Chapter XXI: CLINICAL DIAGNOSIS (continued)

ACUTE GOUTY POLYARTHRITIS

In the pathways of medicine, as in other walks in life, we are apt to become stereotyped, to fall into grooves, and sooner or later the inevitable rude awakening comes. Thus, so prone are we to think of gout as belonging, so to speak, to the foot, that when it erupts elsewhere it is often the last contingency to dawn upon us. If we diagnose it too often and too readily in the foot, we do so too seldom when it appears in joints remote.

Now, while in _initial_ outbreaks of gout it is exceptional for more than _one_ joint to be affected, it is not always so. For sometimes in those strongly predisposed by _heredity_ not one, but _many_ joints, may be implicated in the _primary_ attack. Such cases, however, are extremely rare.

As a rule, this _acute gouty polyarthritis_ occurs in individuals who have already experienced articular paroxysms at the classic site; but in the subsequent polyarticular attacks the _toe_ joints are often unimplicated, and the disease is located in the larger articulations—the knees, ankles, wrists, or elbows. Herein resides the difficulty of diagnosis in these cases: the likelihood of confusion with other polyarthritides.

Confronted then with an _acute polyarthritis_ of obscure nature marked by pain, redness, swelling, and pyrexia, what are the points necessary to establish it as being of gouty origin?

The sex and age should be noted, also the heritage, habits, and occupation. A history of _previous attacks located in the big toe_ would be of prime value. The presence of a cardiac _valvular_ lesion, while it would suggest a previous attack of _acute rheumatism_, would in no wise negative the possibility of the subject developing _gout_ in later life. Here I may say that if the subject is over thirty-five and has never had acute rheumatism or acute gout, it is much more likely at his time of life that his _acute polyarthritis_ is of _gouty_ than of rheumatic origin.

As to the character of the pyrexia, it is usually of _low_ grade; but if the condition be _afebrile_, it is even more suggestive of a _gouty_ arthritis. But recollect, too, that the pyrexia in _gonococcal_ arthritis is also of low grade or absent.

There is nothing distinctive of _gout_ either in the character or distribution of the articular lesions. The ankles, knees, hands, wrists, are most commonly involved, much more rarely the elbows, shoulders, or hips. Naturally the local changes will differ according to the joint involved and the structures implicated; but these local variations in appearance, including œdema, may all be met with in any form of _infective_ arthritis.

As to _uric acid excretion_, Osler, who was deeply interested in this type of arthritis, held that any _lowering_ of the ratio of the _uric acid_ to the _urea excretion_ would be significant of gout. Also we should, as these cases of acute gouty polyarthritis are of the nature of successive paroxysms (“series et catena paroxysmulorum,” to use Sydenham’s expression), note _any variations in the uric acid output_ ensuing _pari passu_ with their rise and wane.

Last, but most important of all, a thorough search must be instituted for _tophi_, not only in the ears, but elsewhere. If anything could emphasise the indispensable _rôle_ played by _tophi_ in the diagnosis of gout, it would be our utter inability to effect in their absence a diagnosis of these _acute_ types of _gouty polyarthritis_. The establishment of the existence _in situ_ of such _articular uratic deposits_ disposes forthwith of all possible doubts as to the true nature of the case; but if, as so frequently happens, the tophi when present are of _ab-articular_ site, then we must withhold our decision pending the exclusion of certain other joint disorders, to the differentiation of which we now proceed.

DIFFERENTIAL DIAGNOSIS

The class of disorders that call for discrimination are those of infective origin. In the first place, _acute articular rheumatism_ must be excluded; nor is it less necessary that we should eliminate _gonorrhœal_ and _syphilitic_ types; while, last, but not least, that vast group, the _undifferentiated infective arthritides_, is but too often a source of confusion.

ACUTE ARTICULAR RHEUMATISM

Unquestionably many cases of _acute gouty polyarthritis_ have been confounded with _acute articular rheumatism_, and _vice versâ_. Garrod on this point remarks: “That many cases of acute gout have been mistaken for acute rheumatism I do not doubt, and, on the other hand, that some few cases of acute rheumatism have been regarded as of a gouty nature I am no less certain. I may refer to the oft-quoted case related by Dr. Haygarth in which gout was supposed to have been transferred from the extremities to the heart as an example of the latter error.”

It is only, of course, with that type of acute gouty polyarthritis accompanied by _pyrexia_, and not the _afebrile_ variety, that confusion with acute articular rheumatism is possible. What then are the points of discrimination?

ACUTE ARTICULAR RHEUMATISM. ACUTE GOUTY
POLYARTHRITIS.

Age and sex Most common between ages Maturity and old
of fourteen and thirty. age. Males.
Predominance of males Females markedly
after twenty. exempt.

Heredity Very disputable. Very pronounced.

Onset Usually abrupt and often Insidious, with
with tonsillitis. premonitory
gastro-intestinal
symptoms.

General symptoms High fever, sometimes Moderate pyrexia.
hyperpyrexia. Profuse Marked daily
acid sweats. remissions.

