Llewellyn J. Llewellyn

“ How elated we are, and rightly, when in an obscure form of arthritis we pounce on these objective criteria of gout, how apt to deem our diagnostic quest as ended, and with what fatal glibness the time-worn “gout” slips from our lips, sure, alas, of ready and almost complaisant acceptance. Fallacious inference, all too prevalent, that the presence of tophi stamps any concomitant arthritis as “gouty.” ”

“ In the history of gout it has ever been so, the changing, oftentimes contradictory, vogues in treatment, always the reflex of equally mutable and conflicting views as to its pathogeny. For who can doubt that the facts of pathology supply the indices of rational as opposed to empirical methods of therapy?
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. ”

“ Despite the fact that heredity plays so dominant a rôle in the genesis of gout, how relatively scanty the attention paid to prophylactic measures! It is the second, never the initial, attack of gout that we endeavour to avert. Surely to inhibit the development rather than to prevent the recurrence of the malady is the better part. The idea is not wholly utopian, for such shrewd observers as Scudamore, Austin Flint, and others, were convinced that by timely and judicious intervention a threatened outbreak might be averted or at least its severity mitigated. ”

“ Indeed, ignorant as we are of the exact etiology of gout, we must at any rate provisionally attribute the proved efficacy of water-drinking in gout to its flushing action on the tissues, its furtherance of the excretion of waste products. Nor can we doubt that the ingestion of hot water, involving as it does equalisation of its temperature with that of the body, must exert a profound and intimate effect upon processes of cell nutrition. ”

“ A man may inherit gout, but he need not foster it by self-indulgence. Much less need he, as so often happens, acquire it by depraved habits of life. In no disease do sobriety and virtuous living ensure so great a reward. As Sir Thomas Watson long since said to those inheriting this unwelcome legacy: “Let the son of a rich and gouty nobleman change places with the son of a farm servant, and earn his temperate meal by the daily [12] sweat of his brow, and the chance of his being visited with gout will be very small.” ”

“ In like refrain, our own countryman Heberden deplores that people “are neither ashamed nor afraid of it; but solace themselves with the hope that they shall one day have the gout; or, if they have already suffered it, impute all their other ails, not to having had too much of that disease, but to wanting more. The gout, far from being blamed as the cause, is looked up to as the expected deliverer from these evils.” Such deluded views being prevalent, it is hardly a matter for surprise that misguided persons deliberately courted a “fit of the gout” by resorting to excess and intemperance. ”

“ If he is over thirty-five and has never previously had an arthritic disorder, it is much more likely to be gout than rheumatism, this only as a broad generalisation.
What occupation does he follow? What are his habits? Is he of the “idle rich” who “fare sumptuously every day”? Is he a plumber, a painter, or a butler, coachman, or club waiter, these last being men who, as Sir Thomas Watson observes, “often live more luxuriously and more idly a great deal than their masters”? In short, we must search for any evidence of overeating, overdrinking, and indolence. ”

“ I can well understand that the illustrious Sydenham, absorbed in his life study, forgot to take a normal amount of exercise. Perhaps, like the renowned Jenner, he would have said, “I never walk at all except from my house into my carriage. I hate walking, and if I could, I would get my servants to carry me to bed.” Nevertheless, I doubt not that Sydenham’s intellectual efforts necessarily entailed sedentary habits, which brought in their wake digestive and intestinal derangements, whence his occasional gouty outbreaks.
Gout, indeed, has taken its full toll of the “Intellectuals.” ”

“ Apart from statistical proof of heredity, how else, save on the basis of an organic predisposition to the disease, can we explain the fact that of a large number of individuals, of slothful habit, and given to alcoholic and dietetic excesses, not one may get gout; while others who lead literally “a godly, sober, and righteous life,” become martyrs thereto. How escape then the conviction that in gout “breed is stronger than pasture”? for, apart from gluttony and indolence, gout is much more prone to arise in persons in whose pedigree it can be traced than in others. ”

“ In judiciously prescribed and skilfully applied massage we have an agent of pre-eminent value in the treatment of gout. Indeed, Sir William Temple—a martyr to the disease—when speaking of the benefit of “friction,” frankly stated that “No man need have the gout who can keep a slave.” In this there is much truth, for the beneficial results of massage are not confined merely to the affected joints or muscles, but, as a result of the improved circulation, waste products are more readily excreted, the nerve centres regain tone, and a general feeling of bien-être is promoted. ”

“ But, in view of our ignorance of the intimate nature of even regular gout, I should myself deprecate affixing the prefix “gouty” to any glycosuria other than one that has supervened in sequence to, or alternates with, gouty arthritic seizures. Moreover, the glycosuria of gout is usually the alimentary glycosuria of fat elderly people, in whom the sugar excreted represents the unconsumed surplus of carbohydrate food. But fat elderly people are not necessarily “gouty,” neither is every so-called benign glycosuria inevitably linked on to a gouty diathesis. ”

