Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

As to the respiratory organs, such chronic maladies as bronchitis and asthma are very frequent in the “gouty,” but I question if they are more so than in non-gouty subjects. In any case their symptomatology and course are the same whether gout be present or not. Much, too, has been made of the fact that asthmatic and arthritic manifestations may alternate. But we must recollect that asthma per se has a paroxysmal tendency; it has a tendency to periodicity and a liability to be excited or aggravated by much the same factors as favour outbreaks of gout. It is said, too, that there is a “gouty” pneumonia, and that the same has been replaced by an acute articular paroxysm. But, in respect of all these alleged “gouty” respiratory disorders, would it not be more scientific to cease talking of them as “gouty” and instead to speak of them as bronchitis and asthma occurring in “gouty” subjects? This, I may remark, is not to say that we should take no count of the reigning diathesis in our treatment of all associated affections.

Of the nervous phenomena relegated to gout we hear nowadays less and less. “Gouty” headaches are almost a thing of the past. The acute “gouty” delirium of older writers in many cases was but an euphemism for alcoholism, and likewise the spinal paralyses; while the convulsions and comas were certainly almost always attributable to uræmia. It would be held rash to-day to speak, like our forefathers, of “gouty” cystitis, urethritis, or orchitis, for there is no evidence of any pathological connection between them; and the same stricture is also applicable to the many cutaneous affections affiliated without sound pretext to the materies morbi of gout.

In the early part of the nineteenth century the French school were most insistent on the prevalence and variety of the cutaneous manifestations of l’arthritisme; but even by them the all-pervading influence of gout in the etiology of skin disorders is no longer held even as a working hypothesis.

Conclusions.—The sum of my experience and reflections on so-called “irregular” gout leads me to regard it as an “abstraction” rather than as a proven clinical fact. Moreover, if I may judge by the “admission certificates” to the Royal Mineral Water Hospital, Bath—a fair test, as I maintain—many are of the same mind as myself, for during the past ten years I do not recall a single instance in which a patient sought admission thereto as suffering from “irregular” gout.

But some writers on gout—indeed, I think I may say all—whatever doubts they entertain as to the propriety of retaining the term, yet qualify their pronouncement in favour of some particular variety of anomalous gout, visceral, cutaneous, or other. Still, in justification of my own uncompromising attitude, I must say that dispassionate analysis of their eclectic claims, in light of present day knowledge, to my mind fails to show any adequate reason for the faith that is in them. Of some of them I feel sure that sub-consciously they have been influenced by a respect for tradition, forgetful of Pliny’s sentiment,—

“Quamvis enim cedere auctoritati debeam, rectius tamen arbitror, in tanta re, ratione quam auctoritate superari.”—Lib. i., Ep. 20.

But, to resume, this much at any rate may be affirmed, viz., that there is no proof that visceral disturbances or cutaneous disorders are due to uric acid. On the other hand, in view of my contention that the inherent morbid potentialities of the “gouty” demand for their fruition the intervention of an infection, the reader may rightly ask whether the same agent may not be capable of evoking the visceral or cutaneous, as opposed to the arthritic, manifestations of gout.

Trousseau, a whole-hearted advocate of irregular gout, drew an analogy between gout and syphilis. Somewhat contemptuously he observes: “To those physicians in whose eyes localisation constitutes the particular disease the differences in appearances are so many different diseases, while to those who consider that the disease consists much more in the aggregate of the general phenomena, in their evolution, in their progress (and that, thank Heaven! is the direction in which sound observation leads), these affections, differing in appearance, are only multiplied expressions of the same species of morbid action. To the real physician exostosis, alopecia, psoriasis, roseola, bubo, and chancre are always syphilis—syphilis in different garbs.” In the same way he held that the infinitely varied manifestations of irregular gout were all affiliable to one and the same morbid agent. He claimed, too, that visceral gout was “the result of a sort of imperfect inflammation analogous to that which manifests itself in the joints.”