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The Relations Between Gout and Other Intercurrent Diseases

gouty, disease, patient, injury, knee, inflammation, predisposition, kidneys and heart

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Numerous authors have remarked that certain diseases are attended by great mortality when they occur in. gouty patients. Thus Mur chison has affirmed that typhus fever in a gouty subject is inevitably fatal. Schmidtmann utters the same opinion regarding low forms of fever in general. Erysipelas has also been included in the same category. Sir Spencer Wells has observed that among the gouty, syphilis tends to assume a scorbutic form. Pregnancy, in the case of a gouty woman, is liable to be attended with unusual difficulties, and may be terminated by abortion.

Now with regard to all these intercurrent disorders, the danger arises not so much from the specific diathesis of the patient as from the fact that his or her internal organs are not in a healthy condition at the time of invasion by an intercurrent disease. The authors above mentioned have in several instances made special note of the fact that the kidneys or other organs were in a state of chronic inflammation and degeneration. Many of the cases, such as typhus fever and ery sipelas, were examples of infectious disease. It is well known that the prognosis in such diseases, as also in pregnancy, is determined largely by the eliminative adequacy of the kidneys and the compe tency of the heart. If the heart can retain vigor sufficient for the task of maintaining the circulation, and if the kidneys can free the system from the flood of toxins and excrementitious substances that are poured into the blood during the course of a fever, recovery will be reached at last. But if the heart and kidneys fail, the patient must inevitably succumb. Now iu advanced cases of gout those organs are seldom healthy. Chronic nephritis and chronic myocarditis are slowly undermining the constitution ; and when an intercurrent disease adds to the burdens of a patient who is scarcely able to support the task of ordinary living, he can no longer maintain himself, and death ensues as a consequence of ummia and heart failure: But in mild cases of a gouty predisposition, where the vital organs are still practically intact, an intercurrent disease need not be inevitably fatal. In fact, it has been already noted that the progress of tuberculosis is often delayed and rendered more tolerable by the concurrence of gouty tendencies.

As to the effect of intercurrent diseases upon the crises of gout, information is almost entirely lacking. Cases have been recorded in which pneumonia, or pleurisy, or tonsillitis, has been averted by an attack of gout. But it is probable that these were congestive parox ysms preliminary to the articular crisis, and that they were to be re garded as premonitory symptoms of the principal disease, rather than as independent maladies arrested by the appearance of gout. Still,

it is not impossible that an independent disorder which would not usually lead to any result beyond its own evolution may, in an ar thritic subject, awaken the latent predisposition, and precipitate a crisis, just as the same thing is often effected by fatigue, worry, or bodily injury. Whatever tends to hinder the processes of elimination may become the exciting cause of an attack of gout. Thus it is not uncommon to witness an explosion of articular inflammation after trifling contusions or sprains. The tissues composing the injured joint become less alkaline as a consequence of excessive use or injury, and urates are at once deposited in them, giving to the affection a specific character and an intensity that would not have been mani fested but for the existing predisposition. Sir James Paget and other surgical teachers have contributed numerous observations of this nature. It has been also frequently remarked that limbs and joints that have been weakened by previous disease or injury are more likely than other parts of the body to be attacked with gout or rheu matism. In this respect these two kindred maladies closely resemble each other. An old sprain is liable to become the seat of either rheumatism or gout, according to the individual predisposition of the patient. For example, a young man of my early acquaintance one day injured his knee by falling over a log while hunting. He was confined to his bed for several weeks with ordinary inflammation. Three years later, inflammatory rheumatism attacked the weakened knee, and extended to the other. In advanced life gouty inflammation appeared first in the knee, and then in the classical situation upon the great toe of the affected limb, while small uratic deposits invaded the ear and the fingers. Sir A. Garrod has recorded the history of a case in which the onset of acute gout appeared to have been deter mined by the shock of an injury. A man had several ribs broken by a blow from the pole of a wagon. Almost immediately he began to experience pain in his elbow, followed by swelling of the fingers of the corresponding hand. This extended on the next day to the op posite knee and to the foot. The case was considered to be one of rheumatism, but its severity and its extension to the smaller joints awakened a suspicion of gout, which was verified by the discovery of uric acid crystals in the serum of the blood. Subsequent inquiry de veloped the fact that the patient belonged to a gouty family, and that he had suffered an attack in the great toe some fifteen months before the present injury.

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