Gout: An Unusual Case with Softening and Subluxation of the First Cervical Vertebra and Splenomegaly Result of Acth Administration and Eventual Post-Mortem Findings

he remained fit, taking part in a-Commando course and then in the invasion of Italy, but in November, 1943, five days after the onset of an attack of jaundice, he developed another attack of pain and swelling in the left knee, which lasted for a month.Infective hepatitis at that time was epidemic.In February, 1944, he had another two weeks of pain and swelling in the left knee and then in the fingers.The trouble in the fingers persisted and, after a course of gold, he was invalided out of the Service in September, 1944, as a case of arthritis.During the next two years he had repeated attacks of pain and swelling in many joints, each attack being followed by a complete or almost complete remission.He lost weight and his general condition deteriorated.In August, 1946, at the age of 21, he was first admitted to the Royal National Hospital for Rheumatic Diseases.He was wasted, anaemic, and debilitated.There was some evidence of involvement of most of the joints of the body and especially of the hands, knees, and feet.There was fusiform swelling of the proximal interphalangeal joints with flexion contractures of the 4th and 5th digits of the left hand, and the knees and ankles were swollen with marked limitation of movement.Tophi were present in the ears.The spleen was palpable, as were glands in the axillae and epitrochlear regions.Investigations, August, 1946.Blood Examination R.B.C. 3,710,000.Haemoglobin 55 per cent.W.B.C. 9,800: Polymorphs 69 per cent.Lymphocytes 22 per cent.Monocytes 9 per cent.Suspension stability 58 per cent.Plasma uric acid 16 mg.and 17-7 mg. per 100 ml.Cholesterol 125 mg. per 100 ml.Urea 44 mg. per 100 ml.Urine showed a trace of albumin, a few red blood cells and uric acid crystals.X rays showed erosion of cartilage, and translucent areas, such as are commonly found in gout.Cinchophen produced little clinical improvement, but the pain and swelling were considerably relieved by colchicine gr. 1 0 three times a day.Progress of Disease.April, 1947.-He was re-admitted to hospital.He had remained almost free from pain on continuous colchicine therapy, but his general condition had deteriorated and he had lost weight.Blood examination showed little change from before, except that the plasma uric acid had dropped to 13 *3 and the cholesterol to 80 mg. per 100 ml.Muscle and skin biopsy showed no abnormality except a slight increase in muscle nuclei.September, 1947.-He was admitted to another hospital.Colchicine was discontinued and immediately he had a fulminant attack of gout with high fever.After this his joints, especially his hands, became much worse and a bilateral flexion deformity became estab- lished in the wrists and knees.March, 1948.-He was re-admitted to the Royal National Hospital, Bath.His general condition and his joint condition were found to be much worse, but the blood findings were as before.In April, after his discharge, his supply of colchicine ran out.Tincture of colchicum was substituted, but within two days there was an acute exacerbation of gout with fever and vomiting.May, 1948.-He was re-admitted in very bad condition, but improved on colchicine therapy.The plasma uric acid was 16 mg.again, and the cholesterol had fallen to 50 mg.Both hands and feet were discharging tophaceous material.X-ray therapy for the right foot caused a very acute exacerbation, but six weeks later there was a local improvement, sufficient to cause the patient to agree willingly to a similar course of treatment for the left.There was again some increase in pain and swelling for ten days, and after this GOUT 283