In the palms of the hands and the pulps of the fingers, the knuckles and phalanges, tophi are found not infrequently; and Trousseau tells of a lady of sixty in whom the cutaneous palmar folds of both hands were “marked with radiating white lines such as are seen in those who have long been employed in tempering plaster.”[38] Similar deposits have been noted in the plantar surface of the feet.
Reverting to the trunk, uratic deposits have been found in the scapular region, also in the perineum. I have twice seen tophi in the corpora cavernosa of the penis. In the face, apart from the ears, they have been found in the alæ of the nose. In the eyelids Duckworth noted uratic deposits in streaks resembling xanthoma; they were chemically tested, and proved to be of this nature. Speaking of “gout in the eye,” Garrod states: “I have witnessed many cases in which conjunctivitis and sclerotitis appear to be distinctly connected with the gouty diathesis, and in two cases there existed deposits of urates on the surface.”
As before stated, we recognise only one type of gout, viz., the tophaceous variety. But even so it must be noted that in some instances the process of tophus formation is greatly accentuated. In other words, the tophi may not only be of prominent size, but of unusually widespread distribution. Indeed, poetic exaggeration has it that one Baylas and one Acragas were entombed while alive in their own uratic deposits. But, apart from such imaginative flights, there are unquestionably some cases in which tophi are most widely diffused. Thus Plater tells of a patient whose whole body, even the eyelids, was studded with them: “ex toto corpore, per poros, adeo ut etiam palpebræ oculorum non exemptæ fuerint, ejusmodi materia gypsœa, circa poros cutis mox in tophos mutata, prodisset.”
These cases of multiple tophi are far more common in men. Duckworth met with some well-marked cases in women. They may occur also in persons who have been lifelong abstainers. Sometimes trauma seems to have played a part in determining their localisation. Garrod held that, given prodigious uratic deposition, the kidneys might be held as unsound and undergoing sclerosis; and, according to Duckworth, the rule commonly holds good.
Affinities Between Gout and Other Diseases
Whatever be the explanation, no fact in practical medicine is better established than this, viz., that certain disorders are peculiarly liable to arise in gouty subjects. Of these the more noteworthy are glycosuria, phlebitis, certain cutaneous disorders, and nephritis. While, for myself, I prefer to regard these affections as merely diseases to which the gouty are especially subject, nevertheless each and all of them, by one authority or other, have been classed as among the irregular manifestations of gout.
This, on the assumption that these several morbid entities may precede, alternate with, or follow arthritic seizures, frequently also on the basis of their alternation in hereditary transmission with arthritic gout. Thus, in a family of marked gouty proclivity, while one son, despite a temperate life, may have severe articular gout, on the other hand his brother may suffer only with irregular manifestations, i.e., phlebitis, eczema, etc.
As to whether these particular disorders, phlebitis, glycosuria, etc., are directly caused by the toxin of gout, or whether their not infrequent association with gout is merely accidental, is a moot point. But to the sources of fallacy in this connection we shall allude more in detail when dealing later with irregular gout. Meanwhile extended knowledge of the intimate etiology of phlebitis, glycosuria, etc., tends to an attitude more critical than that of our forefathers, who, faute de mieux, relegated a large number of conditions whose pathology was inexplicable to the nebulous domains of irregular gout.
Gout in Relation to Glycosuria
That some obscure link existed between glycosuria and gout was long since suspected. Prout noted it as far back as 1843, and Bence Jones discussed the subject under the title “Intermitting Diabetes” (1853), while in the following year Gairdner announced that he had long surmised the kinship between the two disorders. About the same time Claud Bernard remarked that gout and glycosuria might alternate, and so did Trousseau, and many since that day have ranked glycosuria as one of the forms of irregular gout, whether legitimately or not is an open question, but at any rate it does not affect the established clinical fact that glycosuria occurs with significant frequency in gouty individuals.