Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

So much for the broad outline of the picture presented, but a still closer scrutiny is called for. The deformities produced are the outcome of uratic deposits, which, as Charcot long since pointed out, take on the shape of “irregularly rounded or ovoid swellings, bunched, and either large at the base or just the opposite, i.e., provided with a pedicle.”

As shown in the coloured plate, the favourite site for their development is the dorsum of the hand or the vicinity of the metacarpo-phalangeal or mid-phalangeal joint. The resultant disfigurement of the hand is very characteristic. Irregular tuberous swellings surmount the knuckles, and spreading laterally, obliterate the fossæ between them and their fellows. The same extend forward over the first phalanges, from nigh the distal end of which again arise similar bossy excrescences over the mid-phalangeal joints. Encroaching thus upon the length of the first phalanx from either end, but little of its shaft is ultimately left exposed. In like fashion the mid-phalanx may be buried in uratic deposits, its contour wholly lost; and, the terminal phalanx participating, the digits become almost pedunculated, the nails projecting from the ends thereof—the “parsnip hand” of Sydenham. Such is the appearance presented in inveterate chronic gout.

Fortunately such examples are relatively rare, and a study of the condition in its earlier stages reveals some interesting features. The uratic deposits, it is important to note, are not located exactly at the level of the articulation. Unattached as they are to the articular ends, they are not compelled to, nor do they in any way, adapt themselves, as it were, to the contour or shape thereof. In short, the tophaceous formations are erratic, are not like osteo-arthritic nodules, erupted from and continuous with the articular bone ends. Again, relatively independent of the contiguous tissues, they, unlike osseous outgrowths, are slightly movable in lateral directions.

When of recent incidence, their consistence is soft, and, be they never so ancient, they do not attain the density and hardness of bony outgrowths. The overlying skin, to which they are sometimes adherent, takes on a peculiar glossy and satin-like texture, its dusky pink blotched with spots of dead white colour, i.e., subjacent uratic deposits.

In other particulars also they differ from bony outgrowths. The tophaceous masses may soften and disappear after exacerbations of arthritis, and others may form at different sites. Following such absorption or difference in their location, some increase in joint mobility may happily ensue. This same fortunate occurrence may follow discharge of the uratic masses through ulceration and perforation of the skin.

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.