Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

[25] Because the gouty tophi do not suppurate, even when ulcerated, through the skin, it has been suggested that the urates have antiseptic properties. Bendix (Zeit. klin. Med., 1902 (44), 165), however, could not demonstrate such antiseptic properties experimentally.—Gideon Wells.

[26] Levinthal, in a personal experiment, injected half a gram of xanthin dissolved in piperazine into his cubital vein. A few days later, after a moderate strain upon the limbs through dancing, he was suddenly seized with a fairly acute painful attack in one of his knees, attended with some swelling and local heat.

[27] “Tophi sometimes precede by some years ... the development of gouty attacks in joints. The same is true also of auricular tophi.”—Duckworth: “A Treatise on Gout.”

[28] “While, however, tophaceous concretions generally show themselves after attacks of articular gout, cases occur, as I have already told you, in which the secretion of calcareous matter takes place irrespective of any arthritic attack. This sort of cutaneous gravel, if I may employ a comparison based on the great analogy between the composition of urinary gravel and tophaceous concretions, gravel of the skin, constitutes the sole manifestation of the diathesis, and is accompanied merely by a slight feeling of pain, of pricking unattended by any disturbance of the general health.”—Trousseau’s “Clinical Medicine.”

[29] Redness of the skin overlying a developing tophus is not invariable. In a case recently under my care, the dorsum of the mid-phalangeal joints was the seat of small soft localised swellings. The superjacent skin was unchanged in colour. Aspiration of the contents by a hypodermic syringe disclosed the presence of a turbid white fluid, which, when microscopically examined, was found loaded with the acicular crystals of sodium biurate.

[30] “Quod in omnibus podagricorum paroxysmis solemne est, insignior intumescentia venerum membro vexato intertextarum se in conspectu dat.”—Sydenham.

[31] Sydenham’s classical description: “Towards the end of January or the beginning of February suddenly, and with scarcely any premonitory feelings, the disease breaks out. Its only forerunner is indigestion and crudity of the stomach, which troubles the patient for some weeks previous to the attack. His body also feels swollen, heavy, and windy—symptoms which increase from day to day until the fit breaks out. But a few days before this torpor comes on, and a feeling of flatus along the legs and thighs. Besides this, there is a spasmodic affection, whilst the day before the fit the appetite is unnaturally hearty. The victim goes to bed in good health and sleeps. About two o’clock in the morning he is awakened by a severe pain, generally in the great toe, more rarely in the heel, ankle, or instep. This pain is like that of a dislocation of the bones of these parts, and is accompanied by a sensation as of chilly water poured over the membranes of the suffering joint. Then follow chills and shivers and a little fever. The pain, which was at first moderate, becomes gradually more intense, and while it increases the chills and shivers die out. Every hour that passes finds it greater, until at length at night-time it reaches its worst intensity, and insinuates itself with most exquisite cruelty among the numerous small bones of the tarsus and metatarsus, in the ligaments of which it is lurking. Now it is a violent stretching and tearing of the ligaments, now it is gnawing pain, and now a pressure and tightening. So exquisite and lively meanwhile is the feeling of the part affected that it cannot bear the weight of the bedclothes nor the jar of a person walking in the room. Hence the night is passed in torture and a restless rolling first to one side, then to the other, of the suffering limb, with perpetual change of posture, the tossing about of the body being as incessant as the pain of the tortured joint, and being at its worst as the fit is coming on. Hence the vain efforts by change of posture, both in the body and the limb affected, to obtain an abatement of the pain.

“This comes only towards the second or third hour of the morning (a whole day and night after the first outbreak of the fit), such time being necessary for the moderate digestion and dispersion of the peccant matter. The patient then has a sudden respite, which he falsely attributes to the last change of position. A gentle perspiration is succeeded by sleep. He wakes freer from pain and finds the part recently swollen. Up to this time the only visible swelling has been that of the veins of the affected joint. Next day (perhaps for the next two or three days), if the generation of the gouty matter have been abundant, the part affected is painful, getting worse towards evening and better towards morning. A few days after the other foot swells, and suffers the same pains. The pain in the latter regulates the state of the one first attacked, for the more acutely it is tortured the more perfect is the abatement of suffering and the return of strength in the other. Nevertheless, there is a repetition in the second case of all the misery of the first both as regards intensity and duration. Sometimes during the first days of the disease the peccant matter is so exuberant that one foot is insufficient for its discharge. It then attacks both, and that with equal violence. Generally, however, it takes the feet in succession. After it has attacked each foot the fits become irregular both as to the time of their coming and as to their duration. One thing, however, is constant—the pain increases at night and abates in the morning. Now a series of lesser fits like these constitute a true attack of gout, long or short, according to the age of the patient. To suppose that an attack two or three months in length is all one fit is erroneous. It is rather a series of minor fits. Of these the latter are milder and more limited in their extent than the former, so that the peccant matter is discharged by degrees, and recovery follows. In strong constitutions, when the previous attacks have been few, a fortnight is the length of an attack. With age and impaired habits gout may last two months. With very advanced age, and in constitutions very much broken down by previous gout, the disease will hang on till the summer is far advanced. For the first fourteen days the urine is high-coloured, has a red sediment, and is loaded with gravel. Its amount is less than a third of what the patient drinks. During the same period the bowels are confined. Want of appetite, general chills towards evening, heaviness, and a troublesome feeling even in the parts which are free from the attack, attend the fit throughout. As it goes off the foot itches intolerably, mostly between the toes; the cuticle scales off, and the feet desquamate, as if venomed. The disease being disposed of, the vigour and appetite of the patient return, and this in proportion to the violence of the last fits. In the same proportion the next fit either comes on or keeps off. Where one attack has been sharp, the next will take place that time next year, not earlier.”—Sydenham.

[32] “Pain is better borne by the poor man, as I have had opportunities of seeing, than by the man who acquired or promoted his gout with two or three bottles of port wine daily, with the surroundings which such luxury implies.”—Longstreth, “On Gout.”

[33] “The pain is altogether disproportionate to the other signs of inflammation, and, even more, to the consequent structural changes in the inflamed part.”—Paget.