Causation

Arthritis deformans is a chronic disease in which the joints of the body, and particularly those of the extremities, are affected. The alterations in joint structures are produced mainly by impoverished nutrition, and the disease is especially one of advanced life, occurring in persons in whom various evidences of senility have begun to appear. The structural changes in the joints involve proliferation of the cellular elements of the cartilages, with thickening and erosion and with the production of osteophytes. In mild cases there is not much impairment of general health. In severer cases the patient is confined to the house and, on account of pain or immobility of the joints, is unable to take ordinary exercise. Digestion and nutrition suffer considerably in consequence.

Dietetic Treatment

Since the disease is one of debility and impoverished nutrition, it follows that a low diet is harmful and a nourishing diet, with increased frequency of meals, is desirable. James Stewart says: "The practice of limiting the amount of nitrogenous food is not to be commended. Provided there is no general or local contraindication, the patient should be directed to take as much nitrogenous food as can be digested with facility." And Garrod wrote: "I consider it of the utmost importance throughout the whole course of the disease to support the system and to allow the patient as nourishing a diet as he is capable of properly digesting." Good roast beef, beefsteak, mutton, fowl, fish, eggs, and milk may be eaten.

Alcoholic beverages taken with meals in proper moderation are beneficial for their strengthening and tonic effect, and bitter tonics may be combined with them to advantage. The objection which exists to the use of alcohol in gout and acute rheumatism does not apply with such force in this disease. Malt liquors may be given, such as ale or stout, and it is often desirable to prescribe a good Burgundy, port, or sherry. If it is well borne by the stomach, cod-liver oil should be given in teaspoonful doses, an hour after meals, three times a day. It is an excellent food in this disease, and its use should be long continued. Other forms of fat may be used, such as butter, cream, or bone marrow, olive oil, etc.

When acute exacerbations occur the quantity of food and stimulants should be reduced, but otherwise it is important that the diet should always be ample.

Patients do well to try the effect of a course of treatment at the hot springs of Virginia, Arkansas, Mount Clemens, Michigan, or Banff.

Gout

Gout is a constitutional disease which has local manifestations appearing from time to time in the joints, especially the metacarpophalangeal articulation of the great toe, but it must be remembered that the gouty diathesis is a condition which once acquired may exist for years, producing many other and more serious symptoms or structural changes in the body than the local inflammation of one or more joints.

Causation

Gout has been defined as a condition dependent upon disturbed retrograde metamorphosis of the nitrogenous ingredients of the food - a high-sounding phrase, which, it must be confessed, carries with it very little genuine explanation of the nutritive processes involved. Whatever may be the theories in regard to the production of an attack of acute gout, it is universally admitted that careful regulation of the diet is the most important factor in its treatment. Gout and the various conditions allied to it are dependent upon retention in the blood or other fluids of the body of forms of waste matter which normally should be oxidised and completely converted into the soluble materials which are excreted in the urine. For some reason the oxidation of waste matter is suspended, and, as a result, a variety of intermediate products of imperfect solubility may be deposited in the joints or tissues of the body. The active manifestations of gout are due to an accumulation of insoluble urates in the joints.

In conditions which are closely allied to gout, such as the uric-acid diathesis, there is a deposition of crystals of uric acid in some portion of the urinary tract or, in other conditions, deposits of insoluble cholesterin are formed from the bile and accumulate as gallstones in the gall bladder.

The direct relation existing between uric acid and gout has been most exhaustively investigated by Garrod, and this relation may be briefly summarised as follows: First, the gouty diathesis is associated with a more or less constant excess of uric acid in the blood; secondly, the quantity of uric acid normally present in the urine is diminished by at least one half during a severe attack of gout, and increases beyond the normal as soon as the acute symptoms subside. An acute attack of gout is therefore preceded by accumulation of uric acid in the blood, which is a substance that in itself represents incomplete combustion of nitrogenous waste material in the body. The retention of this form of waste in considerable quantity proves markedly irritating to the nervous and other organs of the body.

Sir Dyce Duckworth writes: " We perhaps come nearer a complete understanding of this matter if we regard as present in the gouty 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 into more soluble and less noxious products," and he agrees with Ralfe that the failure to complete the metabolism of uric acid is dependent primarily upon disturbed innervation.

In referring to the habit of overeating Sir Henry Thompson says that in early life it may cause occasional attacks of biliousness, but after the first half of life has been spent the remaining half may be affected in a different way, and "recurring attacks of gout perform the same duty, or nearly so, at this period of life that bilious attacks accomplished in youth".

On the other hand, in persons who are subject to attacks of gout starvation may bring it on (Senator), and "poor man's gout" is by no means a disease induced by plenty.

Sugar eaten in excess is not of itself a direct cause of gout, but sweets combined with certain other foods, such as special fruits and wines, will precipitate an attack in a gouty subject with certainty. According to the view of Sir Dyce Duckworth, it is the combination of sugar with vegetable acids which is injurious.

Sugar, under some conditions of fermentation in the stomach and intestines, forms lactic acid, which is capable of splitting so as to produce carbon dioxide, which, according to Ralfe, forms acid salts of sodium and potassium from their neutral compounds.

Lack of exercise is often assigned as a cause for gout, and with many persons it is true that outbreaks of gout may be intensified in this way; but it is not uncommon for the disease to affect men who lead lives of considerable activity or who practise athletics, but who at the same time consume large quantities of nitrogenous food. By free perspiration the amount of fluid present in the blood is reduced and the solids become both relatively and absolutely increased, making it difficult or impossible for them all to become thoroughly oxidised.

Symptoms

The most distinctive symptoms of gout are the local joint manifestations of pain, swelling, redness, and tenderness. These symptoms usually occur together in an acute attack, but either one may occasionally be absent. Other symptoms may appear from time to time, such as disorders of the mucous membranes, especially of the stomach and bowels; a tendency to catarrhal affections of the mucous membranes of the respiratory passages; chronic endarteritis; alterations in the composition of the urine; and various forms of irritation of the nervous system and the skin.

Children who inherit the gouty diathesis are very apt to present some one or more of this group of symptoms, especially neuralgic pains, digestive disturbances, and skin diseases, which appear at an early age and long before the gout is fully developed with typical localised joint symptoms. The symptoms connected with this diathesis are believed to arise from obscure alterations in the composition of the blood which are more or less remediable by dietetic treatment.