Another peculiarity of gouty irido-choroiditis is its tendency to recurrence, and its final production of complete glaucoma in many instances. It is also singularly intractable to ordinary methods of medication, often yielding only to treatment that is addressed to the underlying predisposition. In this respect the local lesions bear the same relation to gout that the lesions of luetic iritis hold toward syphilis. In each instance specific treatment is essential to a success ful result.
The close relationship that exists between gout and rheumatism is nowhere more apparent than in the course of these ocular inflam mations. Their symptoms, behavior, and results are clinically indistinguishable, whether excited by one or by the other of these diathetic disorders. Unless we possess a sufficient family record, or a personal history of articular or rheumatic accidents, it will be often impossible to decide between gouty iritis and its rheumatic twin.
Gouty affections of the external ear have been already fully de scribed in the section on morbid anatomy. The development of tophi in the body of the helix and at the other points of election goes on insidiously, without attracting any attention in the majority of cases. Sometimes, however, there are brief inflammatory attacks involving the external parts, causing great pain for a short time, but speedily subsiding as the disease develops elsewhere in the joints.
It is usual to encounter progressive deafness among the gouty, as they advance in years. But it is a rare thing to find after death any evidence of uratic deposit about the articulations of the ossicles of the ear. The drum membrane becomes thickened, and the joints of the osseous chain in the middle ear become anchylosed; but even Garrod, with all his vast experience, was unable to find any appearance of tophaceous deposit. The loss of hearing progresses slowly, and without pain or noise in the ears. The membrana tympani grows thicker and less responsive to aerial vibrations; it often exhibits cal careous deposits in its layers, and the handle of the malleolus is no longer visible through it. Ankylosis of the stapes is of fre quent occurrence, exercising a profoundly deleterious influence upon the auditory function by interference with the transmission of vibra tions through the membrane of the fenestra oxalis to the fluids within the inner ear. These changes usually progress without pain, and they are not interrupted by inflammatory paroxysms of an acute character; so that the only evidence of gouty action in the middle and inner ear is to be found in the results of chronic inflammation and ankylosis in the chain of communication between the external and inner chambers of the auditory apparatus.