Obesity is another morbid condition that is closely affiliated with gout. Though seldom manifested together in the same person, the two disorders are intimately associated in the same families. Obesity is not uncommon among the children of gouty parents; and, con versely, gout is no rarity among the offspring of obese progenitors. Excessive corpulence is by no means the simple consequence of over-eating. It often persists in spite of modification of the diet, and is dependent upon deep-seated errors of nutrition that are peculiar to certain constitutions. It is usually associated with rheumatism, gout, asthma, gravel, diabetes, cardiac disease, stone in the bladder, biliary lithiasis, or eczema—thus forming a component of that group of diseases with which gout is so closely connected. Of the cases gathered by Bouchard nearly one-half exhibited obesity as an hereditary disease, and gout was present among the relatives of one third of the patients, while the other latent manifestations of arthri tism occurred in the families of about half the number.
The connection between gout and rheumatism has been discussed at great length by numerous competent observers, but without arrival at complete unanimity of belief. These differences of opinion are largely dependent upon the manner in which the subject is ap proached. Regarding it from the clinical standpoint alone it is diffi cult to distinguish in every instance between the two diseases. But the pathological anatomy of gout differs widely from that of rheu matism, which chiefly manifests itself in the substance of the bones, and in a velvety splitting-uP of the articular cartilages, widely different from the uratic infiltration of those structures. Rheumatism also attacks young children and other patients of every age, and is located as a poly-arthritis in numerous large joints; while gout is a disease of middle and later life, usually manifesting itself in but one joint at a time, and invading by preference the smaller joints of the feet and hands. Repeated attacks of rheumatism may visit the same joints without producing any permanent change in their structure; but it is an uncommon event for gout to leave an articulation without lasting evidence of its occupation. The value of these • differential characteristics is somewhat minimized by Haig and others who do not consider gout and rheumatism as essen tially different from each other. Regarding both diseases as chiefly dependent upon the retention of urates in the tissues, and their.sudden discharge into the blood by reason of causes that occasion a reduction of the alkalinity of the circulating fluids, Haig expresses the opinion (" Uric Acid as a Factor in the Causa tion of Disease," 1894) that the greater relative vascularity and alkalinity of the joints in young people protects them from per manent incrustation and infiltration with uric-acid compounds. The kidneys of such patients, also, are more efficient in earlier life in later years ; consequently the elimination of urates in rheumatic attacks will be so complete that no trace can remain behind. This fact is sometimes witnessed in acute articular gout. But with advancing years the eliminating organs become less competent for their task, the joints become less vascular and less alkaline, so that nrates are freely and permanently deposited in their substance, exciting all the phenomena of chronic gout. According to this line of reasoning uric acid and its nitrogenous congeners are the principal causes of both gout and rheumatism; while the differences that undoubtedly exist are chiefly dependent upon the relative adequacy and activity of the eliminative organs in differ ent subjects.
Without proceeding further at present with the discusSion of this feature of the subject, it is impossible to deny the intimacy of the affiliation between rheumatism and the group of diseases in which gout is so conspicuous. Fuller has shown that of 300 rheumatic patients, whose antecedents he had investigated, about one-third (96) had rheumatic ancestors; while nearly one-half of his gouty patients were of similar descent. Of Bouchard's 100 gouty eases
25 had rheumatic relatives behind them. The same author has re corded 39 cases of rheumatism in the families of 100 patients suf fering with binary lithiasis, and 28 of them had also experience of rheumatism in their own persons. In like manner, he found 35 cases of rheumatism in the families of 100 cases of obesity ; and 45 cases similarly related to 100 diabetic patients. It is hardly possible to give a clearer proof of the intimate connection that exists between all of these diseases.
The question of the pathological affinities of the so-called Heber den's nodes has been often discussed. Appearing upon the dorso lateral surface of the two distal articulations of the fingers, they usu ally develop slowly upon either side of the median line, and produce considerable deformity of the joints. Sometimes they grow without exciting much-pain, but in many cases their appearance is preceded and accompanied by severe suffering and articular swelling in the affected parts. They contain no mineral constituents, but are made up chiefly of fibrous tissue that is formed under the influence of chronic inflammation, often involving also the joints and the ends of the bones themselves. In all these particulars these little tumors are allied with chronic rheumatism ; but in many other respects they seem to be related with gout. The English authors, with their large ex-. perience, generally incline in favor of the gouty character of these growths. They are very seldom associated with acute rheumatism. They commonly occur among elderly women after the menopause, and especially among women who belong to the luxurious class, and \ vho number among their relatives a considerable proportion of gouty subjects. The absence of tophi does not decide against the gouty kinship of these tumors, for women are less liable than men to such incrustations, and many cases of articular gout escape for a long period without notable infiltration of the joints. The frequent ex istence of these nodes upon the fingers of patients who suffer with asthma, sciatica, neuralgia, hemierania, and other manifestations of the arthritic diathesis, forms another argument in favor of their gouty relationship.
Similar questions have been raised regarding the affinities between gout and arthritis deformans. By many pathologists this has been regarded as a strictly rheumatic affection; others have described it as a malady that partakes of the nature of gout; while a third class of writers look upon it as an independent disease, exhibiting certain features of resemblance with both gout and chronic rheumatism, but originated by entirely different causes. In order to indicate its clini cal relationship, it is frequently described by English authors as rheumatic gout. But aside from the fact it is usually manifested iu the smaller joints of the extremities, and that it may produce de viations and deformities of the fingers that closely resemble the ulnar deviation of the fingers that is sometimes occasioned by chronic gout, the points of resemblance are not very numerous. It is gener ally witnessed among broken-down old people, specially those of the female sex, who have been subjected to poverty, hardship, cold, and damp. Tuberculosis and chronic nephritis are also often noted among its antecedents or concomitants. The diseases so frequently affiliated with gout—diabetes, obesity, lithiasis, etc.—are rarely en countered in the environment of arthritis deformans. Still it is not uncommon to find rheumatism among the relatives of these patients, and gout among their ancestors. The three diseases probably origi nate in a common predisposition, but their different modes of evolution depend upon the conditions of life, diet, exercise, exposure, occupation, etc., that vary according to the residence and the social rank of the individual.