The phenomena of lithiasis, of the hepatic variety as well as the renal, are not uncommon precursors of a gouty attack. They occur after the usual fashion of biliary colics, accompanied by pain in the stomach, vomiting, and jaundice. Or there may be excruciating pain along the ureter, radiating down the spermatic cord, and associ ated with retraction of the testicle, high-colored or bloody urine, and finally the discharge of a calculus or a quantity of renal sand.
Sometimes the respiratory organs are the chief seat of disturb ance. Violent fits of sneezing, followed by a copious watery dis charge from the eyes and nasal mucous membranes, may occur in paroxysms of short duration, counterfeiting, while they last, the symptoms of hay fever. In other cases the bronchial mucous mem brane bears the brunt of the attack, and for several hours at a time the patient displays the characteristic phenomena of spasmodic asthma. Occasionally, the oesophagus is involved in a spasm of brief duration, attended by difficult and somewhat painful deglutition and a general sense of suffocation. Gastralgic paroxysms are not in frequent, during which the sense of constriction at the base of the thorax and the obstinate vomiting and pain are not to be distin guished from the agonizing "gastric crises" of tabes dorsalis. Such attacks are more frequent in the third decade of life than at an earlier age.
It might be anticipated that with such an enormous list of premon itory disorders the general health of an arthritic subject must suffer severely. On the contrary, however, the individual usually retains the appearance of vigorous health. The patients are few who present at the same time any considerable number of the above-mentioned disturbances of function. Sometimes it is true that in the same person are united many of the phenomena that are characteristic of the arthritic diathesis; but in numerous cases it is necessary to seek in the family history acid habits of the individual an explanation of the rare and trifling disorders that precede and advertise the advent of an attack of gout. The future patient is fat and fresh looking, frequently athletic and muscular. During the third decade of life the hair frequently begins to whiten and to fall; though in many instances it remains luxuriantly abundant to the last. Dandruff often appears upon the scalp, on the chin, and occasionally among the pectoral hairs upon the sternal surface of the thorax. The pustula tion of acne often deforms the adolescent visage, and a suspicion of eczema may be sometimes detected in the furrow behind the ear or at the base of the ala nisi. Perspiration flows at the slightest provo cation, and there is an uncomfortable sensitiveness to draughts of chilly air. In the folds of skin under the breasts, in the groins, and around the arms, intertrigo is not uncommon. Urticaria frequently appears, and herpotic eruptions break out upon the prepuce and glans; varicocele, hemorrhoids, and varicose veins become annoy ingly prominent, and are frequently associated with acid dyspepsia, constipation, headache, and vertigo. The urine is either copious
and charged with orates, or it may be scanty, high-colored, and acid. From time to time the respiration is disturbed by an attack of spas modic breathing, and the heart is often palpitating, irregular, and feeble in its action. Sometimes, instead of a fair complexion, blond hair, and corpulent figure, the patient presents the characteristics of the bilious temperament, harsh features, a dark complexion, and an angular frame. In such eases constipation, hemorrhoids, bilious derangement, and melancholia have been thought to be more con spicuous than among those of a florid type; but it is probable that the predominance of certain symptoms is controlled by the diet, habits, and conditions of life as much as by the original constitution of the body. Thus it is a matter of common remark that dy spepti symptoms are most conspicuous in the arthritic rich who overfeed themselves and lie in the lap of luxury. They suffer with congestive headaches, epistaxis, or bleeding piles ; seem very ill for a short time, and then quickly recover their ordinary vigorous health, which persists until the next paroxym, or until the precursory ailments are replaced by an attack of genuine gout. Among the nervous and ill nourished subjects of arthritism, headache, insomnia, and neuralgia are the frequent signs of the diathesis. Their dyspepsia is of the nervous variety—it is less severe, but more persistent than the corre sponding form of indigestion that exists among vigorous and robust individuals. They suffer with functional disturbances of the heart, and with bronchitis that is often accompanied by spasmodic disorders of respiration. When, at last, the acute attack of gout is developed, it is not so sudden, or so violent, or so brief as when it appears in a plethoric subject. Its course, also, is usually more prolonged ; re covery is less rapid and perfect; and there is greater danger of the establishment of permanent disability. The whole course of events is controlled by the original constitution and temperament of the patient. The most notable symptoms are furnished by the weak est organs of the body, and consist chiefly in an exaggeration of functional defects which in ordinary health are present but not obtrusive.
From this array of phenomena it is evident that the precursory symptoms of gout may involve a disturbance of every organ and function of the body. Long before ..the final explosion, the arthritic subject has had much experience of ill-health. The paroxysmal character of these episodes, their brevity, and the temporary relief that they afford, serve to indicate their kinship to the real articular attack of gout. It is their existence and their persistent recurrence that indicate the arthritic diathesis, even though, by reason of whole some living, they may never culminate in the acute disease. Recog nition of their presence and significance is of the highest importance, since upon such early and intelligent diagnosis is based the whole art of prophylaxis and of physical education during the early years of life.