Distribution of Preference for large joints Small joints, hand
lesions and markedly mobile. or foot often
involved. Fixity
typical.

Local characters Joints exhibit slight reddish Scarlet hue and
flush. No subsequent œdema with later
desquamation. No residual peeling of cuticle
change. and itching.
Tendency to
involvement of
bursæ and tendons.

Pain Chiefly evoked by movement. Spontaneous, more
intense.

Duration Twenty to thirty days, Six weeks to three
sometimes longer. months.

Associated Cardiac lesions common. Tophi. Occasionally
phenomena glycosuria and
albuminuria.

Therapeutic test Salicylates a specific. Not so in gout, but
colchicum takes
this _rôle_.

ACUTE GONOCOCCAL ARTHRITIS

This disorder, as we know, is sometimes of oligo- or poly-articular distribution. Moreover, as the attendant pyrexia may be slight or absent, it may readily be confounded with the _afebrile_ variety of acute _gouty_ polyarthritis. Osier, discussing diagnosis of the latter condition, observes: “A patient with three or four joints red, swollen, and painful in acute rheumatism has fever, and while _pyrexia_ may be present, and often is, in gout, its absence is, I think, a valuable diagnostic sign.”

This is of course true, but it still remains necessary, for reasons above cited, to eliminate _acute gonorrhœal arthritis_. The tendency to such confusion has been emphasised by Sir Rose Bradford and Sir William Roberts, and I would urge the necessity of being alive to this possibility even in middle-aged men. One thing is certain, viz., we should be extremely chary of pronouncing any coincident urethral discharge to be a so-called “gouty urethritis”; nor should we translate any coincident _conjunctivitis_ or _iritis_ as further evidence of the articular affection being “gouty.” It is far more likely to be _gonococcal_. Apart from these inflammatory ocular affections, the relics also of previous attacks—viz., irregularity in contour or inequality in size of the pupils—have before now put me on the right track in obscure types of polyarthritis.

To sum up, the following are distinctive characters of _generalised_ gonorrhœal arthritis:—

_Etiology._—History or presence of urethral discharge and isolation of the gonococcus.

_Onset._—Insidious, seldom acute.

_General Symptoms._—Absent or slight relatively to extent and severity of joint mischief. Pyrexia, low grade or absent.

_Distribution of Lesions._—Preference for large joints. Special liability of sacro-iliac, chondro-costal synchondroses, sterno-clavicular, tibio-fibular, and temporo-maxillary joints.

_Local Characters._—Persistent passive effusion or peri-articular boggy swelling, with redness and local heat. No tendency to migrancy. Joint swelling very persistent.

_Associated Phenomena._—Involvement of fasciæ, especially plantar, and of tendon sheaths, very distinctive, while coincident iritis or conjunctivitis is almost diagnostic.

SECONDARY SYPHILITIC ARTHRITIS

The ease with which a subacute arthritis of this nature may be confounded with “gout” or “rheumatism” calls for comment. We have met with cases despatched to spas under this impression. The customary _intermittent fever_ of _secondary syphilis_ is usually present. The detection of periosteal nodes in addition to the joint swellings should arouse suspicion, while the presence of _secondary syphilides_ and the rapid response to _specific_ treatment will be confirmatory.

I well recollect some years ago a young farmer being sent to me by a medical man as suffering from _gouty arthritis with gouty eczema_. The eruption was a typical _roseola_, and the condition promptly cleared up under _anti-syphilitic_ treatment.

ACUTE RHEUMATOID OR ATROPHIC ARTHRITIS

While the old term “rheumatic gout” still clings to this affection, it has now achieved its isolation from gout on the one hand and rheumatism on the other. The fact that it occurs in young women in whom gout never occurs, and has a very marked clinical _facies_ of its own, should almost preclude the possibility of its being a source of confusion. Still, for the sake of completeness, we append its chief characteristics.

_Age and Sex._—Most common in young women.

_Onset._—More or less acute.

_General Symptoms._—Continuous low grade pyrexia, quick pulse, and rapid emaciation, and commonly concomitant gastro-intestinal derangements.

_Distribution of Lesions._—Polyarticular. Beginning in the small joints, it spreads centripetally, with a tendency to symmetry. No migrant trend, but a steady, progressive involvement of joint after joint, including temporo-maxillary and cervical articulations.

_Local Characters._—Overlying skin of affected joint white or semi-asphyxial in tint. Contour spindle-shaped, but in terminal stages shrinkage from atrophy of articular structures sets in. Muscular wasting and contracture conspicuous features.

_Associated Phenomena._—Trophic and vasomotor changes prominent, but _no tendency to cardiac lesions_.

INFECTIVE ARTHRITIS OF UNDIFFERENTIATED TYPE

It were well in approaching any acute polyarthritis of obscure nature to bear in mind the axiom that _any or all infections may be complicated by arthropathies_, also that if the said polyarthritis does not respond quickly to colchicum or salicylate of soda we are almost certainly dealing with an infective arthritis either of specific or undifferentiated type. The _specific_ forms of infective arthritis, as far as seems necessary, have been dealt with, but those rarer forms not referred to, viz., _influenzal_, _pneumococcal_, _dysenteric_, _meningococcal_, etc., have also to be borne in mind, if the history reveal any recent occurrence of these disorders.