“ Need for Collaboration of Clinician and Bio-chemist.—Before we shall be able to lay down a diet for the “gouty” on truly scientific grounds much remains to be done. Our clinical examinations, in no way to be despised, must nevertheless be supplemented by the more subtle tests of the bio-chemist. Consider the complexity of the problem. We have to diet not only the “gouty,” but the “potentially” gouty.
They shade the one into the other. Even the man who has had gout has his periods of respite, of apparent unblemished health. ”

“ But this zeal for infinite cleavage and subdivision, so characteristic of the modern school, far from diminishing, does but accentuate, the diagnostic valency of the tophus. It still remains the infallible criterion of diagnosis, and, for myself, I feel convinced that infinitely more good than harm would ensue if we refuse to recognise any individual as being of the “gouty diathesis” unless he exhibit these objective stigmata thereof.
Of course to some such a rigid attitude will spell anathema. I hear them say in oracular tones: “Never forget gout, or awful indeed will be your awakening.” ”

“ These observers noted that on a diet rich in nucleins (sweetbreads, liver, kidneys) the total daily excretion of uric acid was considerably higher than on a milk or purin-free diet. This difference in response to varying dietaries, in respect of the excretion of uric acid, led Burian and Schur to the conclusion that the purins excreted must be partly of exogenous and partly of endogenous origin; in other words, the exogenous purins are derived from the nucleins ingested in the food, whereas the endogenous are the outcome of the breaking down of the cellular tissue of the organism itself. ”

“ In considering the correlation of cause and effect it not infrequently happens that we find no obvious connection between the one and the other. In syphilis, for instance, alopecia is a usual secondary symptom, and we rely on the frequency of the sequence [319] to satisfy ourselves that it is no mere coincidence. If it could be shown that alopecia did not occur more frequently in syphilitic people than in non-syphilitic we might justly doubt the connection. The same reasoning may be applied to iritis and gout: the association is so rare that it is negligible. ”

“ In other words, it may yet happen that the mysterious materies morbi of gout, whether microbic or chemical, may be demonstrated experimentally as capable of inducing, not only the arthritic phenomena, but also those inflammatory lesions in the eyes which provisionally are sometimes called “gouty.”
Lastly, I would enter a plea for more systematic, more scientific, investigation of the true link, if any, between iritis and arthritis. The war has taught us the value of “team-work”; it has taught us that the clinician must be reinforced by the bio-chemist, the bacteriologist and the pathologist. ”

“ As to the retention of uric acid, he deemed it not the cause, but merely a symptom, a consequence of gout. Thus he says, “The good living and the stimulants do not simply cause an excess of uric acid to form, but they end by causing some more permanent change, and probably one affecting the blood globules, which reacts on the kidney, putting a stop to the excretion of uric acid, and causing its retention in the serum, where, passing in the round of the circulation, it is very apt to become deposited as urate of soda.” ”

“ In the same way, I cannot help thinking that the growing infrequency and attenuation of gout is in part due to increasing appreciation by the laity and the profession of the vital importance of oral hygiene and timely and radical treatment of local foci of infection. The fact that in children, victims of so-called infantile gout, the purin metabolism may show those same derangements held typical of the subjects of gout, is surely an indication that the disorder begins betimes, and that we too must not tarry if we would prevent these evil potentialities coming later to fruition. ”

“ How frequently, indeed, is it the direct outcome of an abrupt change in habits—a hunting man, predisposed to gout, sustains an accident, can no longer ride to hounds and takes to motoring. Unless he forthwith curb his food intake, the disorder overtakes him. Sometimes misfortune proves a blessing in disguise, as in the case related by Van Swieten of an opulent and gouty old priest, who, captured by Barbary corsairs and forced to work as a galley slave, soon lost his gout. ”

“ There being nothing specific of gout in the lesions of so-called “gouty” kidneys, we must revert to the clinical findings to refute or establish any causal connection between gout and the renal disorder. Now, gout is a disease of middle and late life, and rarely of itself proves mortal. On the other hand, it appears increasingly probable that the seeds of granular kidney are laid in earlier life, and, on the average, its course is shorter than that of gout. Also the two disorders have clinical facies absolutely distinct the one from the other. ”

“ Only in this way, too, can we preserve for ourselves a clear conception of gouty arthritis as a specific disorder, the which otherwise loses its identity, submerged in a medley of joint diseases. Prior to the differentiation of gout, on the one hand, from rheumatism and arthritis deformans, and on the other from the nerve arthropathies and the infective arthritides, such laxity might be condonable, but not, we think, in the present stage of our knowledge. ”

“ The nonchalance with which not a few writers dismiss the diagnosis of acute gout when located in the great toe or elsewhere in the foot is, to say the least of it, somewhat remarkable. “It is a very easy matter,” say they, and as an earnest of their good faith are silent as to the many pitfalls that await the unwary. Should they deign to differential diagnosis, they are at pains to discriminate between it and acute articular rheumatism, which re classical outbreaks in the toe seems a little superfluous! ”

“ That drugs, such as atophan, which diminish the uric acid content of the blood and increase its urinary output, fulfil an invaluable rôle in ridding the system of excessive amounts of this chemical outcast, I fully admit.
Albeit, this achievement does but deal with the consequences or sequels, not the exciting causes, of gout. In truth, there is no short cut to the cure of gout. Only under suitable treatment, applied to meet all the necessities of individual cases, will any long immunity from its onslaughts be secured or their intensity attenuated. ”

