In the study of chronic gout it is, therefore, necessary to regard particularly the two principal elements of the disease. They may be, in many instances, most intimately associated ; but in many other cases they may be quite loosely connected. In the majority of pa tients who possess a vigorous constitution, the transformation of acute gout into the chronic malady is marked by a predominance of articular phenomena. The joints become extensively infiltrated and disor ganized without any great deterioration of the general health. But in a considerable number of patients, especially among those who have inherited the arthritic diathesis, there may be extensive visceral dis ease and continuous ill-health without any very notable destruction or deformity of the articular structures. Among the older authors this variety was known as atonic or asthenic gout.
Passing now to a consideration of that variety of chronic gout in which the articular changes form the most prominent features of the disease, it is to be observed that a periodical recrudescence of the symptoms is still apparent. The attacks are recurrent, but they are less violent than formerly. There is less pain, though it is more continuous, and the limb can be handled and moved in a way that once would have been impossible. Swelling is not so narrowly cir cumscribed about a particular joint, but is rather widely diffused over the whole extremity. Redness does not appear; the swollen limb is white, and it pits on pressure ; there is no cutaneous inflamma tion, consequently no subsequent exfoliation of the cuticle. But, with all this superficial show of moderation, the infiltration of the joints progresses at a rate that was unknown iu the acute disease. The swell ing of the joints persists for weeks or months after each attack, and consequently the articular capsule becomes dilated, and the ligaments are relaxed; the fluid contents of the synovial membranous sac are thickened with uratic crystals which accumulate in quantity sufficient to hinder the movement of the joint. At the same time the diarthro dial cartilages receive a deposit of urates in their snbserous sub stance, after the manner that has been already described. As this process advances the motion of the joint is restricted in proportion to the degree of infiltration, and the fingers instinctively place them selves in the positions that create the largest capacity in the articular cavities. Since the position of partial flexion is most favorable to this end, the phalanges assume various degrees of semi-flexion or of alternate flexion and extension like what is often remarked in chronic rheumatism. In fact before the degree of infiltration that produces actual deformity has been reached, it is sometimes difficult to distin guish the gOuty finger from that of rheumatism. Before the peri articular tissues have been invaded, while the deposit of urates is still confined to the cartilages, the joint exhibits no characteristic tumefaction. It is merely stiffened, occasionally anchylosed, and a creaking or cracking sound can be heard when it is moved in flexion and extension. The phalanges' skin is thin and drawn clown over the retracted tendons, as if all subcutaneous areolar tissue had dis appeared. In short, the affected extremity may perfectly present the aspect of chronic rheumatism even at a time when infiltration of the cartilages can be demonstrated by dissection after death. This mimicry of chronic rheumatism is, however, a rather unusual event, and it is among elderly females that it is ordinarily observed. These patients also present another deformity which at first sight may be confounded with the nodosities that in chronic rheumatism are found upon the dorsal aspect of the distal phalangeal joints, and are known as Heberden's nodes. But the gouty tumefaction is located along the extensor tendon of the finger, or upon the sides of a joint; and so dense and immovable is it that it may be easily mistaken for an osteophyte. These little nodes are, however, composed of urates that have been deposited outside of the articulations, without producing any modification in the form or substance of the adjacent bone. In this respect the case differs from chronic rheumatism, for iu that disease the phalanges' bones of the affected fingers usually share in the articular swelling. Unlike the smooth and rounded contour of Heberden's nodes, these gouty indurations are often rough and un even by reason of an unequal and irregular deposit of the urates of which they are composed.
Hybrid swellings of this sort may be sometimes difficult of classi fication, but there can be no question about the bulky concretions that form around the joints in cases of chronic gout. Layer upon layer the mortar-like deposit gathers in the fibrous tissues, in the cavity and walls of the serous and mucous bursre, in the sheaths of the ten dons, and in the substance of the ligaments, until everything is over whelmed and mined by the accumulated incrustations. The result
ing form of the diseased joint depends upon the extent of the deposit and the direction of its pressure. Hence great variation in the shape and size of the affected parts. Sometimes the bony structures and sometimes the soft tissues are most severely disorganized, so that there is no uniformity in the changes that occur. In certain cases the whole finger or toe is evenly swelled from end to end, while in other examples the principal deformity is situated upon the sides of the affected Joints, and the incrusted tophi are rough and uneven. In many instances these incrustations are somewhat movable, in this respect unlike the osteophytic growths in chronic rheumatism, which are immovably attached to the extremities of the hones outside of the true articular in argin. The tophaceous incrustations are usually situated upon the knuckles of the hand, or near the me tatarso-pha langeal articulations of the foot. They sometimes manifest a certain degree of isolation from the joints themselves, and are often connected more intimately with the sheaths of the tendons and the bum° than with the articular capsule. So long as the skin escapes infiltration it remains thin, smooth, shining, and movable above the subjacent incrustations. But finally, after numerous repetitious of the gouty crisis, the integument becomes infiltrated and adherent to the neigh boring tophi. At such points there appear whitish spots which may become ulcerated, permitting the discharge of tophi that are thus loosened by inflammatory action. In the vicinity of these patches the veins are enlarged, so that the participation of the vascular system gives to the whole process an aspect that is truly pathoguo monic. The formation of tophi, though usually connected with the course of chronic gout, may also follow au acute attack of the disease. In such cases, it is during the period of decline, as the swelling and pain are subsiding, that a new focus of painful tumefaction suddenly appears outside of the joint, upon the sheath of a tendon, or in a mucous bursa. There is every appearance of an abscess, even to the occurrence of fluctuation, but on incision nothing escapes but a little blood mingled with a pasty fluid that is filled with crystals of sodium urate. After a few days the inflammatory symptoms disappear, and at the end of a month or more the fluid contents of the tumor have dried away, leaving in the soft parts a little hardened concretion, that will serve as a foundation for future incrustations. But in cer tain cases these minor .tophi form at a distance from the affected joint, and it is thus that they are developed upon the ear, the nose, or the forearm, as already described in the section on pathological anatomy. In this way, becoming more numerous after each attack, they may be at last very considerably multiplied, exhibiting an inter esting variety of age and stage of development. Sometimes, it hap pens that tophi which have been deposited during a previous attack are reabsorbed and removed during subsequent attacks, while new ones are formed as if at the expense of the older concretions.
After the formation of a tophus has been completed, the mass usually remains dormant in the connective tissue. Sometimes it gradually increases with the recurrence of each acute attack. In many instances, the skin finally ulcerates over the tumor, and the chalky substance is evacuated very much like the core of a boil; or it may gradually melt down and ooze away in the form of a gritty sero-puru lent discharge.
Such is the course of evolution for the tophi that are associated with acute gout. But in the majority of cases their formation is successive to chronic gout, and is unattended with any considerable amount of pain or constitutional disturbance. A peculiarly indolent variety of tophus is presented by the little dermal concretions that form in the ear, and upon the palmar surfaces of the fingers. When reabsorbed from this latter situation, they leave behind them certain star-shaped cicatrices that are quite characteristic.
The mere presence of uratic deposits in different parts of the body does not necessarily imply extensive injury of the general health. In a certain proportion of cases, on the contrary, the patient is completely broken down, even though the articulations and other parts of the locomotive -structures exhibit very little evidence of local disease. This failure of health is the consequence of visceral change affecting the kidneys, the circulatory apparatus, or the respiratory organs. The variety of cachexia that is thus produced depends chiefly upon the predominant form of visceral disease. It is therefore necessary to note the characteristics of visceral gout and the gouty cachexia.