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The Morbid Affinities of Gout

gouty, biliary, lithiasis, colic, articular, disease, renal, disorders, patients and time

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In this lengthy enumeration of disorders and symptoms that are directly or indirectly connected with the manifestation of articular gout, it is often difficult to decide whether a particular malady is directly caused by the arthritic constitution of the patient, or is merely an accidental concomitant of the primary affection. It becomes also a matter of importance to ascertain the character of the tenden cies, if any, that may be transmissible from generation to generation along a line of gouty descent. The influence of arthritism upon inter current diseases of a non-arthritic character demands careful study ; as well as the reciprocal influence of such diseases upon the tendency to gouty manifestations of every kind. We have already noted the frequent concurrence of asthma, bronchitis, heart disease, biliary disorders, gall stones, renal inflammation, gravel, and renal calculi with gout. A more detailed examination of this relationship will be found useful, not only for the purpose of discovering an answer to the questions thus raised, but also with a view to the acquisition of general ideas regarding subjects that have been too much neglected in the study of pathological anatomy ; a study which has given pre cision to our knowledge of the topographical and histological features of disease without adding to the stock of ideas anything but notions regarding the local manifestations of disorder, and the local causes of morbid change. A broader view of the connection and relation of disease with constitutional conditions is needful for the complete comprehension of diathetic disorders like gout and the other mem bers of the class to which it belongs.

Notable among the maladies that are most frequently associated with gout are the different varieties of lithiasis. Of these, biliary lithiasis is the most frequent and most evidently affiliated with gout. Of common occurrence among women and elderly men as a consequence of inactive habits and retarded nutrition, its existence among the gouty and in gouty families is still more often observed than among a corresponding number of patients who are not thus re lated. Hepatic colic, and the obstructions which are its cause, are more often encountered among women than among men, so that at first sight it might be inferred that, as the female sex is comparatively free from gout, biliary concretions are less favored by the arthritic predisposition than by its absence. But further investigation reveals the interesting fact that in the line of descent from a gouty ancestry it is usual for the men to experience articular disease, while their sisters escape inflammation of the joints, but suffer severely from other diathetic disorders. Among these, hepatic colic and biliary lithiasis are conspicuous. In a valuable work on the subject (" Traits des Coliques hepatiques"), Senac has collected 166 cases of which 69 belonged to gouty families. Of these 69 patients 30 were them selves victims of gout as well as of lithiasis. Besides these 30 there

were 26 more who had suffered from gout without belonging to arthri tic families. Fifty-six of the whole number of lithiasics, therefore, were themselves gouty, while 95 (57 per cent.) were either gouty or belonged to a gouty stock. Of the remaining 43 per cent. it is probable that longer observation would have assigned a consider able number to the list of gouty subjects. Similar statistics have been furnished by other competent observers. Thus Bouchard found that of 100 cases of biliary lithiasis under his observation, 30 per cent. had gout among their hereditary antecedents.

Two facts serve to obscure in some degree this affiliation between the hepatic disorder and its articular relative : the sex of the patients, and their comparative youth. It has been already noted that women are less subject to gout than men. This may be explained by their greater temperance, and by the influence of menstruation. Lith iasis, moreover, is a disorder in which the painful paroxysms of colic are most frequent in early life. Young women, therefore, may suffer with biliary colic long before they become gouty, if ever; so that their predisposition to arthritic disease may for a considerable time, or forever, escape notice. In certain cases, however, as time ad vances, the attacks of colic become less frequent and less severe, and the patient begins to exhibit either the genuine crises of articular gout or other of the minor manifestations of the diathesis, such as chronic thickening of the joints of the fingers and toes, or Heberden's nodes may appear upon the distal articulations of the phalanges. Occasionally, after the establishment of articular gout, it happens that its crises alternate with the attacks of colic, affording a com plete demonstration of the close relationship that exists between the two disorders. All that has been noted regarding the affiliation of biliary lithiasis and gout is equally true of renal lithiasis. The clinical teachers from the most remote antiquity to the present time are all agreed upon this observation. Whether manifested in the form of stone in the bladder, gravel, sand, or renal calculi, the re lationship is equally evident. Usually, the occurrence of gravel an tedates the articular disease; but sometimes it follows its attacks, or alternates with them. Occasionally, but rarely, the two maladies are coincident, and the patient suffers with renal colic at the same time that he experiences pain and swelling in his joints. &iliac, who enjoyed unusual opportunities for observation among patients who resorted to the springs at remarked the fact that of 166 cases of biliary 98 had suffered with gravel, and 95 had either experienced gout in their own persons or were descended from gouty ancestors. In three instances urinary calculi were also present, an unusually large proportion, since the percentage of such calculi among all kinds of patients is less than one per cent.

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