“ Sir Hale White, discussing the diagnosis of acute gout of unusual localisation, remarks: “The real difficulty in acute cases comes when it is suggested that an acute arthritis with pyrexia and swelling and redness of a joint other than that of the great toe is caused by gout. I have recently seen the difficulty in one patient in the wrist, in another in the knee. Such cases, if they are not gout, are some bacterial arthritis.” ”

“ As to the axiom, generally accepted, that the earlier in life gout makes its début, the more unfavourable the outlook, there are exceptions. Where longevity marks the stock, they usually are true to type. Thus, even if the first outbreak occurs in the twenties, I have known them reach the allotted span and over. Nor if their urine show traces of albumen is this necessarily of grave import, for these gouty veterans may for many years, even to old age, exhibit traces of albumen without apparently developing genuine Bright’s disease. ”

“ Now, as we hope to show later, whatever be the proximate cause of gout it is at any rate not uric acid. The fact, too, that higher degrees of lithæmia are to be met with in conditions, not even remotely connected with gout, renders it impossible to accept the view that the excess of urates in the blood is responsible for all the varied symptoms accredited by Murchison and his followers to lithæmia. For the same reason, it is difficult to uphold the hypothesis that “the tendency to lithæmia in early life may be an early expression of the ‘gouty’ diathesis.” ”

“ A man has iritis and tophi; ergo we say he has gouty iritis. But why? They co-exist, it is true, but where is the link of attachment of cause and effect? How different is our attitude if we know in another case that our tophaceous iritic patient has gonorrhœa. We then say, gonorrhœal iritis in a gouty subject. Would it not also in the first case be more scientific if we frankly confessed that it was an infective iritis of undifferentiated type occurring in a person of gouty diathesis?
In considering the iritides in relation to gout there are two types which demand our attention. ”

“ Alcohol in Gout
Said Sir Thomas Watson: “I am sure it is worth any young man’s while who has had the gout to become a teetotaler.” Few will gainsay the wisdom of this advice. But I would fain go further and impress on gouty parents the incumbent duty of bringing up their children as total abstainers. For gout, once avowed, has a vicious tendency to recurrence. The illustrious Sydenham, I think, would have approved of such advice: “Water alone is bad and dangerous, as I know from personal experience. When taken as the regular drink from youth upwards it is beneficial.” ”

“ For myself, I have never seen a case under thirty-five years of age, and am sceptical as to the occurrence of infantile gout of regular type, believing with Scudamore that “the commonly asserted cases which represent the existence of the gout in very early youth are really examples of rheumatism.” Nor am I less but more inclined to cavil at the claims of Comby and others, as to the frequency in children of irregular manifestations. As Osler dryly observes, “The tendency in some families is to call every affection gouty. ”

“ In the gouty, even the malign influence of bad habits of living is greatly mitigated by active exercise and labour. “The gout very rarely visits the poor man’s cottage.” Nothing can so effectually counteract a predisposition to the disorder, and what Sydenham thought of its value we may guess from his trenchant remarks on horse exercise. “And, indeed, I have often thought if a person was possessed of as effectual a remedy as exercise is, in this and most chronic diseases, and had the art likewise of concealing it, he might easily raise a considerable fortune.” ”

“ Even a total abstainer, when coming of gouty stock, may develop gout, haply through overeating.
To my mind, the only supposition deducible from these facts is that some individuals are born with a tendency to gout, and that this tendency may never assert itself as actual disease; that in others the dormant proclivity, under the influence of alcohol, forthwith becomes manifest; lastly, in some again, so nicely poised is the equilibrium of their nuclein metabolism, that the most venial alcoholic indulgence suffices to evoke an outbreak. ”

“ Precisely so, but what constitutes the “right” diet? We are told that this is good and that is bad for gout. Some would have us eschew red meat and cleave unto white; for others common salt is the devil that must be cast out. Some speak ill of all the fruits of the earth. Strawberries especially, they say, are the bane of gout, yet in these same Linnæus found salvation. For many, again, sugar is anathema, tea and coffee but uric acid solutions, and alcohol in all forms rank poison! ”

“ As to the modus operandi of alcohol in inducing gout, I believe that [50] it acts indirectly, viz., by slowly sapping the protective mechanisms of the body, and so paving the way to infections.
Much stress has been laid on the fact that certain occupations conduce to gout; but, if we exclude plumbers, painters, or other workers in lead, no other callings in life can be held to entail a specific predisposition to its development, save in so far as they promote overeating, overdrinking, and inactivity.
It is well established that workers in lead are specially prone to develop gout. ”

“ The intrusion of some other factor, “something vital, something biological,” seems essential for the elucidation of uratosis, i.e., uratic deposition. For this, not uricæmia, is the specific characteristic phenomenon of gout. If we cannot explain uratosis on physical or chemical grounds, then how much less, in view of the non-toxicity of uric acid, can we on this basis account for the inflammatory phenomena of the disorder! ”