It is an interesting fact that visceral calculi when encountered in gouty subjects are not necessarily composed of uric acid alone. They are sometimes made up of ammonium orate, or of calcium oxalate. These last may he, however, considered as derivatives of uric acid, since that substance can be split up into urea, allantoin, and oxalic acid. Sometimes the growth of a stone in the bladder is modified by changes in the composition of the urine, so that the ir regularly spherical mass comes to he formed of concentric layers of different substances deposited around the original nucleus. Thus a stone may consist of alternate layers of calcium oxalate and uric acid; or numerous calculi may be successively formed of earthy phosphates, orates, and pure uric acid. Sometimes the urine ex hibits a varied succession of earthy sediments which continue to ap pear until everything is cleared up by a pronounced attack of articular gout.
An intimate connection between gout and diabetes has long been remarked. The two disorders are often encountered along the same line of descent, and not infrequently they are experienced by the same individual. It is usually among those who have had early at tacks of gout, or who have arrived at middle life and have acquired the arthritic constitution, that this farm of diabetes is evolved. The patients are big, stout, and florid, great eaters, and of inactive habits. They may have suffered with acid dyspepsia or with biliary or renal lithiasis. At first they complain of inexplicable lassitude, and of profuse sweating on slight exertion, yet they do not lose weight or color. After a time an inordinate thirst attracts the attention of every one, and an examination of the urine reveals the presence of sugar. In many instances such an attack of glycosuria is merely a transient incident that soon yields under the influence of a change of diet and appropriate medication. The patient recovers his vigor, and his health appears to be quite restored. But in the majority of cases this glycosuria, though temporary and fugitive, is an indication of impending disaster. It proves that the liver is no longer compe tent to guard the system at all times against the excessive introduc tion of sugar into the general circulation. Unless the diet and habits of the patient are carefully regulated, there will be, sooner or later, a transition from simple glycosuria to confirmed diabetes.
As a general thing, however, the course of gouty diabetes is slow and comparatively mild. It is often witnessed among the corpulent
of both sexes. It often appears among women who have led a life of leisure, and have gained in weight with advancing years. At the time of the menopause they frequently begin to exhibit phalangeal nodosities, or other arthritic symptoms, and their urine contains sugar. They often suffer with vague nervous symptoms, are afflicted with sleeplessness, and are exceedingly prone to attacks of vulvar pruritus. In this condition, if prudent in the matter of diet and mode of life, they may pass many years without marked failure of health ; but usually the glycosuric crises become more frequent and persistent, until at last the symptoms of confirmed diabetes are established. When this stage has been reached the course of the disease does not differ from that of the ordinary forms of diabetes, and the patient inevitably succumbs to the exhaustion incident upon gangrene, pyeinia, inanition, or tuberculosis. To express in statisti cal form the relationship between gout and diabetes is a difficult matter. The physician who studies these diseases in a wealthy clientage, or at the mineral springs where arthritic patients congre gate, will arrive at results that differ from the opinions of observers whose knowledge is principally derived from the observation of pau pers in a public hospital or dispensary. Thus Seegen, at Carlsbad, found that 30 per cent. of his diabetic patients were also gouty ; while Griesinger, at Berlin, could discover but three gouty subjects among 225 diabetics. At Vichy, Durand-Fardel, excluding all cases of biliary lithiasis, found, among 270 cases of diabetes, that about 14 per cent. were gouty or sufferers with gravel. Gout and diabetes are often associated in the same line of family descent, but they seldom attack the same individual. The following table, from indicates the close affinity between diabetes and other arthritic disorders that becomes apparent when the family history of the patient is subjected to scrutiny. In the families of 100 diabetics he found: Since all these diseases have been shown to be most intimately connected with the arthritic diathesis, it is difficult to resist the belief that they are all connected with a common cause. Their alternation with each other has been often observed; and their general disap pearance, for a time at least, after an acute attack of gout serves to emphasize their apparent kinship.