Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

Again, Ransom, of New York, found that no systemic disturbance ensued in two cases of chronic nephritis, following the taking by the mouth of 3 grammes of uric acid per diem for three days in succession. All that resulted was a notable increase in the uric acid output. In one case, he went further, and on the fourth day administered 6 grammes, but nothing happened.

Walker Hall, with commendable devotion, took large doses of uric acid with resultant headache and malaise, which endured for some hours. But as Luff shrewdly observes, “almost any substance, however (common salt for example), will produce toxic effects if taken in very excessive quantities.” Despite his brief indisposition, Walker Hall maintains that uric acid is rather a symptom of, than the precise materies morbi in gout.

Nor, apparently, even in gouty subjects can aggravation of the condition be induced by intravenous injection of uric acid. Bass and Herzberg did so until the blood content of uric acid reached the high level of 10 mg., and yet no joint attack supervened. Neither, for that matter, has it been possible to establish any relationship between degrees of uricæmia and the incidence or severity of gouty paroxysms.

Again, taking a typical instance of acute gout in the big toe, how difficult to conceive that the same owes its origin to uric acid circulating in the blood especially when we realise that the blood content of uric acid in gout exceeds but by a few milligrammes that in normal blood. Moreover, if it does so, then why does it fail to ensue in leukæmia and in other states associated with uricæmia. Also, we like to think that the penchant of acute gout for the toe is that the circulation is inefficient at this peripheral site. But how often is the circulation all too vigorous in gout, and for that matter frequently feeble in leukæmia and in ill-nourished children. But, notwithstanding that in the two latter conditions, uricæmia exists yet, despite favouring circulatory conditions, they develop no gout.

Garrod contended that the violent pain, intense inflammation, and profound constitutional disturbance of acute gout were due to mechanical irritation occasioned by the sudden deposition of biurate crystals in the delicate interior of the implicated joint. Also, that the absence of constitutional disturbance in the inter-paroxysmal periods was because the deposition of urates, being gradual, the tissues acquired tolerance, and yet, forsooth, this same substance is held responsible for the fulminant outbreak that ensues anon.

But it is, as Ringrose Gore shrewdly observed, “against the usual laws of nature that, if an irritant foreign body remains in any organ the symptoms should quickly subside, while the irritant actually increases, for after each attack, and during the intervals between the attacks, the deposits of such biurate enlarge.” In conclusion, is it not infinitely more probable, as Gore states, that the inflammatory reaction precedes the deposition of urates and that these latter, in short, are the consequence and not the cause of the gouty arthritis?

Reverting to tophi, their experimental production, it is claimed, has been achieved by His.[24] Administering alcohol to dogs and simultaneously injecting them locally with sodium mono-urate, he produced deposits which seemed identical with tophi produced spontaneously in gout. But, unfortunately, up to the present, it has been found impossible to induce their formation by flooding the circulation with urates. The utmost, indeed, that His and other workers in this sphere feel able to postulate is that uric acid is a “weak tissue poison.”[25] Scarcely the words in which to describe the poison responsible for gout! for, as we have before stated, the agent that is responsible for tophi must also be capable of inducing the arthritic phenomena and other features of the disorder.

The sum of our reflections is that the toxicity of uric acid has been grossly over-estimated, and that, like its relative urea, it is practically non-irritating and inert; in other words, it cannot any longer be regarded as the essential cause of the acute or chronic forms of gout, whether of articular or ab-articular site. Moreover, far from its presence in excess in the blood being pathognomonic of gout, it must, as Walker Hall contends, be held merely “as symptomatic of conditions which help or prevent its solubility and excretion and does not itself cause lesions which accompany uricacidæmia.”

Are the Precursors of Uric Acid Toxic?

Naturally the upholders of the uric acid theory were loth to find their fetish uric acid was allotted a meaningless rôle. That it should be deemed inert was to dislodge the very corner-stone of the imposing superstructure they had been at such pains to raise. Uric acid not responsible for the genesis of gout! But, haply, maybe their position was still unassailable; for what of the purin bases, the forerunners of uric acid? Might not the blame lie with these?