insidious development of this form of disease and the difficulty of its
early diagnosis. Recent investigations point to the value of the
changes in the urine in the progress of the gouty dyscrasia as bearing
upon this question. It has already been noted that in the early history
of gouty persons the urine is often scanty, high-colored, excessively
acid, of high specific gravity, occasionally albuminous and saccharine,
and frequently depositing sediments of urates and calcium oxalate.
McBride of New York[9] has recently called attention to this condition
of the urine and its association with high arterial tension as the
functional stage of the granular kidney--as the stage, that is to say,
during which the necessity of eliminating large amounts of imperfectly
oxidized nitrogenous material maintains a constant state of renal
hyperæmia, which finally induces the changes in the tubular and
intertubular structures which constitute the anatomical features of
this form of disease.
[Footnote 9: _The Early Diagnosis of Chronic Bright's Disease_, T. A.
McBride, M.D., New York, 1882.]
The occasional presence of sugar in the urine of gouty persons has
already been noted. I have repeatedly observed this symptom in the
urine of gouty dyspepsia. It occurs more commonly in obese subjects,
and is usually intermittent and easily controlled by dietetic
restrictions. In these cases it is not necessarily associated with a
very large amount of urine. In chronic gout and in connection with the
granular kidney a more serious form of glycosuria is occasionally
observed. Under these circumstances it increases largely the polyuria
which is characteristic of gouty nephritis, and is sometimes overlooked
because it occurs in a urine of a low density, often not more than
1.010. It is not controlled by diet {124} to the same extent that it is
in the cases previously described, and is in my experience a prognostic
sign of bad import.
Some of the most distressing symptoms to which gouty persons are
especially liable are those connected with the passage of gravel from
the kidney to the bladder. Where gravel alone passes, it may cause
little uneasiness, and the fact is only recognized through the
discovery of blood in the urine in connection with uric acid or calcium
oxalate crystals. When, however, the sand forms concretions in the
pelvis of the kidney, their dislodgment and passage through the ureter
are accompanied by the well-known agonies of renal colic.
Dysuria is a symptom from which gouty persons often experience much
inconvenience and suffering. It is usually associated with extremely
acid urine of high density containing crystalline sediments. It may
manifest itself only in frequent and painful micturition, or it may be
associated with such a degree of vesical tenesmus as to cause retention
and necessitate the use of the catheter.
DIAGNOSIS.--If the term gout be restricted to that form of arthritis in
which an excess of urates is found in the blood with tophous deposits
in the affected joints, the cartilages of the ear and nose, and in the
subcutaneous connective tissue, then the diagnosis of this disease is a
simple one. It is a disease with a pathognomonic sign. But if the
pathology of gout consists rather in a more complex morbid condition of
the blood, of which an excess of urates in the serum is only one of a
number of phenomena, and not necessarily the sole and essential cause
of the local lesions, then the question of diagnosis involves a
consideration of all the correlated morbid conditions which are so
frequently associated in gouty persons and gouty families as to justify
the inference that they have a common origin in a perverted nutrition,
the essential nature of which is imperfectly understood.
The very existence of the terms gouty rheumatism and rheumatic gout
which are in common use shows that what is regarded by many excellent
authorities as the confounding of distinct entities must have some
foundation in clinical experience. If we consider gout, in its
strictest pathological sense, acute inflammatory rheumatism, rheumatoid
arthritis, or gouty rheumatism, and senile arthritis or the arthritis
deformans and gonorrhoeal rheumatism as separate and distinct diseases,
we shall find ourselves compelled to ignore certain common clinical
facts which indicate a bond of union between them. Heredity, for
example, is common to them all, and more than this, there appears to be
a tendency to a differentiation of the taint in families. It is well
known, for instance, that the children of gouty parents are especially
liable to acute rheumatism, and acute rheumatism in youth is often
followed by gout in later years. It is also a fact of common experience
that while the men in gouty families are the victims of true gout, the
women are apt to be the subjects of rheumatoid arthritis. The arthritis
deformans which develops with the degenerations of advancing years is
not infrequently associated with a family history of genuine gout.
Gonorrhoeal rheumatism also, according to the experience of many
trustworthy observers, often recognizes an inheritance to gouty
lesions. But it is not alone in heredity and the differentiation of the
type of the disease in families that the unity of these affections
displays itself. The same disturbances of digestion which {125}
characterize the history of true gout are observed in those who are
liable to acute rheumatism, to rheumatoid arthritis, and to arthritis
deformans. It is true that excesses in food and fermented liquors do
not determine, as in gout, attacks of acute rheumatism nor of the
chronic forms of arthritis, for these latter diseases are commonly due
to causes operating upon the nervous system, as exposure to cold and
dampness or to physical or emotional shock of some kind; still, there
is in the subjects of these diseases a more or less marked tendency to
the same dyspeptic disorders, and especially to the diminished capacity
in digesting the carbohydrates, which the subjects of true gout
exhibit. In the diagnosis of gout, therefore, it would seem that the
question of differentiating this disease from those which simulate it
is not one in which we are called upon to distinguish one morbid entity
from another, as typhus from typhoid fever or syphilis from cancer, but
rather to determine, first, the presence of a recognized constitutional
vice; and, secondly, to differentiate the variety of the lesions by
which this vice manifests itself.
