The diseases of the joints do not properly fall under our notice in medical diagnosis, but yet it is very necessary we should be able to satiety our own minds whether, m any given case, there be not some more definite disease going on than that which, for want of more accurate linowledge, we call iheumatic. We have already noticed the degeneration of the synovial mess brane, and we have stffi to mention ulceration of cartilages, scrofulous disease of bones, and caries of the spine. In regard to all we observe, that their course is very protracted, their commencement insidious, and that they us chiefly characterised by absence of pain in the early stage; pain, when it does come on, is shooting, transitory, and frequently attended by starting of the limbs ; it is only in the advanced stages that it presents any permanence of character. We may further observe, not only that there is absence of pain in the quiescent state, but that cautions movement does not bring it on, while the slightest jar, causing concussion of one bone against another, is sure to cause pain, and that sometimes of very severe kind. The patient who cannot bear his own weight on the ground while perfectly motionless, is capa ble of mach movement in bed without suffering, when the pressure is removed from the affected joint. A very frequent source of obscurity in the early his tory of these cases is the circumstance that pain is not referred to the joint itself, but to a more distant one, in which it is only sympathetic ; this point, when ascertained, serves as an additional ground for gnosis. The age and aspect of the patient are suggestive with reference to the nature of the affec tion ; thus we look for disease of bone in the young and delicate, ulceration of cartilages in the early part of adult life, and chronic rheumatism after its period, in persons who are fat and flabby or cachectic and anemic. In canes of the spine, the early progress of the case is scarcely marked by any feature which can distinguish it till the prominence of one spinous pro cess at the seat of pain indicates the irreparable mischief which has already taken place. In connection with this we must not forget that lumbar and roes abscess, or deep-seated pelvic inflammation and suppuration, when advancing slowly, are apt to simulate rheumatic affections of the loins and hips.
In chinnic rheumatism we chiefly meet with two important complications, which seem each to have more or less to do with its development when pre sent—constitutional syphilis and granular degeneration of the kidney. It is also intimately connected with malnutrition, whether tending to accumula tion of fat or to general cachexia. • § 5. Gout—The researches of recent times have gradually led to the discovery of an important element in gout—the presence of an excess of uric acid in the blood. This knowledge holds out a prospect of our arriving ultimately at more accurate diag nosis ; at present it is only in the hands of a few that such a chemical test can be relied on. But we may derive, from the mode of its attack, pretty certain indications of the nature of this disease.
In regard to history, an attack of gout is usually ushered in by dyspeptic symptoms and feeling of discomfort, for some period before it becomes localized in the joints ; and this, it may be re marked, is not generally the case with rheumatism. Further, in
the first seizure, the pain and redness are almost invariably con fined to the smaller joints, especially those of the foot. In any subsequent illness, where the evidence is at all indistinct, the manner of its first incursion must be carefully inquired into, because the statement of the patient that he has previously suf fered from either gout or rheumatism is generally not trust worthy.
When the joint is already attacked, and this is very commonly the great toe in the early seizures, the disease is marked by intense pain, redness, and inflammatory swelling, just as in acute rheuma tism ; but there is no great amount of inflammatory fever. If it tend to pass from one foot to the other, it does not fly from joint to joint all over the body, but, as it appears in one extremity, it usually recedes from the other. The pain is commonly aggravated at night. There is none in the shoulders, the hips, or the knees and while, in these respects, it resembles the abortive attack of rheumatic fever which we have described as subacute rheuma tism, confined to one joint or to one extremity, the inflammatory action of that is very much greater in intensity and painfulness. In a few words, the condition of the joint resembles that seen in acute rheumatism, while the state of the patient is more analo gous to the subacute form of the disease, in the absence of fever, perspiration, &c.
It is very rare that a first attack should localize itself anywhere but in the foot ; and this fact, therefore, becomes a great help in determining the nature of subsequent illnesses, when the hands, or even the knees, the shoulders, and the hips may be the sea( of the gouty paroxysm. Repeated attacks of gout very frequently leave chalky deposits in the textures around the joints, and these serve as landmarks to distinguish cases which would otherwise be very perplexing. The more frequently the patient has suffered, the less defined does the character of each seizure beoonie, until the description of the case, but for these two circumstances, is scarcely to be recognized as at all different from subacute rheu matism. All the conditions are then greatly modified; the pain and swelling are less severe ; the number and variety of joints implicated much increased.
Gout can scarcely be confounded with the local suppurations in and around thejoints seen in pyiemia, the general disturbance of suppurative fever being so different from the dyspepsia preceding gout. It may be useful to add that, while the redness and swelling are in both cases well-marked and of limited extent, the one is a much more painful affection than the other; it is quite remarkable how very little suffering is occasioned by these secondary suppu rations.
The history of any previous seizure may be made available for diagnosis by a comparison of the age of the patient with the date of the first appear ance of the disease. Gout seldom shows itself before the middle period of life, while a first attack of acute rheumatism is rarely met with after that age. The different duration of the attack in each case should also be borne in mind.