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Visceral Lesions of Gout

renal, kidney, tubules, tissue, kidneys, sometimes and usually

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VISCERAL LESIONS OF GOUT.

The most important of these are the changes that are produced in the kidneys, of which the granular or gouty kidney furnishes the type. Usually surrounded with masses of fat that are adherent to its cap silk, the kidney is reduced in size, and its capsule appears thick ened, with an unevenly warty surface due to retraction of the fibrous trabecuhe within the substance of the organ. Small cysts frequently protrude beneath the capsule, and they may be easily recognized by their translucent envelope. Owing to the adhesions that have grown up between the fibrous trabeculin of the organ and its investment, it is difficult to peel off the capsule; and the attempt usually results in considerable laceration of the true renal surface. An incision carried through the kidney exhibits very decided reduction in the thickness of the cortex, so that it is sometimes reduced to a mere capsular in vestment of the tubular and pyramidal portions. This part of the organ is less atrophied, but the tubules are spread apart by the in jected vascular tissue and the intense hyperemia in the vessels that surround the pyramids. The walls of the renal pelvis are thickened and congested; its cavity is usually dilated, and is often compressed by outside masses of encroaching fat.

Microscopical examination reveals in the cortex an extensive pro liferation of connective tissue, by which the convoluted tubules are crowded apart; the glomeruli are contracted, and their thickened capsules are fused with the surrounding connective tissue, while the vascular loops and tufts within their cavities exhibit the characteristic changes that are due to peri-arteritis. Among the uriniferous tu bules, some have yielded to the pressure of the contracting fibrous elements, and have disappeared; the majority of them are reduced in calibre, and exhibit evidence of atrophy, though still conserving their normal epithelial lining. In a word, the histological changes are those which are characteristic of ordinary interstitial nephritis. The only pathognomonic sign that is usually present in the majority of gouty kidneys is the appearance of uratic crystals or concretions. These must not be confounded with the nric-acid crystals and concre tions which are commonly found in the renal pelvis and tubules of calculous patients. It is true that gouty subjects may become calcu

bons, and then the kidneys may exhibit a mixture of uric-acid and uratic deposits; but in the uncomplicated gouty kidney uric acid is only present in combination with a sodic or calcic base. It is then encountered, not in the secreting apparatus of the organ, but in its excretory structures, in the pyramidal portion. Here may be discov ered a deposit of amorphous unites apparently occupying the lumen of the uriniferous tubules, and becoming visible as fine, white stride that follow the course of the excretory ducts. Careful microscopical ex amination, however, renders it evident that these deposits do not lie within the tubuli, but that they encumber the fibrous tissue between the uriniferous tubules which still remain pervious to liquids. Here, then, the uratic deposit follows the same law that was observed in the infiltration of the articular structures.

The vascular structures of the kidney are not always invaded by disease, but it is highly probable that in the majority of advanced cases their walls are involved in the sclerotic process.

Ebstein reports a case in which the renal papilla) had ulcerated as a consequence of the encroachment of tophaceous deposits. This must be a rare event.

Mention has been already made of the multiple cysts which so frequently abound in the renal substance. These are sometimes very numerous, and their magnitude may cause the almost complete dis appearance of renal tissue. The capsule of the kidney may then en close a number of contiguous though separate cysts. Their contents are subject to considerable variation of color and consistence, being sometimes clear and colorless like water; or sometimes pigmented and jelly-like. The pelves of such kidneys frequently contain calculi of various sizes and shapes; and similar concretions are sometimes found in the cystic vacuolations that have replaced the renal substance. The concurrence of these concretions with the characteristic articular lesions of gout serves to indicate the intimate relationship that asso ciates gravel, calculous kidneys, and arthritic disease of the joints.

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