VISCERAL GOUT AFFECTING THE DIGESTIVE ORGANS.
Among the subjects of the arthritic diathesis it is a common thing to meet with disorders of the alimentary canal and its appendages ; and it is not always easy to distinguish between gouty affections of the digestive apparatus and accidental maladies that have no special relation, with the diathesis. It will, however, be useful to pass in review the principal diseases that are frequently encountered among those who have either inherited the gouty predisposition or have already experienced its crises. Pharyngeal inflammations are usual among all sorts of people, but among children and young people who subsequently suffer with arthritis it is a frequent event to meet with chronic inflammation of the pharyngeal mucous follicles. Sir Dyce Duckworth says (" A Treatise on Gout," p. 88) : " The gouty throat is like no other. The pillars of the faeces, especially the posterior pair, the velum, and the uvula, are very red and glazed. . . . The uvula is greatly enlarged and elongated, sometimes seeming to fill up the gap between the pillars. It has often an oedematous border . . . and tip. . . . The surface of the latter (pharynx) is not so smooth as that of the fauces. It is coarse, with red, glairy promi nences upon it, and depressions here and there covered with grayish, slightly adherent patches of mucus, and it has sometimes enlarged veurdes upon. it. In elderly people the redness is less marked." Sometimes concretions of calcium carbonate and orate are discharged from the enlarged mucous follicles of the pharynx.
Another frequent event among the gouty is acute suppurative ton sillitis. This sometimes recurs with a regularity that equals that of the genuine articular attacks. Sometimes an attack of gout is ushered in by severe inflammation of the tonsil. With certain pa tients the acute crisis always commences in this way. In other cases the attack is preceded for several days by slight pharyngeal redness, accompanied by somewhat painful deglutition which, at the end of five or six days, disappears and is succeeded by ordinary articular signs.
Occasionally it happens that a spasmodic stricture of the oesopha gus is experienced by the arthritic subject. This usually occurs in nervous patients who are dyspeptic and somewhat neurasthenic. It sometimes immediately precedes an acute articular attack, and disap pears with the evolution of its paroxysms. But it may occur inde pendently of the attack, and it is usually experienced during the act of eating. It is often associated with precordial oppression and great anxiety. Its duration is usually brief, occupying only a few minutes, and it is often terminated by the regurgitation of liquids that have been recently swallowed.
The obscurity that surrounds the relationship between these affections of the pharynx and the oesophagus and genuine gout does not involve its connection with disorders of the stomach. The major ity of the subjects of hereditary gout are victims of gastric disease. Long before the explosion of articular gout, they have had chronic and painful experience of manifold forms of indigestion. But it is impossible from these signs alone to recognize an arthritic predispo sition—the family history, or some previous malady of the arthritic type, is necessary to the establishment of an etiological diagnosis.
As a general rule, however, gouty dyspepsia is marked by gastric pain. There is a sense of distention after eating; there is flatulence and more or less acid eructation ; digestion is retarded; attacks of gastralgia are not uncommon, and in many cases a burning sensation in the epigastrium is frequently felt. These various symptoms may he grouped in two principal classes : in the first, the phenomena of atonic dyspepsia and auto-intoxication are most prominent; in the second, the symptoms of chronic gastritis chiefly engage the atten tion. In the atonic form, there is loss of appetite, sometimes amount ing to a real disgust for food. After a meal there is some swelling of the epigastric region, accompanied by feelings of constriction and weight about the stomach ; for two or three hours an inclination to sleep, and an evident loss of the power of attention and application to business are apparent, but there is no considerable pain. In the catarrhal form, there are distressing eructations that may be either acid or bitter, and burning. Violent pain and cramps are felt in the region of the stomach, sometimes radiating into the cardiac area and interscapular space. Nausea and vomiting sometimes occur to a degree that renders it impossible to take food. Frequently a con siderable quantity of glairy mucus, sometimes streaked with blood, is thrown up from the stomach. Sometimes these evacuations are daily occurrences ; while in other cases, especially when characterized by gastric dilatation, a large amount of offensive liquid of a yellow ish or greenish color is vomited at intervals of three or four days. All these symptoms, however, may be exhibited as the result of sim ple indigestion, and there is nothing in their evolution that is pathog nomonic of gout. It is only the frequent association with the. diath esis that is remarkable. For this reason many able authors have denied the existence of anything more than accidental connection between gout and gastric disorder. Such writers usually express great incredulity regarding the existence of an arthritic diathesis. But it seems impossible to reconcile such opinions with the facts that are revealed by a large clinical experience where the causes of arthri tism are continually operative. Dealing with patients who are past the middle of life, and who are confirmed gluttons or drunkards, it is easy to formulate the belief that all their gastric symptoms are the direct consequence of persistent intemperance in the matter of eating and drinking. But there is another large class of chronic dyspeptics who are of gouty lineage, yet who, by reason of intelli gence and forethought, have avoided the exciting causes of acute arthritism, and have never experienced an articular attack, but are continual sufferers with dyspepsia that is identical with that which is experienced by their imprudent companions who are victims of unimpeachable gout. When, in advanced life, such people are finally attacked with articular crises, the complete disappearance of their gastric disorders is an event too notable and too intimately associated with the outbreak of gout to admit of anything but the conviction that these are two alternating phases of the same disease.