towards the end of July, but from that time until the 20th of September it is in excellent condition for clothing, after which it becomes too long. 

It is not only the length of hair which is right in the month of August, but also the thickness of the hide itself. From Christmas time until May the skin is as thin as parchment and there is very little strength to it. In June it begins to thicken, but is as yet full of bot-fly holes. Towards the end of July these holes heal up and the skin becomes of the right thickness, while by October it has become too thick and unpliable for use as clothing. For that reason we use the hides of ordinary animals taken in September and October for clothing only in emergencies, and otherwise utilize them for bedding only, except the skins of the old bull caribou, which have often the thickness of sole leather and which we accordingly use for boot soles for our winter footwear. 

It was because we knew the caribou were getting into condition and because we had to “ take thought for the morrow ” in the matter of clothing for winter that we set out on July 30th southward to look for caribou. 

The Endicott Mountains look like mountains true enough as seen from the sea, but when in the three-mile walk inland you have climbed up two thousand feet or so you find yourself on a fairly level table- land, although within three miles from the sea the streams begin to flow inland towards Horton River, which lies about fifteen miles away, parallel to the coast. 

Soon after I reached the top of this plateau and about five miles from camp I came upon a grizzly bear accompanied by two small cubs. I did not realize how small the cubs were at first and shot the old animal and one of the cubs. On closer approach I saw that the living animal was but the size of a wolverine and showed no fear or concern of me whatever. It occurred to me then that it would be a very interesting thing to take the thing alive; but unfortunately I did not have any string with me or other means of taking the cub along to the coast. I therefore returned home and immediately hitched our dogs to a sled, with which and an empty box we started to fetch the bear. It was a matter of eight or ten hours until we got to where I had left the cub behind; but although he had not been afraid of me then, the poor fellow had by now evidently realized the death of his two relatives, and we were at least half a mile away when he saw us and took to his heels. I followed him a considerable distance while the others skinned the two dead bears, but I never got anywhere near him. 

With me the matter of big game hunting is another case of " swords sticking to hands that seek the plow.” I am afraid I am not a true sportsman. It is impossible for me to get enjoyment out of the killing of animals (and as for that, if I did I should get a job in the Chicago stockyards rather than follow poor frightened wild things around with a rifle). It is mere nonsense to talk of wild animals (in the case of those on the continent of North America at least) having a chance for their lives against the hunter. They all give us as wide a berth as they can; their only desire and hope of safety is in hiding or in flight. None of them, so far as my experience goes, will fight unless wounded or cornered, or in the defence of their helpless young. No matter how well they are provided by nature with claws and teeth and stout muscles, they have no more chance against a man with a modern rifle than a fly has against a sledge hammer. 

Unfortunately the Barren Ground grizzly is a priceless thing scientifically. There are practically none of them in museums and one of our avowed objects in coming North was to get some. I never allowed any to pass, therefore, and I shot altogether thirteen, but somehow the killing of these poor animals affected me more than that of any others. They are provided by nature with a fighting equip ment second to no animal on the continent, and yet they try their best to live peacefully and inoffensively. They feed on roots almost entirely, and whenever they discover the sign of a human being, whether they see or smell his footprints, or see him or get his wind, they immediately use every means in their power to get out of the way. But they are dull of sight and not very quick of hearing and when the hunter once sees them there is no escape. 

August 8th Palaiyak hunted to the south also and shot three deer about five miles away from camp. We were about to set out to fetch the meat of them when a sail appeared to the north which our glasses told us was Captain Bernard's Teddy Bear. It was reasonable enough she should arrive just then, although we had not expected her for a week or so yet. 

The Teddy Bear dropped anchor in the harbor late in the afternoon of August 9th, bringing Dr. Anderson, Tannaumirk, and Pannigabluk, all safe. Spring had been very early in Coronation Gulf, and they really could have come out sooner than they did. Cruising up along the southwest coast of Victoria Island they had found our beacon on Bell Island and had thereby, as we intended, been saved from the trip to Banks Island to look for us. 

I was very confident that we would be able in the neighborhood of Langton Bay to kill caribou and grizzly bears enough for our food the coming winter, but our Eskimo knew very well that their country men at the Baillie Islands, less than a hundred miles to the westward, would have plenty of flour, tea, and things of that sort, and we felt they would not be content with us unless they had it also. Captain Bernard had a considerable stock of these things and kindly furnished us with a supply. Dr. Anderson and I are not particular about such luxuries as flour and sugar, but our Eskimo had no scientific interests to keep them in the country, and, like servants everywhere, wanted as high wages and as good food as possible. So of course we had to supply them with what we could get in the way of imported food. 

It is not really so much that these Eskimo regard baking powder bread as such excellent food, but it is rather that they know it is expensive and they are human enough to want to have their neighbors know that they can afford to have this and that to eat even if it does cost money, differing not so much from the rest of humanity in that matter. They judge things chiefly by price, and desire them in proportion to their current market value. 

