As to the peculiar character of the pain, Duckworth states: “Nothing at all like it occurs in any other joint disease.”
[34] Sydenham noted that “sometimes the morbific matter is thrown upon the elbows and occasions a whitish swelling, almost as large as an egg, which becomes gradually inflamed and red.”
[35] “Regular gout may supervene suddenly, and be chronic; that is to say, its outbreak need not have been preceded by paroxysms in any way characteristic of acute gout.”—Trousseau, “On Gout.”
[36] As Trousseau puts it: “Regular chronic gout, in respect of the frequency of the recurrence of the paroxysms, resembles acute gout with successive paroxysms, there being this capital difference, however, that its attacks are longer and during the intervals are not entirely absent.”
[37] Mr. James Moore, surgeon to the Second Regiment of Life Guards (Medico-Chirurgical Transactions, 1809, Vol. I.):—
“This effusion” (meaning the milky fluid containing the urate of soda) “occurs not only during fits of gout, but likewise in the intervals; and as the extremities, particularly the hands and feet, are the principal seat of gout, it is there the greatest accumulation of chalk takes place. Though this process is usually preceded and accompanied by inflammation, the chalk is never inclosed in a cyst, like pus in an abscess. It lies usually in the cellular membrane, in the bursæ mucosæ, or in the cavities of the joints. I have even seen it thrown out between the cutis and the cuticle. But, as the gouty inflammation is of the erythematous kind, there is no extravasation of coagulable lymph, and no new-formed covering surrounding the chalk. This point is of the first importance, and explains many of the peculiarities of gout, which is generally considered as a phlegmon. But the absence of coagulable lymph in the inflamed parts I consider as full evidence of the inflammation being erythematous.
“The chalky liquid when first secreted gives to the finger the feeling of fluctuation, and cannot be distinguished from the ordinary serous effusion of gout. But unfortunately the absorbents cannot suck up the chalky particles. The consistence of the liquid therefore becomes thicker and thicker, till at last nothing remains but a hard mass. When even a considerable effusion of this kind occurs, the quantity of chalk which ultimately remains is comparatively small, as by far the greater quantity is merely serum. It therefore usually requires repeated effusions to form any great mass of chalk, and the consistency depends upon its age and the activity of the absorbents. The quantity at last accumulated by repeated paroxysms is in some instances immense, which augments very seriously the sufferings of the gouty. The distress, however, is not owing to any irritating quality in the chalk, but to its obstructing the motion of the tendons and joints, occasioning often complete anchylosis, and pressing and distending the surrounding parts by its bulk. It acts, therefore, by mechanically embarrassing the machine of the body, and not upon the living principle, for it will often remain for years in parts highly sensible without exciting the slightest pain or inflammation. Although these concretions are of so mild a nature, they often are the cause of extensive mischief, bursting externally, occasioning ulcers very difficult to heal. When a violent fit of the gout attacks a chalky tumour, the appearance is frequently very alarming, the new paroxysm being accompanied with a fresh serous and chalky effusion, which, added to the old deposit of chalk, occasions a prodigious swelling; the cutis when distended to the utmost opens, yet sometimes the cuticle remains entire. The chalky or serous liquid may then be seen through the semi-transparent epidermis. The surrounding integuments appear of a deep red, or of a purple hue, threatening mortification, while the pain is excruciating.
“At length the cuticle gives way, a discharge of serum and chalk takes place, and a remission of all the symptoms usually follows. During the whole of this alarming process suppuration never occurs; but soon after the opening has taken place suppuration commences, and pus and chalk are then discharged from the ulcer. There are several unexpected occurrences in the progress of such ulcerations. When an opening is formed, the whole of the chalk never escapes, and its complete evacuation is often a very tedious process; this is owing to its being diffused through the cellular membrane, as in the cells of a sponge. One cell must sometimes give way after another, and small portions of chalk are successively thrown out, so that months and even years pass away before the whole is discharged. It also frequently happens that the orifice contracts and closes over, leaving portions of chalk underneath. This kind of cicatrix sometimes stands its ground, but more commonly breaks out again and again to discharge chalk. Even openings into joints, which are so dangerous when occasioned by other extraneous bodies, are often attended with no serious symptoms when the joint is filled with chalk. On such an accident happening a surgeon unacquainted with these peculiarities might be tempted to propose large openings, or even amputation, as the only resource for hindering extensive inflammation and carious bones. But if he treats the disease mildly, he will find that no such severe plans are requisite, for the parts will probably fall into a very tranquil or indolent state; a sore will continue for a certain period, discharging pus, and occasionally a bit of chalk, till at last the orifice will close up. Independent of the opening formed by a fit of the gout, the skin, stretched over a mass of chalk, is sometimes thinned, absorbed, and pierced by mere pressure. At other times this is effected by common inflammation and suppuration. When openings take place in these milder ways, a less quantity of chalk is usually evacuated; but this depends entirely upon the degree of inflammation. When the suppuration is great, it naturally detaches and washes out a greater quantity of chalk.
“The last peculiarity is the rarest, namely, that a dry, hard piece of chalk shall pierce the skin, and remain like an excrescence, without exciting either inflammation or suppuration.”
[38] According to Adler, about one-tenth as much uric acid is excreted in the sweat as in the urine, sweat containing 0·1 mg. per cubic centimetre.