In the diagnosis of the gouty dyscrasia the first point to determine is
that of heredity. This requires a careful inquiry into collateral as
well as direct descent, and does not necessarily involve the discovery
of arthritic diseases in the ancestors, though these are doubtless the
most striking and trustworthy proofs; but the tradition in the family
of persistent dyspepsia, or what is commonly called biliousness, of
chronic catarrhal affections of the skin and mucous membranes, and of
the chronic forms of renal disease, are significant indications of this
dyscrasia. In the personal history the evidences of the lithæmic
tendency, as indicated by the characteristic dyspeptic symptoms which
have been described, and especially by the feeble capacity for the
digestion of carbohydrates, are of great diagnostic value.
The diagnosis of gouty joint-lesions, whether acute or chronic, depends
partly upon the determination of the gouty dyscrasia, and partly upon
the differential distinctions which separate gouty inflammations from
acute rheumatism, rheumatoid arthritis, and from the arthropathies
which result from traumatism and from lesions of nerves and
nerve-centres.
Gouty arthritis may be distinguished from acute rheumatism by the fact
that it is more often hereditary--that it occurs in older subjects,
attacking generally the smaller joints, and, as a rule, in the acute
form, localizing itself in one or two joints. It is also noteworthy
that the constitutional symptoms are not as severe as in rheumatism.
Gout deforms the joints, while acute rheumatism leaves no traces of the
inflammatory process. In addition to these distinctions there is,
according to Garrod, the crucial test of an excess of urates in the
blood-serum.
From rheumatoid arthritis or rheumatic gout, gout in its acute and
regular form is distinguished by the more acute local and
constitutional symptoms. Gout is periodical in its attacks, while
rheumatoid arthritis is progressive. It attacks the smaller joints or
those most exposed to strain, while rheumatoid arthritis occurs in the
large as well as the small joints, and appears to be more independent
of traumatism as an exciting cause. Gout is more common in men,
rheumatoid arthritis in women. According to Garrod and other excellent
authorities, deposits of urates are never found in the joints in
rheumatoid arthritis, and there is no excess {126} of urates in the
blood. This statement is denied by Hutchinson. Ulcerations of
cartilages, contractions of tendons, atrophies of muscles with
subluxations of joints, are more common in rheumatoid arthritis than in
gout.
While these local distinctions are undeniable, it is proper to observe
that in rheumatoid arthritis the constitutional symptoms of the gouty
dyscrasia, especially the dyspeptic derangements and the nervous
disturbances, are often well marked; and it should also be noted that
the principal distinction, the absence of urates in the blood and in
the diseased joints, is one that is based on the exclusive theory that
uric acid is the materies morbi of true gout. If, as is still
maintained by some excellent authorities, uric acid is not essential to
gout, then it must be confessed that the other distinctions are purely
lesional, and that the common constitutional symptoms suggest that
these diseases are divergent branches of a single trunk.
Gouty arthritis is not always easily distinguishable from traumatic
inflammation of the joints, inasmuch as traumatism plays so important a
part as an exciting cause of gouty attacks. The history of previous
seizures and the presence of predisposing causes of gout are the points
upon which the determination of the gouty nature of the inflammation
would depend. A termination in suppuration would exclude the idea of
the gouty nature of an arthritis.
With the arthropathies of purely nervous origin, such as occur in
paralyzed limbs, in Pott's disease, and in tabes dorsalis, gout can
hardly be confounded, although the arthritic complications in these
diseases have been used to illustrate the neurotic theory of both gout
and rheumatism.
The diagnosis of irregular gout--_i.e._ of gouty affections of the skin
and mucous membranes, of the structures of the eye, and of the
parenchymatous organs--must be based more upon the hereditary history
and upon the correlated phenomena recognized in the personal history
than upon any specific character in the lesions themselves. In the
gouty form of nephritis there are, it is true, in the urinary symptoms,
in the anæmia, in the arterial fibrosis, and in the cardiac
hypertrophy, diagnostic signs of great value.
