Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

Gout in Relation to Phlebitis

It is to Sir James Paget that we are indebted for recognition of the fact that phlebitis occurs with significant frequency in gouty subjects. This great surgeon held that the disorder was the outcome of a modification or transformation of gout, the result of “morbid conditions changing and combining in transmission from parents to offspring.” At the present time some regard it merely as a complication of gout, others as one of the irregular manifestations of the disease.

It occurs most commonly in men, women being rarely the subjects of gouty phlebitis. It may install itself insidiously with but mild local discomfort, and yet on examination a cord-like hardness is detected. In others it announces itself with pain, in rare instances intense, this more commonly if the deep veins of the calf are its seat.

Its predilection is for the veins of the lower extremity, the superficial rather than the deep vessels. If the former, a faint blush over the affected veins may be seen, but if the deep veins, then œdema and tenderness may be the sole token of its presence.

Frequently the phlebitis is patchy in distribution and migratory. Thus, as Paget says, it may on one day be located in a short length of the saphenous vein, flitting the next day to some other portion thereof, or, it may be, to the corresponding vein of the opposite limb. This tendency on its part to metastasis and symmetry led Paget to the conclusion that “the essential and primary disease is not a coagulation of the blood, but an inflammation of portions of the venous walls.”

Its duration is not uncommonly prolonged, and it displays a marked tendency to recurrences, the latter determined by blows, unusual exertion, or, according to some, exposure to cold. Most cases end favourably, but death from embolism sometimes occurs. Occasionally, given occlusion of the large veins, some degree of swelling lingers permanently.

The instances most indicative of a gouty origin are those in which the veins of a limb, the seat of acute gout, are simultaneously attacked by phlebitis. In three cases of this nature recorded by Garrod, the subjects, despite their suffering from acute articular gout, persisted in leaving their beds to record their votes in the parliamentary election of 1884. This type of case, according to Garrod, is usually confined to men, and, with the exception of the cases above noted, a varicose condition of the veins of the legs of long standing existed in his series of examples.

Garrod recognises in addition a second type, in which phlebitis, “usually of a much less acute character, ensues without the previous development of gouty inflammation in the neighbourhood of the part.” Here we may recall that, according to Paget, the incidence of phlebitis in an elderly person without any external cause warrants the suspicion of gout. Perhaps the chief justification for such an assumption rests on the fact that phlebitis appears sometimes to be hereditary. Paget cites the instance of a man who suffered from phlebitis of both saphenous veins during an attack of acute gout. On the maternal side his mother, two uncles, a grandmother, and two cousins had been the subjects of phlebitis.

In conclusion, for myself, I would suggest that the term “gouty” phlebitis be restricted to those instances in which a limb, the seat of acute articular gout, is complicated by phlebitis of the veins of the affected part. Here we are dealing with what is palpably an extension of the gouty inflammation from the affected joint to the veins, and which, I venture to assert, is strongly confirmatory of the view that an infective element intrudes in “gouty” arthritis. We may recall that, e.g., gonorrhœal phlebitis of the lesser saphenous veins is not so uncommon, while the frequency with which phlebitis complicates infections calls for no emphasis.