Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

Concussion iritis would fall into line, for it is possible in this case that the iris is rendered a pars minoris resistentiæ by the blow, and that the iritis which follows is due to a cryptic focus, it may be in the gastro-intestinal tract or elsewhere. The chief sources of iritis are syphilis, gonorrhœa, tubercle and infections from undifferentiated organisms of low grade. If these said iritides occur in a person of gouty diathesis they are unmodified by it clinically or pathologically, macroscopically or microscopically, save possibly in the direction of chronicity—a result, it may be, of those inherent peculiarities of tissue metabolism ingrained in a gouty subject, and in which presumably the iris shares.

And that which has been said of iritis in the gouty applies equally to other forms of so-called gouty ocular manifestations. There are no statistics available to show that there is any differential frequency in those who are gouty compared with those who are not. Authors have laboriously recorded cases of eye diseases which have waxed and waned in unison with podagrous toes, but the publication of these cases is in itself a confession of the rarity of the coincidence, a rarity which destroys the authenticity of any communal kinship. Coincidence is merely another name for the rigid and immutable law of chance, for a cycle of events which occurs with irregular regularity. If it could be shown that a diet rich in purins brought on an attack of ocular disease in gouty people, and if the experiment could be repeated with a similar result and sufficiently often to exclude all probability of coincidence, scepticism would no longer be justified. But until more definite evidence is forthcoming “gout” in the eye is nebulous.

In attempting to define the relationship of gout to ocular disease, there is one author to whose opinion we turn with the respect due to a master. Garrod’s judicial summing up supports the view that there is a connection between gout and ocular disease, but his cautious statement seems to imply that the affection of the eye is modified by rather than due to gout. His statement is as follows[56]:—

“Gout of the Eye.—A form of ophthalmia connected with gout has long been recognised, and appears to be tolerably well established, but as rheumatic inflammation of the eyes is equally allowed to exist, difficulties may at once arise in the diagnosis. I have witnessed many cases in which conjunctivitis and sclerotitis appeared to be distinctly connected with the gouty diathesis, and in two cases there existed deposits of urates on the surface; gouty iritis also occasionally occurs. I once saw a case of acute inflammation of the sclerotic coat and iris which supervened a few days after the operation for cataract in a gouty subject. By active treatment the disease was arrested, but distinct articular gout soon manifested itself.

“Our information on this subject may be thus summed up: patients having a well-marked gouty diathesis now and then experience attacks of inflammation of the different structures of the eye; and it is important to bear in mind the fact that the state of the habit considerably modifies and keeps up such affections, and also that treatment directed to the gouty condition of the system proves very effectual in curing the local mischief.”

It will be observed that Garrod tells us that his two important cases of sclerotitis “appeared to be distinctly connected with the gouty diathesis.” With the reticence of the careful and accurate observer, he does not say they were due to it even though there were deposits of urates on the surface. He would seem to recognise that cases of sclerotitis with uratic deposits were unusual events, and that generalisations cannot be based upon exceptional cases. A gouty man is gouty to his innermost cells, and the eye, like every other part of the body, is a potential uratic site. We must grant therefore that the course of an iritis, however caused, may be influenced, though not necessarily dominated, by the diathesis. Consequently it may be necessary that cases of iritis of undoubted gonococcal or other infective source occurring in gouty people should be treated by iodides, salicylates, atophan or colchicum.

From the academic point of view ocular gout may exist, but from the practical point we should invariably seek, and we shall probably find, some still more important source of infection requiring treatment.

Ocular Symptoms in Hyperuricæmia.—The popular view that gout depends upon uricæmia is so generally accepted that the expressions “uric acid diathesis” and “gouty diathesis” are tantamount to tautology. Nevertheless they are different, the first postulating the supposed cause, the second the inferred result. There is a commingling of cause and effect. Uricæmia is a normal condition of the blood, but in certain diseases—gout, leukæmia, plumbism, pneumonia, etc.—a considerable excess of urates is found. No form of ocular disease is included as an associate of hyperuricæmia unless one or other of the ancillary diseases is also present.

In leukæmia when severe there is an extremely pale fundus, with a yellowish tint; hæmorrhages, when they occur, are often pale; the choroidal vessels also, if they can be seen, are pallid; the veins in the retina are full and tortuous. There may also be yellow foci, and occasionally retinitis with white spots. In a word, the leaking vessels tell of vascular disease.

In lead-poisoning we find paralysis of ocular muscles, amblyopia, contracted fields of vision, papillitis and retro-bulbar neuritis. It is the nervous system upon which the stress principally falls.