DIAGNOSIS - GOUT.
Typical cases of acute articular gout are easily recognized. It is only necessary to review the symptomatology of the disease in order to form a picture that cannot be mistaken for anything else. Chronic cases in which the joints of the fingers and toes—perhaps other larger joints also—have become deformed by repeated attacks of inflammation, and by the deposit of urates in the articular structures, are seldom difficult of recognition. But great difficulties may arise in connection with certain unusual or obscure manifestations of the disease. Sometimes many joints are simultaneously attacked, so that the patient appears to be suffering with acute inflammatory rheu matism. Even the most experienced clinical observers have been thus occasionally led astray. Sometimes, again, it is the chronic form of the disease that assumes the garb of chronic rheumatism, progressing by successive subacute exacerbations that involve the joints of the fingers and toes, producing noclosities and deformities that appear to be common to both diseases. Occasionally the autopsy alone, by revealing the presence of urates in the joints, can give precision to the diagnosis. In many instances arthritis defor mans has been mistaken, sometimes for rheumatism, sometimes for gout; but this uncertainty can be usually traced to the once prevalent notion that this species of arthritis is an hybrid disease, sharing in the characteristic phenomena of chronic gout and chronic rheumatism.
Very few clinical observers at the present time will undertake to maintain the identity of gout and rheumatism, even in their more obscure and chronic forms. If we pass in review the etiology of the two diseases, we find that while certain events, such as exposure to cold and damp, contusions, sprains, injuries, psychical exhaustion and physical fatigue, may act alike as occasional or exciting causes for either affection, the remote, predisposing, and essential causes are widely different. Gout, even in England and Holland, is a rare disease, while rheumatism is one of the most common. Gout, thanks to an improved acquaintance with the laws of health, is becoming less frequent, but rheumatism is more and more widely diffused. The one disorder is unknown in tropical countries, and is most prevalent where wealth and luxury are enjoyed under inclement skies in a damp and chilly climate; the other is confined to no country or clime, it prevails alike among rich and poor, temperate and gluttonous, in dolent and laborious. Exposure to cold and hard work in the open
air are safeguards against gout, but they are common exciting causes of rheumatism. The first is a disease that mostly affects the male sex, after the attainment of adult life; but the second strikes both sexes alike, and is even more commonly experienced, at least in its acute and abarticular forms, among children and youth. The personal habits of the individual exert comparatively little influence upon the evolu tion of rheumatism, while gout is largely dependent upon excessive eating and drinking, lack of exercise, and the intemperate use of fermented The morbid anatomy of the two diseases presents equally conspic uous differences. Both are nothing if not articular in their manifes tations, but the effect upon the joints differs widely in either malady. In rheumatism the symptoms of local inflammation are most painfully evident, but they rapidly vanish with the subsidence of disorder in the affected joints. The articulations may be repeatedly inflamed without leaving any appreciable trace that can be recognized during the intervals of perfect health that succeed each attack. But in gout, every attack leaves behind it a permanent alteration of structure in the joint that has been the seat of disease. Consequently, the gouty subject after his first crisis can never be considered as perfectly well. He is henceforth more or lass of an invalid; and each recurring attack adds to the disorganization of the affected articulations. In chronic gout the joints are enlarged and stiffened by an infiltration of orates into the cartilages and fibrous tissues that enter into the structure of the joint. In chronic rheumatism it is the extremities of the bones that are the seat of disease —a tedious swelling, inflamma tion, and deformity of the osseous substance beneath and behind the articular cartilage, while the synovial cavities exhibit no trace of dis ease greater than is implied by a slight excess of the synovial fluid. Examination of the internal viscera of the body reveals an opposition of signs that is equally convincing. Rheumatism by preference causes pathological changes in the heart and vascular canals ; the blood is rich in fibrin, and its corpuscles undergo rapid destruction. But in gout it is uric acid that is present in excess, and the kidneys are the usual starting-point of internal disease.