Along with these we must take into consideration the habits and aspect of the patient; for, while it is true that no degree of abstemiousness will serve to ward off the occurrence of gout when the predisposition is strong, it is unquestionably among the over-fed and the plethoric that it is most constantly found.
No positive rules of diagnosis can be laid down for determining the nature of what has been called erratic or unfixed gout; but we shall very generally be right in concluding that anomalous cases of disorder in gouty habits are more or less due to, or modified by, the excess of uric acid.
Gout is especially associated with disease of the kidney; and so frequently has this been observed that some pathologists have spoken of the gouty kidney, a phraseology which is highly objectionable. We may be also pre pared to find other ill effects of intemperance in those who have brought oa themselves this painful infliction, but none of them have any definite relation to it.
§ 6. Rheumatic•Gout—We cannot refuse a separate place in our classification to a disease which, though its place in pathology be as yet undetermined, is very well marked in particular cases. The peculiar twisting and distortion of the joints in persons who have suffered for any length of time from its effects, is such as cannot pass unobserved by any one who is familiar with the aspect of disease.
In its early history it partakes most of the character of sub acute rheumatism. It differs from an acute attack chiefly in the absence of fever, and in the circumstance that comparatively few of the joints are under its influence at the period of its com mencement; there is a good deal of swelling, and perhaps of redness, of one or two joints, but these are not marked by the extreme tenderness and pain so distinctive of rheumatic fever or of gout ; while the local inflammation is more decided than in the subacute form of the disease, if we except a few cases which we have characterized as abortive attacks of acute rheumatism. If due consideration be given to these circumstances, the practi tioner will be prepared for the incursion • of a most inveterate and most hopeless malady. And, let it be remembered, that diagnosis has in this case very much to do with prognosis; where we re cognize rheumatic fever, we know that, except the heart become implicated, the patient will be in a few weeks at most, as well as ever, and that he is not very much more liable to a second attack than his neighbors ; when gout is clearly established, we are sure that the patient will be for a time, in better health than usual after the present pain and distress have subsided ; but that all the care possible will scarcely serve to ward off a second attack; when we have only subacute rheumatism to deal with, we look for either a trivial and passing affection, or for a lingering illness, as we find less or more of local action; but., with rheumatic gout,
we ought to know that our patient is exposed to protracted suf fering, and is liable to remain a cripple for life. When this is not foreseen, much discredit may unnecessarily be brought on the profession—much undue praise be given to the quack, into whose hands such cases are very apt to fall ; he will not scruple to throw on the regular attendant the blame of all the mischief which has happened, and claim for himself the credit of any im provement which, under favorable circumstances, nature herself may slowly produce.
As the disease proceeds, its peculiar characters begin to develop themselves; the swelling subsides in some measure; the redness, if any, is gone from the joints first attacked, but they remain tender, and useless; while others, in succession, become the seat of inflammatory action ; until, at length, the unfortunate patient is reduced to a condition of utter helplessness. When convales cence has slowly been established, as it may be, after either months or years of suffering, considerable distortion and perma nent stiffness are the invariable results.
Observation seems to prove that this form of disease is especially prone to attack females at the two great periods of the commence ment and cessatio' n of the menstrual fimctions. It is also frequently associated with constitutional disorder, in the form of scrofula, tubercle, or disease of the kidney ; but we know not in what re lation they stand to each other. There is good grosmd for the belief that its permanence is in great measure due to the super vention of local disease upon the primary constituticmal disorder; and for this reason it has received from some authors the name of "Chronic Rheumatic Arthritis."