Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

Albeit, much remains to be done before we can claim to fulfil the demands of ideal treatment of gout. For we are still ignorant of its exact etiology, cannot yet boast of our control of the morbid potentialities that constitute the pathological groundwork of the malady. We cannot obliterate the diathesis, and must still deplore with Sydenham that “as for a radical cure, one altogether perfect, and one whereby the patient might be freed from even the disposition to the disease, this lies, like truth, at the bottom of a well; and so deep is it in the innermost recesses of nature that I know not when or by whom it will be brought forward into light of day.”

But although we cannot dissipate the inherent proclivities to the disorder, we can, I think, claim to fulfil the humbler rôle, viz., obviate their coming to fruition. Haply in the fulness of time we may be able to influence the endogenous factors that make for gout, may through the labours of the bio-chemist be able to translate or assess them in terms of functional inefficiency of this or that particular viscus. But meanwhile we must perforce content ourselves with the eradication or control of the exogenous factors of gout—the excitants whereby or through whose agency the malady from being latent becomes manifest and overt.

Radical Treatment of Local Foci of Infection or Toxic Absorption

When discussing the etiology of gout we emphasised the probability of the intrusion of an infective element in its genesis. We commented, too, on the extreme frequency with which local infective foci are encountered in gouty subjects and the imperative necessity of their early recognition and radical treatment. In doing so, we but conform to what should be regarded as the salient canon in the treatment of any form of arthritis, viz., a diligent search for a focus of infection. A monarticular arthritis, such as gout in its initial outbreaks almost invariably is, calls for the same painstaking investigation as a polyarticular, for one never knows when the former may merge into the latter. Nor, if we find one focus, should we rest content, assuming that this is the only one of significance. For in many instances there are probably several foci. Thus, how frequently are septic teeth conjoined with tonsillar and aural troubles, and, as modern investigation shows, these, again, may be associated with remote foci in gall bladder, appendix, etc.

To begin with, a thorough examination of the mouth and nasopharynx is essential. During the inspection any artificial dentures must be removed, lest we overlook concealed and septic stumps. “Bridges,” again, are a notable source of sepsis. The roots upon which they are fixed or the related gums may be infected. Phlebitis, as we know, is a common associate of gout, and C. A. Clark, emphasising the septic potentialities of bridges, cites an obstinate case of phlebitis which only cleared up after removal of a filthy device of this nature.

Again, devitalised teeth that have been “crowned” should always be suspect. Infection at the root is common, with abscess formation. Such are not necessarily painful, and may give no indication of their presence until they find an exit of discharge, maybe by a gumboil or viâ the antrum, etc. These abscesses around the apices of non-vital teeth are difficult of diagnosis in their early stages. Even the X-rays may fail to detect them when minute, this owing to the small amount of pus, or because abstraction of the lime salts from the bone has not proceeded to an extent that may be appreciable by skiagraphy. The first indication of their presence is a small area of rarefaction in the bone around the apex of the root.

It is important to recognise that teeth that appear sound upon external examination are not necessarily so. In short, ordinary clinical examination may be quite inadequate. Not only must the condition of the “crowns” of the teeth, but that of their roots also, be ascertained. For when we reflect that, in addition to abscesses, cysts, buried roots, inflamed and impacted molars may be present, we see, if we are to achieve a full and accurate diagnosis, radiographs of the jaws are essential. A single-plate negative is practically of no value. A series of films taken all round the mouth is the only satisfactory procedure. Such give finer detail, and show up the interstices of the teeth—the sites of predilection for periodontal disease or pyorrhœa alveolaris.

Passing to pyorrhœa alveolaris, which has been defined as the twentieth century scourge, it cannot be denied that if all the evils attributed thereto are to be nipped in the bud, then X-ray examination of the teeth must be resorted to at a much earlier stage than it commonly is. Clean as well as unclean mouths fall a prey thereto, and, as a rule, investigation of the teeth is an after-thought, this particularly in the subjects of gouty arthritis. Usually the gout has been in full swing for years. The patient’s dyspeptic symptoms have been dismissed as “gouty,” and “alkaline stomachics,” etc., have been his lot, though his teeth may be in a foul condition—one which would not have been tolerated probably in any form of arthritis other than “gouty.”

But if to diagnose pyorrhœa alveolaris in its early stages we must needs invoke radiography, on the other hand we should be careful not to overlook its presence when advanced. The gums may be pale and shrunken, at other times red and swollen and very prone to bleed. When pockets form round the teeth, pus and blood may be expressed. Probing may not reveal their true depth, whereas X-rays do.