Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

In pneumonia we do not expect to find any ocular complications; in spite of the uricæmia, the eyes are scatheless.

It seems unlikely that hyperuricæmia can produce such widely different signs in the eyes. Rather, on the other hand, the ocular symptoms conform to the type we should expect to find associated with leukæmic blood in the first and with lead-poisoned nerves in the second.

In this congeries of ocular symptoms, marked by hyperuricæmia, we do not find iritis included, and yet this is a commonly accepted gouty affection of the eye.

False Gout.—It often happens that patients tell us that they are gouty although they do not claim to suffer from attacks in the old-fashioned way. With them there is a wide difference between the substantive “gout” and the adjective “gouty,” the latter apparently implying an attenuated form of the former. Such patients are seen at health resorts and are very frequently those in whom obesity and plethora are present to a marked extent. The full-blooded appearance involves the head, body and limbs, but the eyelids, for some unexplained reason, may escape. The patients have lived not wisely, but too well. On examination an increased quantity of uric acid in the urine is found, and is supposed to justify the diagnosis of gout. Sometimes the malassimilation, is associated with arterio-sclerosis, with diabetes, or with albuminuria. But the patient is almost invariably convinced that he has gout, that it is hereditary, that it has been handed down to him through a long line of ancestry from primeval days, and that an ascetic life would not have prevented it in his case.

Should such a one be attacked by iritis, the circularity of the argument is complete: he has iritis, therefore he is gouty; he is gouty, therefore he has iritis. But usually in the early days of this so-called gout we see no ocular changes; the time for organic disease (inflammatory and hæmorrhagic) has not yet arrived; auto-intoxication has not yet begun. But sooner or later with the maturation of disease come ocular degenerative signs, retinal hæmorrhages, and so on. The sequence is malassimilation, “goutiness,” sub-infection, ocular disease. Thus in diabetes melitus (omitting toxic and traumatic forms) we find pancreatic disease, nutritional changes, and not usually until late retinitis, cataract, iritis, etc. In renal disease retinitis is also late and often ushers in the final scene.

If in these cases of so-called gout we implicitly accept the patient’s nomenclature of disease, we shall find plenty of gouty iritis, but we may overlook the fundamental condition of his arteries, of his kidneys, and of other organs.

The sins of repletion in such patients may be relieved by the virtue of abstinence, not by colchicum.

Retinal Hæmorrhage.—That retinal hæmorrhage may be caused by gout was firmly maintained by Jonathan Hutchinson.[57] This opinion was shared by Gowers, who states that the “influence seems well-established.”[58]

Hutchinson pointed out that in cases of retinal hæmorrhage of renal origin, stellate white deposits occurred, whereas in gouty cases they were absent. By this criterion he classified his cases. In his first patient Hutchinson relates that he can only state from memory that there was no albumen, but that “he seemed in good health and that there was reason to suspect gout, although he had not had a definite attack.” In his second case, a woman who had suffered from rheumatic gout and true gout, there were numerous hyaline casts in the urine, but no albumen. In both cases the hæmorrhages were flame-shaped, and Hutchinson lays stress on the shape in gouty retinitis hæmorrhagica. The group consisted of fifteen patients, eleven men and four women. “Gout had been positively present in six, and was strongly probable in four or five others. In one the gout was complicated, and probably in part produced, by lead poisoning, and this is the only instance in which the urine contained much albumen. In another in which no history of gout was obtained, the patient, a man æt. 67, had diabetes, which was the probable cause of the retinitis.... In about a third of the cases albumen was found in the urine, but it was usually a mere trace and only present occasionally.... In four, including the case of diabetes, white deposits characteristic of renal retinitis were present in small quantity, and in all these albumen was found in the urine.”

Hutchinson sums up his cases with the catholic observation that retinitis hæmorrhagica is a malady the boundaries of which are very indefinite. And when we bear in mind the changes of modern medical opinion with regard to the influence of arterio-sclerosis on the retinal circulation and the effects of vascular hypertension the etiological difficulties regarding retinal hæmorrhages are hardly less illimitable than they were when Hutchinson penned his valuable contribution. In all his cases (as in those which we see now forty-two years later) there are many factors which may have been responsible for the hæmorrhages apart from gout.