PROGNOSIS.--Acute, regular, articular gout is probably never a fatal
disease where it occurs in a robust person without visceral
complications. In rare instances the first attack may never be
repeated, or only two or three attacks may occur in the course of a
long life. In the majority of instances, however, frequent repetitions
are the rule, the intervals between the attacks growing progressively
shorter; occasionally repeated seizures go on through a long life, the
attacks becoming milder with advancing years, and, save the crippling
effects of the disease, the patient may enjoy in the intervals a fair
degree of health. This, however, is the exception. With the increased
frequency of the arthritic attacks the signs of the constitutional vice
become more marked. The dyspeptic disorders become more persistent and
rebellious to treatment, various transformations of the disease
manifest themselves, and tissue-changes make insidious and inevitable
progress. When this stage of the gouty disease is reached, the
prognosis becomes more grave because of the complications and accidents
to which the sufferer is liable. These complications and accidents are
the result of the nervous, vascular, and visceral lesions which have
been {127} described. Vaso-motor instability gives rise to a great
variety of painful functional derangements resulting from serious
cerebral, pulmonary, gastric, and renal congestions. Glycosuria is not
an uncommon complication in chronic gout, and seriously affects the
question of prognosis. Arterial degenerations may cause thrombotic
accidents, and the formation of miliary aneurisms in the brain may
determine a fatal issue by softening or hemorrhage. Anginal attacks due
to cardiac muscular degeneration may also imperil life.
The principal visceral lesion which leads directly or indirectly to a
fatal issue in gout is that of the kidney. This involves danger either
through the induction of a hopeless anæmia and its consequences in
dropsical effusions, or by determining inflammatory accidents of the
gravest nature.
That gout shortens life in the majority of cases is unquestionable--a
fact which is sufficiently attested by the care with which
life-insurance companies exclude risks in which a well-pronounced
inherited tendency or existing manifestation of the disease can be
substantiated.
The prognosis varies of course with the rapidity with which the
constitutional dyscrasia is developed, and this rapidity will depend on
the intensity of the inheritance and the mode of life. Some gouty
subjects escape the vascular and visceral complications of the disease
for a long period, although crippled and deformed by its articular
ravages, and attain advanced age; others may succumb in comparative
youth to its most profound lesions. It is a happy circumstance that
under wise hygienic management and judicious medication acquired gout
may be checked in its progress, and even a strong inherited tendency
may be largely controlled.
TREATMENT.--A logical consideration of the treatment of gout embraces,
first, the treatment of the constitutional vice, based, as far as
possible, on the nature and causes of the disease; and, secondly, the
treatment of the lesions which the disease determines. If we regard the
accumulation in the blood-serum of the salts of uric acid as the
essential cause of the gouty lesions, then the origin of the
constitutional vice is in the conditions which bring about this
accumulation. As we have urged, none of the theories of the production
of the lithæmic state harmonize all its phenomena. It is impossible to
represent the complex processes of nutrition by chemical formulæ, and
equally impossible to divorce chemical reactions from a share in their
production. We can trace the metabolism of the azotized and
carbonaceous foods through many changes to their ultimate
disintegration into urea, carbonic acid, and water, but we do not know
all the steps by which this conversion is effected, nor the organs or
tissues in which it is accomplished. We may reasonably assume that the
agent through which the potential energy of the food is evolved is
oxygen, and that the process of nutrition is hence partly, at least, a
process of oxidation. This chemical view of the digestion and
assimilation of food may be said to be the rational basis of the
treatment of the lithæmic state. To control the accumulation of
azotized matters in the blood, and to secure their thorough combustion
and conversion into urea, carbonic acid, and water are the recognized
aims of the treatment of the vice upon which gout depends.
DIET.--The prevention of the accumulation of azotized matters in the
{128} blood involves, first, a consideration of the question of the
diet appropriate to the gouty dyscrasia. The almost uniform counsel
upon this point of all the authorities from Sydenham to the present
time is, that albuminous foods should be sparingly allowed in the diet
of the gouty patient, and that vegetable foods, especially the
farinaceous, should constitute the principal aliment. This counsel is
based upon the theory that uric acid is the offending substance, and,
this being the outcome of a nitrogenous diet, the nitrogenous element
in diet must be reduced. My own observation has led me to believe that
while this may be a legitimate deduction from the uric-acid theory of
gout, it is not supported by the results of clinical experience. If
there is one signal peculiarity in the digestive derangements of gouty
persons, it is their limited power to digest the carbohydrates, the
sugars and starches. In whatever form these foods are used, they are
more commonly the source of the dyspeptic troubles of sufferers from
gout than the albuminous foods. They provoke the acid and flatulent
dyspepsia which so generally precedes the explosion of the gouty
paroxysm; and it must have attracted the attention of every observer
who has studied the dyspeptic disorders of sufferers from inherited
gout, who have sought to control their unhappy heritage by abstemious
habits, that these disorders are especially provoked by over-indulgence
in saccharine and amylaceous foods.
