Gout Or Podagra, is a disease in which there is deposited within the joints, in the articular cartilages, uric acid and its compounds. It generally affects the small joints of the hands and feet, particularly the big toes. These salts may be deposited elsewhere, as tophi in the cartilages of the ear and in the meninges. As a result of these deposits the joints may be much deformed. Lesions of other portions of the body are usually present. There is a marked tendency toward the formation of connective tissue in the form of interstitial nephritis and of arteriosclerosis; fatty changes also take place in the heart and liver. Gout usually appears after middle life in those who have lived very well, drunk plenty of wine, and have not taken exercise. It is a chronic disease, but exhibits periods of acute and painful inflammation lasting several days.

It is probably the outcome of insufficient oxidation, by which the precursors of uric acid and similar bodies are not fully oxidized, and by their accumulation and toxicity set up morbid changes.

The salts concerned are the sodium biurates and quadri-urates, uric acid existing in the blood in the form of the latter. The soluble quadriurates circulating in the blood, if in the presence of uric acid and sodium salts in excess, are precipitated as insoluble crystalline biurates.

In oxaluria and phosphaturia there is an excess of either oxalic acid salts or of phosphates. The presence of oxalic acid is thought by some to be due to the amount present in the vegetable matter consumed, while others think it is the result of deficient oxidation of the carbohydrates. It is of chief importance in the formation of calculi, it being precipitated in the crystalline form mainly when there is an increased amount of calcium in the urine.

The phosphoric acid exists in the form of the phosphates of magnesium, ammonium, and sodium. These may form calculi in the bladder when they occur in excessive amount in an alkaline urine, as they remain in solution if the reaction is acid.

Acetone and diacetic acid are often found in the blood and urine in the later stages of diabetes.

The bile may vary in amount and consistency and may be prevented from passing into the bowel. The normal amount secreted varies from 500 to 1000 c.c. in a day. It is composed chiefly of water, but contains bile salts, cholesterin, lecithin, fat, and coloring substances. The salts are the gly-cocholate and the taurocholate of sodium. The important pigments are bilirubin and biliverdin, both of which are derived from the blood. Bilirubin undergoes oxidation to form various other pigments. It resembles hematoidin, and the toxic effects of the retention of bile seem to depend upon its presence, as when the bile is freed from its coloring-matters by filtration it is only one-third as toxic as in its original condition.

The most important function of bile is to increase the activity of the pancreatic ferments. It not only increases the fat-dissolving action of the steapsin, but it dissolves and increases the solubility of soaps, and so renders their absorption more easy. Consequently, if bile is absent from the intestines, but pancreatic juice is still secreted, from one-quarter to one-half of the fat taken in the food is unabsorbed.

Bile is not, as has been supposed, an antiseptic, consequently its absence from the intestinal contents neither increases the number of bacteria nor their fermentative or putrefactive activity.

If there should be any obstruction to the outflow of bile the condition known as icterus or jaundice follows. This obstruction may result from a catarrhal condition or a stenosis of the bile capillaries, inflammation of the common bile-duct, or of the papilla. It may be due to foreign substances, such as gall-stones, inspissated mucus, round-worms, or tumors within the large duct, or to pressure upon it from without. The jaundice is due to the absorption of the bile into the general circulation by means of the veins or lymphatics. A large amount of it is eliminated by the kidneys, while the excess is deposited within the connective tissues.

As a result of the absorption of the bile the skin is at first yellow, but if the condition continues for some time the pigment oxidizes and becomes greenish in color. This discoloration will be seen in the sclera, the lining of the arterial system, the mucous membranes, and in most secretions and exudations, normal or pathologic. The heart's action is frequently slowed (bradycardia) to 50 or even 20 beats a minute.

The effect upon digestion may be quite marked. There is found an excessive amount of fat in the feces. The stools become very light in color, due to the absence of hydrobili-rubin, and may be very offensive on account of the loss of the laxative action of the hepatic secretion and consequent stagnation of the intestinal contents. There may be some interference with the outflow of the pancreatic enzyme, which would have a distinct effect upon the amount of fat present and also upon the color of the feces.

Sometimes there are marked nervous symptoms, probably the result of the presence of the biliary acids and salts in the circulation rather than due to the pigments.

Another form of jaundice is that of hematogenous origin. It occurs when no obstruction to the outflow of bile can be found. Although bile cannot be formed in any other place than in the liver cells, there are cases in which a general yellowish discoloration takes place without any hepatic lesion being present. It occurs in certain infectious diseases, as in yellow fever, malaria, etc., in poisoning by venom and tolu-olendiamin, and in the newborn in the form of icterus neonatorum. In all these conditions, particularly in the last named, there is a very marked destruction of the erythrocytes. The blood-pigment is changed into bile-pigment and thus stains the tissue. This form may be due to some nervous disturbances that cause a contraction of the circular muscles of the bile-ducts. It may be that there is an increase in the viscosity of the bile on account of the presence of the blood-pigments, and in that way the ready outflow is prevented. It has also been shown that the concentration of the bile is associated with an inflammatory condition of the bile-ducts.

Besides the secretion of bile the liver also forms urea and glycogen, but these two latter bodies are carried off in the blood.

Intestinal disturbances may bring about a condition of putrefaction accompanied by various symptoms of self-intoxication, inasmuch as the feces are made up of the remnants of digestion and of waste products. Their odor is due to the presence of indol and skatol.

The intestinal disturbances are due chiefly to the presence of bacteria and their products. Fermentation may take place in the stomach with the formation of acetic, lactic or butyric acids, or of alcohol. It results from the breaking down of the carbohydrates. In the intestine the proteins may undergo putrefaction and produce amido-acids, or aromatic bodies, as acetone, tyrosin, cresol, skatol, and indol. Ptomains may be formed and give rise to many symptoms. These bodies resemble quite closely many of the vegetable alkaloids and give rise to symptoms similar to those resulting from the drugs.

As a result of these disturbances diarrhea may occur. In this condition the feces are too soft and the bowel movements too numerous. It is an attempt to free the body of the irritating substances and may relieve the patient. The diarrhea may be due to increased rapidity of peristalsis, increased secretion of the intestines, diminished absorption by the large intestine, or disturbances of the controlling nervous mechanism, these depending upon many causes. These may be mechanical, inflammatory, infectious, obstructive, hepatic, and pancreatic.