CHRONIC GOUT.—Chronic gout may occur as the result of a long series of acute attacks which gradually have weak ened the constitution of the patient, or it may appear in feeble subjects as the only manifestation of gout. In both cases the joints successively get enlarged, deformed, stiff,—even immovable,—nod ulated, owing to the deposition of urates in their structure. The skin covering them is congested and thin, with large, blue veins; ultimately it may rupture, and discharge whole chalky masses of urates,—tophi,—sometimes followed by suppuration and ulceration. The de formities of hand and foot are caused by partial dislocations of the phalanges, with deflection of the fingers in various directions; when the affected articula tions are moved, a scraping sound is heard and felt. In the most advanced cases not only fingers and toes, but also wrist and elbow, ankle-joint, and knee are stiff and deformed, and at last the patient may be obliged to remain immov able in his chair or in his bed as an im potent cripple.
In chronic gout urates may be depos ited in different structures, such as tendons (especially the tendo Achillis), bursam, aponeuroses, and periosteum; in the cartilages tophi may be found, very frequently in the ear, but also in the eye lids and on the nose. These tophi are generally of the size of a pin's head or a bead; at first they contain a whitish fluid containing crystals of urate; ultimately they become solid and form small, hard nodules.
2. Fibroid thickenings and little lumps in the hands of those who suffer from gout.
3. Fibroid thickening of bursa;.
4. Gelatinous deposits, sometimes dif fused and sometimes nodular. These are much softer than the fibroid variety.
5. The rheumatic nodules of Barlow. O. The nodules met with in sclero Finger-nodes are divisible into two classes: In one class the nodosities are true osseous enlargements, and are of rheumatic origin; in the other class the nodes are composed of urate-of-soda deposits and are connected with the true gouty diathesis. The outward appear ances are illustrated by the accompany ing cuts (Figs. 1 and 2), while the osse
ous enlargement of the ends of the bones A Fig. 3.—Osseous enlargement in gout. A represents the phalanges from the back, and B the side-view. For purposes of comparison a delineation is given of the dorsal surface of a normal phalangeal joint,—shown in C. (Pfeiffer.) in the rheumatoid cases is seen in Fig. 3. Emil Pfeiffer (Lancet, Apr. 11, '91).
Varieties of nodules that may be met with 1. Non-calcarcous nodules in the ears in the subjects of declared gout.
derma. These are similar to the "rheu matic nodules," and possibly identical with them.
7. The lumps which often accompany Dupuytren's contraction of palmar fascia.
S. Lumps developed in tendons. These occur most frequently in the tendo Achillis. It is sometimes difficult to tell whether they are syphilitic or gouty in origin.
9. The indurations in the skin of the hands, which constitute the "Judson Bury" group. These occur with inher ited gout.
10. The livid indurations in the skin which have been described in sarcoma melanodes. These occur in adults with inherited or acquired gout. J. Hutchin son (Hutchinson's Archives of Surg., Apr., '96).
Personal examinations of gouty tophi have shown that the deposit was composed, not of urates, but of calcium phosphate and carbonate with some cal cium sulphate. The acidity of the urine was also found but one-third the nor mal. When, therefore, hyperacidity ex ists, the gouty deposits are tribasic cal cium phosphate. The tophi are in creased by the administration of large quantities of alkalies. Morel-Lavallee (Jour. des Praticiens, May 25, 1901).
In the skin tophi are more rarely found, but have been observed in the face. The urine in chronic gout is ordinarily pale and watery, sometimes slightly albuminous, and commonly abundant; it contains always casts of renal tubnli, hyaline or granulated. The patients are weak and pale, suffering from disorders of digestion; they are sub ject to cramps, neuralgias, and other nervous disorders.