PROGNOSIS - GOUT.
Garrod has informed us of the very signifidant fact that the English assurance companies always demand a higher premium for the insurance of applicants who have had articular attacks of gout than for those who have not experienced that misfortune. This is decisive as to the opinion of business men regarding the prospects of life among the gouty. Premature old age may be expected for them, and with it all the accidents to which senility is liable. Still, it is not an uncommon event to meet with individuals who have reached great age in spite of numerous articular incidents. The future of the patient will be largely determined by three things : original vigor of con stitution, occupation and manner of life, and the particular mode in which the local manifestations of the disease are evolved. In very many cases, especially among those in whom the disease is an ac quisition rather than an inheritance, the constitution is excellent, and it endows the patient with a power of resistance and persistence that carries him safely through many acute attacks till advanced age has been reached. This original vigor may contribute either to the safety or to the danger of the individual. If properly advised, and if sufficiently docile to conform his habits to the laws of health, such a patient may so far recover as to suffer but little during the re mainder of life. But if, as is so often the case, the return of health and strength, after an attack, gives occasion to relax vigilance, and to unloose every appetite with all its pristine force, the downward course must be rapid. Feeble subjects, who have inherited weakly bodies, or have made shipwreck of an originally respectable constitu tion, are also liable to a rapidly progressive course of the disease.
The prognosis largely depends. also, upon the kind of life that is led by the patient. The victim of an hereditary predisposition to gout may enjoy a comfortable existence, and may reach a good old age, provided he avoids all excesses, and takes an abundance of muscular exercise. Yet this rule has its exceptions. Such patients, sometimes, despite the neglect of every precaution, pass carelessly on through life, with but few reminders of their predisposition; while others, who observe, all the precepts of wise physicians, and live with the most scrupulous regard for the laws of health, become gradually infiltrated with orates, crippled and confined to their chairs, dying miserably with dropsy and asthma, or lingering for years in a con dition of hopeless wretchedness entailed by the cachexia of chronic Despite these exceptional cases, it is safe to offer a favorable prognosis when the attacks of gout are infrequent, and are limited to a single joint (great toe) ; when they are uncomplicated by visceral disorders, and when the general health remains good dining the inter vals of the disease. But, on the contrary, the future is dark for the patient who experiences frequent attacks that are separated by diminishing intervals, especially if the disease puts off its original intensity, and prolongs the duration of its crises, invading one joint after another, and ascending to the larger articulations, while the affected limbs become indolently oedematous, and remain in a state of torpid swelling for long periods of time without manifesting any very acute symptoms. Such patients have become the victims of chronic gout, and will continue in an invalid condition during the re mainder of their lives. This, however, does not necessarily signify
the probability of an early termination of existence. Life may en dure for many years under these conditions, but recovery is not to be expected. With each succeeding attack the strength of the sufferer diminishes; the joints become infiltrated and disorganized; finally there is established a confirmed cachexia that is the result of the uni versal failure of function in every organ of the body. So long, how ever, as the heart, liver, and kidneys do not become seriously dis organized, the general health may remain tolerable, even to a late period of the disease.. Careful observation of these important organs should therefore always lie at the foundation of prognosis. It should never be forgotten that in every stage of gout there is a tendency to disease of the vascular apparatus and of the kidneys. Even in the early period, before the joints have become infiltrated, while the patient is still florid and vigorous, it may sometimes be discovered that the nocturnal urine is increased in quantity, awl that it contains a faint and transient trace of albumin, perhaps accompanied by a few epithelial casts. The pulse may he also tense and resistant, and the heart sounds may be accentuated beyond the normal degree of sharp definition. All these symptoms indicate a general hyperminia or the beginning of actual inflammation iu the kidneys. At a later period these indications of vascular excitement are likely to be succeeded by the persistent discharge of urine that is irregular in quantity and of a low specific gravity, with or without the presence of albumin and casts ; symptoms that are indicative of progressive interstitial nephri tis. If, in addition to these changes, the sounds of the heart be muffled, or reduplicated, and the arteries show signs of atheroma in their walls, the typical morbid changes of gout are present, and the prognosis assumes the most depressing character. Urcemia, dropsy, cerebral hemorrhage, paralysis, coma, and death are among the even tualities that may be precipitated by the most insignificant accident. Even in cases that have not yet reached this degree of severity, the enfeebled condition of organs so important as the kidneys and the heart exposes the patient to a host of dangers that would under other conditions be easily evaded. A trifling bronchitis, a commonplace influenza, becomes rapidly transformed into a fatal pneumonia ; or a scarcely noticeable traumatism develops into a diffuse and gangrenous inflammation. It is in such cases that the occurrence of metastasis of the articular symptoms of gout is liable to be followed by the most formidable results. In the examples of advanced visceral disease, these so-called metastases are, doubtless, sometimes the direct conse quence of the visceral disorde'r, rather than a novel manifestation of gout; but in certain cases they are really what they seem to be, a genuine transfer of gouty manifestations from the external articula tions to the internal organs of the body. The prognosis must be, therefore, largely influenced by the present condition of those inter nal organs. If they be in comparatively good health before the attack, revulsive measures will be frequently rewarded with success. But, if the brain, the heart, the stomach, or whatever structure is affected, be the seat of chronic morbid change, death may occur, and that with very brief delay.