Tophi: Their Evolution and Distribution
In our chapter on Uratosis we dealt with the chemical nature and mode of formation of tophi. Also we affirmed our belief that tophi, whether articular or ab-articular in site, were always preceded by local inflammatory reaction, and to the clinical tokens of their impending eruption we need not recur. Albeit this point, i.e., antecedent inflammation, is of such prime importance that we have not hesitated to append to our text a lengthy footnote,[37] this because, as Garrod, who quotes the same in extenso, rightly claims, the genesis and evolution of tophi has never been so graphically depicted as in Moore’s description.
It will be seen that this observer holds that tophus formation “is usually preceded and accompanied by inflammation.” Garrod, as we know, believed uric acid to be the cause, and not the consequence, of gouty inflammation. But he emphasises the fact that the phenomena attendant on the eruption of auricular tophi are “exactly the same as when a joint is affected, and constitute, in fact, a true gouty paroxysm, commencing with infiltration of the tissue and subsequent inflammation.” Still, though venturing to differ as to the sequence of events, we gladly invoke this authority’s observations in proof of the fact that the inflammation even in the ear is not always of negligible grade: “I have seen many cases in which the ear symptoms have proved very annoying, so that patients have been unable to rest their ears on the pillow.” Subacute gout sometimes occurs in the ears, says Duckworth, who furthermore believed that the indurations in the cartilage observed by him in gouty subjects were the outcome of such attacks. Laycock, too, long before noted that the ears of gouty subjects often appeared to be “soldered.”
Pain or discomfort in auricular tophi often presages an oncoming articular paroxysm. “Those gouty persons,” said Scudamore, “who are affected with concretions (chalk-stones), experience for a short time before the fit pricking pains in the parts where they are situated. This is described even by those who have minute points of concretions in the lobes of the ears and in no other parts of the body.” Hence tophi have a prognostic as well as diagnostic valency in that the incidence of pain at their site may foretell the oncoming of articular outbreaks.
While, as before emphasised, the eruption of tophi may antedate the occurrence of articular gout, on the other hand tophi may be present at the joints, but lacking in the ears and all other ab-articular sites. Auricular tophi, extracted occasionally by patients, are sometimes shed spontaneously. According to Duckworth’s statistics, in one-third of all well-marked cases of gout the ears present tophi in the helix, the anti-helix and its fossa and the lobule, and in some cases they may be situated on the posterior surface of the pinna.