It is not possible to explain satisfactorily why the lithæmic condition
should be induced by the carbonaceous aliments, but we believe there
can be no question as to the fact. If, as modern physiological
investigations tend to show, the liver is the organ in which urea as
well as glycogen is formed, it may be that the overtaxing of its
functions manifests itself more readily in the conversion of the
albuminous than in that of the carbonaceous foods; or it is possible
that the carbonaceous foods are destined chiefly for the evolution of
mechanical energy, and that when this destiny is not fulfilled through
indolence and imperfect oxygen-supply, they escape complete combustion,
and so vitiate the blood. But whatever may be the cause of this
anomaly, the clinical fact remains that in gouty persons the conversion
of the azotized foods is more complete with a minimum of carbohydrates
than it is with an excess of them--in other words, that one of the best
means of avoiding an accumulation of lithates in the blood is to
diminish the carbohydrates rather than the azotized foods.
The diet which a considerable experience has led me to adopt in the
treatment of the gouty dyscrasia is very similar to that which
glycosuria requires. The exclusion of the carbohydrates is of course
not so strict. Abstinence from all the fermented preparations of
alcohol is perhaps the most important restriction, on account of the
unfermented dextrin and sugar which they contain. This restriction
accords with the common experience respecting the part which wine and
beer play as predisposing causes of the gouty disease and as occasional
exciting causes of gouty lesions.
Next to the fermented liquors, the use of saccharine food in the diet
of gouty persons needs to be restricted. This limitation also is one
which common experience confirms. Sweet foods cannot be said to be as
provocative of the dyspeptic derangements of the lithæmic subjects as
wine and beer, but they are certainly often responsible for the
formation of {129} the dyscrasia and for perpetuating many most
distressing ailments. Their more or less strict prohibition may
constitute the essential point of treatment not only in controlling the
progress of the constitutional vice, but in subduing some of the most
rebellious lesions. It is important to observe that this prohibition
sometimes involves abstinence from sweet and subacid fruits, in the raw
as well as in the preserved state. Paroxysms of articular gout have
been known to follow indulgence in strawberries, apples, watermelons,
and grapes, and the cutaneous and mucous irritations which follow even
the most moderate use of these fruits in some gouty persons are
certainly not uncommon.
Next in order to the saccharine foods as the source of indigestion in
gouty persons come the amylaceous aliments. These constitute,
necessarily, so large an element in ordinary diet that the limitation
of them in the dietary of gouty persons applies, in the majority of
cases, only to their excessive use. This excessive use, however, is
often observed. There is a popular prejudice in favor of this class of
foods, and a corresponding prejudice against the too free indulgence in
animal foods. The purely starchy aliments, such as potatoes and the
preparations of corn and rice, and even those which contain a
considerable portion of gluten, like wheat, oatmeal, and barley, often
provoke in gouty subjects a great deal of mischievous and painful
indigestion. This feeble capacity for the digestion of farinaceous
foods is most frequently observed in the children of gouty parents, and
especially in persons inclined to obesity, and in those whose
occupations are sedentary and whose lives are passed for the most part
in-doors, and they are least common in those whom necessity or pleasure
leads to much active muscular exercise in the open air.
The fats are as a rule easily digested by gouty dyspeptics. This is a
fortunate circumstance, for the reason that in the anæmia which is
frequently one of the consequences of chronic gout the fatty foods are
of inestimable value. In cases of persistent and rebellious lithæmia an
exclusively milk diet constitutes a precious resource.
The succulent vegetables, such as tomatoes, cucumbers, cauliflower,
cabbage, and the different varieties of salads, constitute for the
gouty as well as the diabetic subject agreeable and wholesome additions
to a diet from which the starchy and saccharine vegetables have to be
largely excluded.
The quantity of food proper for gouty persons to consume can only be
determined in individual cases by the age, the habits, and the
occupation. It is fair to assume that in adults, in whom there is no
longer any provision to be made for growth, the daily quantity of food
must be regulated according to the amount of energy which is expended.
In this energy must be reckoned the amount necessary for the
maintenance of animal heat and the other vital functions, and the
amount which is necessary for the operation of every variety of nervous
force. In other words, the potential energy latent in the food must
correspond to the active energy exhibited in the daily evolution of
vital, intellectual, and mechanical work. The more nearly this balance
is maintained the more closely the physiological standard of health is
preserved. That an excess of food is a most frequent cause of the gouty
dyscrasia among the well-to-do classes is undeniable, and it is
possible that regulation of the quantity according to the rule above
mentioned {130} may, after all, be the most important point in the
management of many gouty patients. It may be, also, that the reason why
the withdrawal of the carbohydrates produces its good effects upon
these patients is that we thereby exclude a large amount of
force-producing foods which do mischief because they are imperfectly
consumed.