Dr. Anderson was anxious to communicate with the whaling ships if possible for the purpose of sending out mail and for other reasons,, and so he continued west with the Teddy Bear toward the Baillie Islands with the intention of returning thence with Ilavinirk and Nat kusiak in our umiak, while Tannaumirk and Pannigabluk came ashore and joined us. As the caribou season was now at its best we stayed around Langton Bay only a few hours after the Teddy Bear left and then started inland in the search for game. 

As we have pointed out elsewhere, the caribou hunt is not merely to secure meat. A supply of dried venison to tide you over the sunless days helps you to face the season with confidence, but the main consideration is to secure skins for clothing against the winter. Our method of hunting is in general that we travel from one high hill to another high hill, pause on each hilltop and with our field glasses and telescopes carefully examine every inch of visible ground in the hope of seeing caribou. 

On these summer hunts the dogs are equipped with pack saddles, consisting essentially of two big pouches that nearly reach to the ground on either side of the animal when the pack is in place. These pack saddles are loaded with the heaviest and least bulky things we have to carry. A fifty-pound dog will carry a forty-pound pack or even a heavier one, and he will carry it all day, although his walking gait is rather slow, perhaps not much over two miles an hour. The people of the party will carry on their backs the bulky things, such as the bedding, tents, and cooking utensils. A man does not carry more than thirty or forty pounds, although under special conditions he may carry as much as a hundred and fifty or even two hundred. 

When caribou are discovered, the women and children, if there are any in the party, stop and make camp, while the men secure the caribou, skin them, and cut them up. Usually long before the skinning is done camp has been made; and if the caribou are located so near that the women know the killing has actually taken place, they come with the dogs to help bring home the meat; or if a considerable number of caribou are killed, it may be easier than moving the meat to camp to move the camp up to the scene of the slaughter. The meat is then cut up into thin strips and spread out on the ground or on stones to dry; or if there are sticks available a frame is made over which the meat is hung up. The skins too are spread out to dry. The process of drying meat delays camp moving, so the men go out and hunt for more caribou in all directions from the camp; and if they secure any they usually bring home the meat, unless indeed they make a big killing, in which case it is easier to transport the half-dried meat and the camp gear to the deer kill than to bring home the fresh meat to camp. Then whenever the meat is dried and if no more caribou are likely to be found in that immediate vicinity, the meat is cached in the safest way possible, usually by stones being piled on top of it, and the party moves on, carrying with it the dried caribou skins, for they are too precious to leave behind to the uncertain safety of a cache. The same kind of traveling as before is resumed as soon as all the meat killable in any locality has been turned into dry meat, the party marching from hilltop to hilltop and continually looking for game, which is finally found. And then the same process repeats itself. 

On the particular hunt under discussion the caribou were not very numerous. First we went about fifteen miles south from Langton Bay to the head of a small wooded creek that runs into Horton River from the north, and here during the course of a week we killed about a dozen caribou and three grizzly bears. The Eskimo generally merely wind-dry the meat, but personally I rather prefer the Indian method of smoke-drying it, and so we built a spruce bough lodge in the Indian style and dried the meat that way. This has an additional advantage, for when you want to leave for another hunting camp you can with tolerable safety cache anything you want inside of the abandoned lodge, for the smoke smell, while it is at all fresh, will keep beasts of prey at a distance. Eventually, of course (in a fortnight or so), some wolverine will become contemptuous enough of the fire smell which it at first dreaded, and will venture into the deserted house to steal. 

We remained about a week in the camp on the wooded creek-head where we had made our first kill, and then we were forced to leave it on account of the absence of caribou in that neighborhood, and by the fact that I one day happened to kill four animals a long way to the eastward in a country where game signs were more numerous. Moving to these better pastures was a matter of nearly a day's walk, for we traveled heavy laden with the caribou fat and skins that were too precious to risk leaving behind with the meat. Traveling at this time of year is particularly pleasant, for while the days are still warm, the placid nights are cool and the power of the mosquito has been broken. There are few things in one's experience in the North that are so pleasant to remember as these autumn hunts, when the camp is pitched among a clump of spruce trees at the bottom of some ravine, and when at the end of a day's hunt you can gather around a crackling fire in the enveloping darkness, for the four-months' summer day is just over. The occasional howl of a wolf in the near shadow lends an additional romance, especially if, as not seldom happens, the wolves are so numerous and near that the dogs become frightened and gather in a close circle around the fire. Few meals can be more satisfying, either, at the end of a hard day's work, than a caribou head that has been rotated continuously before the fire until it is roasted through, even to the base of the tongue and the center of the brain. The dreams of boyhood seldom come true, but I am not sure that there is not sometimes as much romance about the reality of such evenings as there was about the dreams of Crusoe- like adventures on desert islands.

