Moreover, we would emphasise the fact that tophi, more often than is thought, occasionally precede by some years the outbreak of arthritic attacks. Both Duckworth and Garrod are quite definite on this, and we can confirm them.
In such instances, then, even granted that our attention be drawn to them in their initial stages, how easy to misinterpret their true nature! Thus, we have known tophi in their early stages of formation confused with chilblains. In this connection we might remind the reader that, according to Duckworth, amongst the peculiarities of tissue in those goutily disposed is feebleness of the peripheral capillary circulation, “a condition leading to disorders of chilblain-type, the vessels filling slowly after being emptied.”
We repeat that the cause or causes of tophi and, alike, of the arthritic phenomena of gout are, and must be, one and indivisible, for the process of tophus formation is but an attack in miniature of gout. Although he may never have had an arthritic outbreak, the individual who exhibits a tophus undeniably has gout. More certainly so than if he had had an inflammatory outbreak in his great toe; for this, at any rate, may be of non-gouty origin, but the tophus, never!
Reflecting on the foregoing considerations, we would submit—
(1) That tophi are always preceded by local inflammatory reaction of varying grades of severity, and that the uratic deposits are sequels thereto;
(2) That in their early stages their presence is betokened by soft red swellings associated often with sensations of pricking and tenderness;
(3) That their transmutation into white pearly concretions is a process that takes months to mature;
(4) That tophi and arthritic outbreaks have a common causal origin.
The question that now thrusts itself upon us is,—What, then, is the cause of the inflammatory phenomena which determines the eruption of tophi, and alike of the arthritic outbreaks?