Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

The evidence that a relationship exists between irregular and regular manifestations of gout rests upon the following sequences and alternations of clinical events:—

(1) The subsidence or disappearance of functional visceral derangements following the development of articular gout;

(2) Their occurrence directly after an articular paroxysm has been apparently suppressed;

(3) Their recurrence and alternation with arthritic outbreaks, this in some instances repeatedly;

(4) Lack of any appreciable cause for the functional derangements and their indefinite anomalous character;

(5) Their favourable response to specific gouty therapy.

As before noted, digestive troubles frequently precede the initial outbreak of articular gout. The same likewise are frequent in chronic cases between the intervals of arthritic seizures.

Now it has been customary to regard the alimentary or other disturbances that precede an initial articular attack as “gouty,” and likewise those that intervene between the gouty paroxysms in long-standing cases. In other words, in light of the subsequent articular outburst, what was mysterious ceases to be a mystery. All the vague “acidities, flatulencies, megrims, and biliousnesses, of whatever occult kind,” are forthwith hailed as “gouty,” this merely upon the ground of the sequence of clinical events, because the symptoms have disappeared from, e.g., the stomach to reveal themselves in the joint or joints, or vice versâ.

Now my own view is that the antecedent hepatic or digestive disturbances that so frequently precede initial attacks of gout are in all probability, nay assuredly, not gout. They should rather be regarded as the cause, the foundation, of the malady than its effect, a cause inoperative save in the presence of individuals victimised by inherent morbid tissue potentialities. For similar symptoms are but too common in the non-gouty. They are very common antecedents of, e.g., rheumatoid or atrophic arthritis. Nevertheless we do not when the arthritic disorder subsequently manifests itself talk of the preceding digestive disturbances as “rheumatoid” dyspepsia. Then why this presumptive and retrospective diagnosis of similar prodromal phenomena as “gouty” dyspepsia? For there is pending the articular outbreak nothing distinctive in the digestive derangements, nothing that would enable us to diagnose them as “gouty.” They might, for aught we know, be significant of oncoming rheumatoid arthritis.