The Variations in the Content of Sugar in the Blood

Alimentary glycosuria, as exhibited in the renal excretion of sugar when undue amounts of carbohydrates are ingested by persons who fail to manifest this symptom under ordinary conditions of diet, has long been recognized and investigated. The prominence which the clinical estimation of the sugar-content of the blood has assumed in recent months, and the diagnostic importance which has been attached to the variations in this blood-constant as a possible index of incipient metabolic disorder, have seemed to call for a careful determination of the precise effect which the ingestion of carbohydrate may exert in altering the quantum of blood-sugar under well controlled conditions in otherwise healthy persons. The determination of normal values and physiologic deviations from them is always essential as the rational beginning in the establishment of a new scheme of diagnostic procedure. Such an undertaking has lately been carried out in the medical clinic of the University of Copenhagen by Dr. Jacobsen. Estimations were made after comparatively brief successive intervals in the same persons who had taken various substances in suitable quantities three or four hours after breakfast. It is well known that healthy persons frequently exhibit glycosuria after the ingestion of from 150 to 200 gm. of dextrose under similar conditions — and this is usually taken as an index of alimentary glycosuria. In contrast with some earlier studies the Danish investigator has observed an unmistakable hyperglycemia in every instance after ingestion of 100 gm. of dextrose; in some instances glycosuria likewise appeared simultaneously. In view of this fact, Jacobsen points out that a mild transient glycosuria under such circumstances is no longer to be looked on as a diabetic symptom. 

Comparable quantities of starch administered in the form of bread likewise led to hyperglycemia. The increase in the percentage of sugar was quite as pronounced, in some cases, as that which occurred after the introduction of glucose; but the onset of the hyperglycemia was slower, as might be expected, in view of the slower liberation of sugar by the digestive processes. Fat or protein, in contrast with glucose or starch, were without effect on the level of tbe sugar in the blood ; but when starch was administered along with fat the degree of the alimentary hyperglycemia was relatively mild. The explanation of the inhibitory effect of the fat on the tendency to hyperglycemia is presumably to be sought either in the fact that the presence of the fat mechanically interferes with the ready digestion of starch and consequent liberation and absorption of sugar, or that fat retards the discharge of contents from the stomach and delays absorption in this way. 

Effects of a similar sort were observed also in the blood of diabetics fed as indicated before. There is a tendency, however, for a greater increase in the bloodsugar content to assert itself in the abnormal than in the normal persons after an identical intake of carbohydrate; and the same increment of blood-sugar in diabetics is far more likely to lead to glycosuria. In healthy persons, for example, the content of blood-sugar may be raised to 0.16 or 0.17 per cent., without inducing an elimination of glucose. In diabetics the consequences are exaggerated in every direction. The possession of these newer data will serve to orient us better in the direction of successful diagnosis on the' basis of the information to be obtained for the estimation of the sugar-content of the blood under known or controlled conditions of diet.

1. Jacobsen, A. T. B.: Untersuchungen Uber den Einfluss verschiedener Nahrungsmittel auf den Blutzucker bei normalen, zuckerkranken und graviden Personen, Biochem. Ztschr., 1913, lxvi, 471. 

The Staub-Traugott Phenomenon

Up to the present the masterly work of Allen and his collaborators has dominated the conception of diabetes mellitus, but recently another line of research has begun to turn thought in a different direction. In 1919 Hamman and Hirschman described the phenomenon which is now usually referred to as the Staub-Traugott effect. They showed that if two consecutive doses of glucose are given to a healthy subject the hyperglycaemia resulting from the second dose is lower than that after the first.

Studies on Blood Sugar - Effects upon the blood sugar of the repeated indigestion of glucose by Louis Hamman

In a communication to the Archives of Internal Medicine Hamman and Hirschmann have demonstrated the blood-sugar response Ito the ingestion of a single large dose of glucose in normal persons and in others suffering from various diseases. For this study 100 grams of glucose were administered in the early morning after the night fast, and the blood sugar and urine sugar estimated at short intervals thereafter. It was demonstrated that there are two important types of reaction, the normal and the diabetic. There is still a third type, not nearly so clearly distinguished as these two, the reaction of increased carbohydrate tolerance. Although the reaction in normal persons varies in different individuals and in the same individual under different circumstances, its general characters are as follows: The blood sugar rises rapidly, but seldom exceeds 0.15 per cent; it falls somewhat more slowly to the original level, the whole reaction being over in less than two hours. In diabetics the rise is higher and longer sustained. If the blood sugar surpasses 0.18 per cent, sugar usually appears in the urine, but sometimes it appears at a somewhat lower level; at other times it fails to appear, even though 0.2 per cent of blood sugar is exceeded. From two to five hours pass before the blood sugar reaches the original fasting level. When the carbohydrate tolerance is increased, there is only an insignificant rise in the blood sugar, which has usually a low fasting level.