A hundred years ago: Gouty glycosuria
By Alfred W. Sikes, M.D., D.Sc. (Lond), F.R.C.S.,
Late Medical Registrar and Demonstrator of Medicine to St. Thomas’s Hospital.
By Alfred W. Sikes, M.D., D.Sc. (Lond), F.R.C.S.,
Late Medical Registrar and Demonstrator of Medicine to St. Thomas's Hospital.
Extracted from the July 1907 issue of The Practitioner Gouty glycosuria is usually met with in the latter half of life, and the patients are often of a robust constitution, and with a tendency to the development of fat. It is said to be more common amongst males. With many patients, glycosuria has probably existed for years before some slight disturbance, such as the passing of an increased amount of water, has caused them to consult their medical attendant, and has led to an examination of the urine.
Gouty glycosuria is usually met with in the latter half of life, and the patients are often of a robust constitution, and with a tendency to the development of fat. It is said to be more common amongst males. With many patients, glycosuria has probably existed for years before some slight disturbance, such as the passing of an increased amount of water, has caused them to consult their medical attendant, and has led to an examination of the urine.
In the milder cases, glycosuria is often associated with some digestive incapacity for starchy foods, and we also know that gout is conditioned to a large extent by the improper elaboration of the food in the alimentary canal. Again, in many cases, it is associated, as is also gout, with inadequacy and indefinite congestive states of the liver. Although these cases may rapidly clear up under proper treatment, there is some danger, if they are not attended to, that they may progress, so that eventually a condition indistinguishable from true diabetes obtains.
Some of these mild cases show a certain alternation from the usual uratic condition of the gouty to one where there is sugar in the urine with amelioration of the gouty symptoms; then a return to the uratic condition of the urine, and so on. If untreated, this pernicious habit may become permanent.
With glycosuria, as also with gout, the nervous element must be considered. Worry, business troubles, and mental overwork have much to do with the onset and the maintenance of the glycosuria of gouty patients. From these slight conditions, with a small amount of sugar in the urine, there is every possible grade to states indistinguishable from true diabetes.
We must not be misled by a slight reducing action of the urine. It is well known that substances, such as uric acid and creatinine, will cause some reduction of the copper salt. This is more likely to occur in a concentrated urine with a high specific gravity containing much urate. We must be on our guard to prevent mistakes, and, if necessary, other tests for the presence of sugar must be applied. In the milder cases of gouty glycosuria, it is very probable that the elaboration of sugar in the liver and the muscles is at fault. In gout, there is no doubt that the liver is not functioning normally, and it is easy to understand that liver cells, which apparently allow uric acid to pass through them without further elaboration, will also not do their duty with regard to the carbohydrate, and will permit more than small quantities to pass unchanged. When it is once in the general circulation, the sugar will act as a foreign body, and will be excreted by the kidneys.
Slight cases nearly always clear up on treatment, at least for the time. There is a tendency to recurrence, but, in many cases, it seems to make little difference to the general health of the patient. Cases of glycosuria are often associated with cardiac degenerative conditions in elderly people, where the arteries and the kidneys are also diseased. It is usually better, in the mild cases, not to tell the patient that he is passing sugar. Certainly to call it diabetes is not only to make an erroneous diagnosis, but often has a very bad effect, as it depresses the patient to think that he has developed a condition with such a bad outlook. We have all met gouty patients, who had been told years before that they had "diabetes," and who, when we examined them, had not a trace of sugar in the urine.
Intermediate cases occur where there may be some slight thirst, and perhaps some loss of weight, and where the amount of water may be increased. The gouty signs and symptoms are usually better, due probably to the increased amount of water passing through the body. This is also noticed when the patient has never suffered from articular gout, but only from the irregular manifestations of the disease, such as excess of urates, migraine, neuritis, etc. As the prognosis, and the significance of the sugar, in these intermediate cases, often cause us anxiety, it is encouraging when we find the uratic condition of the water returning under treatment. As gouty people are liable to true diabetes, we often cannot be sure, in these cases, until treatment has been continued for a time, that we may not be dealing with this latter disease. The presence of an excess of urea will help us in forming an opinion, as it indicates a more pronounced change in the metabolism, but more than traces of ß-oxybutyric acid and acetone are present only when the condition is such as to admit of no doubt, although here their estimation is useful, from the point of view of prognosis. Even when the state is indistinguishable from true diabetes, it is well to remember that the prognosis, as regards the duration of the disease, is not so bad as when it is independent of gout.
Exercise must be encouraged, and massage, baths, etc., keep the body in good condition. The urine should be frequently examined, and the treatment modified as the amount of sugar lessens. In some mild cases, a few days' treatment may be sufficient to clear up the sugar. Change of air and scene are at times necessary, as the patient thus gets away from his usual surroundings; and those spas, in which there is an alkaline, or sulphurated alkaline, or a chlorinated and sulphurated water, are beneficial: such as Karlsbad, Neuenahr, Harrogate, Llandrindod, etc. A sea voyage is often advisable, as a relief from letters and business worries is thus ensured.
In more severe cases, it may be necessary to recommend the passing of the winter in milder climates such as Southern Europe, or Egypt. In a few cases, in which the heart and the circulation are in good condition, a sunny bracing climate at a moderate altitude may be good. Although glycosuria in the gouty seems to indicate some further advance in the already defective metabolism, still, cases have been known to go on for fifteen or twenty years, and, generally, the prognosis is good.