Still far more common than any of these are the _acute infective arthritides_ of _undifferentiated_ type. As we before remarked, an extraordinary general clinical resemblance obtains between these types of joint disorder and _acute gouty polyarthritis_. Indeed, _in the absence of tophi_, their differentiation is well-nigh impossible. Even the blood picture in both types of the disorder is strikingly similar in the matter of _leucocytosis_ and _secondary anæmia_.

Recently Dr. Henry A. Christian, lecturing at a clinic of the Harvard Medical School, emphasised this clinical similarity and the difficulty of discriminating between these two types of joint disorder. As he rightly says, “while there is a definite _acute gouty polyarthritis_ (as evidenced by external tophi or deposits in bone or cartilage with variations in uric acid output) and also an equally definite _infective arthritis_, yet between those two there is a very considerable number of cases that present some of the factors suggestive of _gout_ and other factors suggestive of an _infectious arthritis_, and there is where the difficulty comes.”

This is precisely the state of affairs, and one may well ask where _gout_ ends and _infection_ begins. Let us take an example. A man exhibiting _tophi_, the subject also of _pyorrhœa alveolaris_, develops an _acute polyarthritis_. What then is the nature of the joint disorder? There is a gouty element in his case, as attested by _tophi_, also an infective element, as evidenced by _oral sepsis_.

Now are we to regard such a case as one of _infective arthritis_ of _undifferentiated_ type occurring in a _gouty_ subject, or are we to proceed on the assumption that the presence of _tophi_ negatives the possibility of infection and forthwith to class it as a case of _acute gouty polyarthritis_ of so-called _metabolic_ origin?

This is no theoretical quibble. In the Royal Mineral Water Hospital, Bath, one constantly meets with cases in which the very elect would be puzzled as to whether they should be placed in the category of _gouty_ or in that of _infective_ arthritis. I have at present in my wards a middle-aged man, stout of body, rubicund of face, with well-marked auricular tophi and widespread arthritis. There are no tophi round his joints. On X-ray examination his phalanges show Bruce’s nodes, and his phalangeal joints show changes indistinguishable from those constantly met with in infective arthritides occurring in _non-gouty_ subjects.

Indeed, this overlapping may proceed still further, the gouty and the infective characters neighbouring in such proximity as to suggest actual fusion, a community of origin. What else in truth can be the inference, when one meets with examples in which the _peri-articular_ tissues are the seat of demonstrable _uratic deposits_, while the X-ray changes within the joint proper, the bone and cartilage, are typically those met with in _infective_ arthritis?

Now, who will deny that if tophi were absent in such a case we should without hesitation hold the case to be one of infective arthritis? My own contention is that even in the presence of tophi the same appellation is indicated. In other words, I submit that _acute gouty polyarthritis_ is itself but a form of _infective arthritis_ which derives its _specific_ character from the associated _uratic deposits_.

As to differentiation of the latter from these cryptic infective arthritides, this will rest mainly on—

(1) The presence of tophi;

(2) A history of previous attacks in the great toe;

(3) A swift response to colchicum.

In addition, acute gouty polyarthritis is confined to _middle-aged males_, while no period of life is immune from infective arthritis, and both sexes are equally liable.

Again, acute gouty polyarthritis may be _afebrile_. Pyrexia when present is moderate in grade, its curve undulating as the paroxysms rise and wane. In infective arthritis the temperature curve is irregular and erratic.

Lastly, the _uric acid output_ in acute gouty polyarthritis drops a day or two before the paroxysm, rises markedly after its inception, then sinks again. Also we may add that occasionally glycosuria or albuminuria is present.

In conclusion, I would allow myself a brief digression regarding these infective arthritides of undifferentiated type. They constitute the bulk of the cases of arthritis that find their way to the Royal Mineral Water Hospital, Bath, under one or other of the appellations “gout,” “rheumatism,” and “rheumatic gout.” It is within this category that most of the cripples met with at spas fall, and their obduracy to “drug” treatment accounts for their belated despatch thereto.

I would that I could sufficiently emphasise the imperative necessity of early recognition of the true nature of these cases. Colchicum is a most valuable drug, and so is salicylate of soda. But they have their limitations. They act swiftly or not at all. Persistence with them in the absence of any response is worse than futile: it is definitely prejudicial. Because of our unreasoning devotion, our almost fetishistic addiction, to these drugs, I often feel that these agents, especially salicylate of soda, have made more cripples than they have saved. For, unfortunately, unqualified reliance on these drugs is apt to blind us to the surgical necessities of these cases. Foci of infection pass unnoticed, joints stiffen at unfavourable angles, and not infrequently a potential bread-winner is lost.

I make no apology for this digression, for it is, strictly speaking, wholly apposite, this in view of the fact that failure of quick response to the action of colchicum or salicylate of soda, say within a week, speaks in favour of the infection having ensued in a _non-gouty_ as opposed to a gouty subject.