SYMPTOMS OF CHRONIC GOUT.
The progressively invasive character of gout has been already indicated. In typical cases of the uncomplicated disease, its onset is experienced during the early years of the fourth decade of life. Either with or without characteristic prodromes, it breaks out suddenly with a violent nocturnal paroxysm that is repeated every night with declining severity for five or six times in succession, and at the end of ten days recovery is complete. Good health may be then enjoyed for many months, perhaps for a number of years. But a tendency to recurrence is usually evident; the attacks are repeated with the return of spring and autumn; they become less severe, long er in duration, and more frequently renewed. Instead of being restricted to the great toe, the oedema involves the arch of the foot, and persists long after the subsidence of inflammation. Both feet become involved, and all their joints are invaded by the progress of the malady. Then the ankles and the knees are attacked, and some times the fingers, wrists, elbows, and even the spinal articulations are infiltrated and inflamed. It is unusual to find more than two or three joints at once in a state of active inflammation; but the course of the disease is steadily progressive, advancing from the smaller joints to the larger, returning often upon as if unwilling to quit the scene of initial disorder, but in the long run invading an ever widening territory, and approaching the internal organs and impor tant viscera of the body. Especially after middle life is it apparent that every exacerbation of the disease leaves the patient weaker and less capable of withstanding its inroads ; he has become the victim of chronic gout.
Such is the usual course of evolution by which acute and sthenic gout passes insensibly into the chronic form of the disease. But in many instances, especially among old people and among the descen dants of a gouty ancestry, the acute stages of the disease are not mani fested, and from the first it exhibits the subacute and lingering pro cesses that are characteristic of its chronic form. A considerable number of elderly people find their joints gradually stiffened and hampered by the accumulation of orates in the articular tissues, without ever having experienced any of the painful inflammatory symptoms above described. Women after the menopause, and the
debilitated scions of gouty families are not infrequently victims of this insidious variety of gouty arthritis, rendering evident the fact that the clinical forms of the disease are dependent upon the consti tutional characteristics of the individual rather than upon the intrin sic nature of the malady itself. Keeping in mind this peculiarity, it will be impossible to fall into the error of supposing that mere dura tion of time and frequent recurrence of the attacks are sufficient to confer upon the disease the character of chronicity. Many an athletic subject has reached a vigorous old age without a single experience of chronic gout, though he may have had numerous acute attacks peri odically recurring during the course of a long lifetime.
Two principal factors combine to constitute what is correctly termed chronic gout: the existence of a profound cachexia, and the establishment of permanent disability through infiltration of the joints and peri-articular structures with uratic salts. In acute gout recovery after an attack is perfect; the affected joints are soon capable of their ordinary movements, and the general health is often better than ever. But when the disease is chronic, there is no such elastic rebound ; after every exacerbation the patient is left enfeebled, exhausted in mind and body, and more than ever predisposed to morbid function of his locomotive and nutritive organs. Despite the comparatively trifling severity of the active crises, they are more persistent and more injurious than the acutely painful attacks. CEdema becomes more extensive, and its duration increases until it finally assumes a permanent character. There is loss of appetite, continuous indiges tion, intellectual torpor, and an increasing somnolence. With the progressive destruction of the articulations of the lower extremities the patient loses the power of walking, and exercise grows more diffi cult. This enforced confinement reacts prejudicially upon digestion, and a vicious circle is soon established, to the utter ruin of the health. Visceral complications supervene ; the kidneys and the organs of circulation give way ; and death results from toxamia and exhaustion.