Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

What occupation does he follow? What are his habits? Is he of the “idle rich” who “fare sumptuously every day”? Is he a plumber, a painter, or a butler, coachman, or club waiter, these last being men who, as Sir Thomas Watson observes, “often live more luxuriously and more idly a great deal than their masters”? In short, we must search for any evidence of overeating, overdrinking, and indolence. For of this triad of vices is gout too oft begotten.

As to illnesses, his past may tell of classic outbreaks, one or more in the great toe, and if to this be added a visible tophus, we stand face to face with a “gouty diathesis.” More eloquent this than a “cloud of witnesses” as to previous attacks of migraine, asthma, eczema, etc. All these and more may emerge during the subject’s recital, and by all means let them be ascertained. But forget not that they often arise in the non-gouty. Above all, though, miss not the significance of heightened blood pressure, a cardiac lesion of degenerative type, sugar or albumen in the urine. For these are of the things that will out, but let it not be to our discomfiture!

Even presuming that all facts and observations up to now point to a “gouty” origin of the arthritis, the end is not yet. What has evoked the arthritis? We seek a cause. For to call an arthritis “gouty” is but to restate the problem. How clear the need then for a meticulously careful investigation, in the hope of achieving not a merely nosological, but an etiological, diagnosis.

To narrow our field, we should, in the first place, exclude gonococcal infection, and failing this, influenza, syphilis, or any of the zymotic or other disorders prone to be followed by or associated with joint affections.

If none of such be forthcoming, we should search for local foci of infection. The mouth and its accessory cavities first claim attention. It should be closely scanned for the presence of oral sepsis, the most fruitful source of which is pyorrhœa alveolaris. If dentures are worn it is wise not to take the subject’s word that all his teeth have been extracted. Like others, I have in such found the broken-off stumps still in situ. The condition of “bridges” should be noted, fruitful sources of sepsis as they are. Clinical examination of the mouth may prove inadequate, as buried roots, cysts, or abscesses, not to mention alveolar rarefaction, etc., demand for their detection radiographs.

The pharynx and tonsils should be thoroughly investigated, for disorders of these same are by no means uncommon in “gouty” subjects. Any history of aural or nasal discharges demands the same careful local examination; and, needless to say, the same course must be pursued in regard of any local infections of the genito-urinary passages. In short, in gouty, as in non-gouty, forms of arthritis, thorough and routine examination of every patient by modern bacteriological methods is imperative.

Ignorant of the precise etiology of gouty arthritis, we can ill afford to overlook any associated infective foci which may prejudice the well-being of the victim, as, for aught we know to the contrary, we may be overlooking the very fons et origo mali. Compare our attitude towards other arthritides of cryptic origin, how systematic our search for infective foci, and what a light has thereby been shed on their intimate etiology!

Here may we lodge a plea for routine examination of the blood in all cases of gout? For, as shown, the findings, leucocytosis, etc., have doubtless some profound significance. Apart from this, the routine employment of complement-fixation tests for the organisms responsible for local infections might illumine the obscurity that overhangs this complex problem of their relationship to remote pathological lesions.

If up to now our search for local foci prove futile, it remains for us to note the presence or absence of functional derangements of the alimentary tract, or its accessory glands. We must not, because we think perhaps that the patient “looks gouty,” assume that his dyspeptic symptoms are of like origin. It is our duty to ascertain, if possible, the precise nature and origin of the dyspepsia.