THE PEDIGREE OF GOUT
Under the vague term “articulorum passio” or “arthritis” the physicians
of antiquity handed down to posterity the clinical description of a
disease in the varied symptomatology of which we may descry at one time
the features of gout and anon those of rheumatism. But centuries had to
elapse before gout became differentiated from rheumatism. For there is no
doubt that not only the Greek and Roman physicians, but those also of the
Græco-Arabian school, confounded these two disorders, or more accurately
failed to differentiate rheumatism.
So it is that Charcot, reviewing the antiquity of gout, while he
pays a graceful tribute to the ancient physicians for their masterly
disquisitions thereon, at the same time deplored their silence on the
subject of articular rheumatism.
This absence of allusion thereto is the more remarkable in that the term
“rheumatism” or “rheumes” dates from a very remote period. Both words,
in truth, were indifferently enlisted to denote all those diseases
deemed attributable to the defluxion of some acrid humour upon one or
other part of the body. Used by the ancients more in accordance with its
etymological sense, the term “rheumes” or “rheumatism,” finds a place
even in the writings of Pliny and Ovid. But our modern conception of
the disorder differs widely from “the flux of humours” which the Greeks
named rheumatism, or “the sharpe and eager flux of fleam” which for them
characterised an attack of the “rheumes.”
The early English authors, too, invoked the word as a general term
descriptive of various forms of disease. Sir Thomas Elyot, in his
“Castel of Health,” so scoffed at by the faculty in his day, inculcates
abstemiousness in those afflicted with the “rheumes,” and in “Julius
Caesar,” Brutus is warned by Portia not to tempt “the rheumy unpurged
ayre of night,” a clear indication that the term was used as a synonym
for fluxions, humours and catarrhs of all sorts. But as to the malign
_articular_ forms of the affection, never a word; and this almost
inexplicable silence led Sydenham, Haecker and Leupoldt to surmise that
articular rheumatism was a modern disease unknown amongst the ancients.
ISOLATION OF ACUTE ARTICULAR RHEUMATISM FROM GOUT
Hallowed by tradition, this erroneous conception of the identity of gout
and rheumatism endured until 1642, when Baillon, in his treatise “De
Rheumatismo et Pleuritide,” effected a cleavage, at any rate between the
acute varieties of these two diseases.
Dissociating the term “rheumatism” from its primitive interpretation,
Baillon restricted its usage to that particular group of symptoms we now
call _acute articular rheumatism_. In the same century Sydenham, in his
“Classical Observations,” materially clarified the existing clinical
confusion, defining with his customary lucidity the essential differences
between the two disorders.
TARDY DISSOCIATION OF CHRONIC GOUT FROM CHRONIC RHEUMATISM
Bearing in mind the centuries that elapsed before the _acute_ articular
forms of gout and rheumatism were dissociated, one ceases to marvel that
the task, incomparably more difficult, of discriminating between the
_chronic_ forms of these diseases is even now barely accomplished.
“Rheumatissimus agnatus podagræ” said our forefathers, the axiom
postulating not the actual identity of the two affections, but a near
relationship, and in this non-committal phrase we may, I think, descry
the birth of that modern term “_L’arthritisme_,” so beloved of the French
physicians. Even as late as the beginning of the nineteenth century
Chomel at the Saltpetrière taught his pupils that gout and rheumatism
were but clinical variants of an underlying “arthritic diathesis,” his
successor Pidoux being still more insistent that the two disorders sprang
from one common root. Even Charcot and Trousseau, convinced as they were
of the essential distinctness of the two disorders, nevertheless admitted
that at the bedside their _chronic_ manifestations were with difficulty
dissociated, the former pointing to the terms “rhumatisme goutteux” and
“rheumatic gout” as tacit acknowledgments of our impotence.
Nor did this view that _gout_ and alike _rheumatism_ are the outcome of a
_basic arthritic diathesis_ fail of doughty supporters in this country.
Thus Hutchinson, in his “Pedigree of Disease,” observes “gout is but
rarely of pure breed, and often a complication of rheumatism. It so often
mixes itself up with rheumatism, and the two, in hereditary transmission,
become so intimately united, that it is a matter of considerable
difficulty to ascertain how far rheumatism pure can go ... when this
complication exists. It shows its power, we may suspect, by inducing a
permanent modification of tissue, and it is to this modification that
the peculiarities in the processes (transitory rheumatic pains in joints,
fasciæ, and muscles, chronic crippling arthritis, destructive arthritis
with eburnation, lumbago, sciatica) are due. Hence the impossibility
under many conditions of discriminating between gout and rheumatism.”
Laycock also subscribed to Charcot’s view, and Sir Dyce Duckworth
confesses that the conception of “a basic diathetic habit of body
called _arthritic_ has well commended itself to my mind,” while as to
the clinical commingling of the two disorders Sir Charles Scudamore
spoke with no uncertain voice. That an individual may in youth suffer
from _acute articular rheumatism_, and later in life develop _gout_, is
undeniable, as also the reverse, that a gouty subject may be harassed by
manifestations of chronic rheumatism or _fibrositis_. But this mutual
trenching of the one upon the clinical territory of the other must not be
allowed to impair our views as to the essential distinctness of _gout_
and _rheumatism_. It is undeniable that the difficulty of differentiating
between the _chronic_ forms of these two disorders is great, for not even
the revelations of _skiagraphy_, in the absence of a clinical history,
will suffice to effect a discrimination. But to a further consideration
of this vexed matter we refer the reader to the coming chapters on
Diagnosis.
IDENTIFICATION OF MUSCULAR RHEUMATISM
But to resume our thread, one great step forward we owe to Cullen, who
not only differentiated _acute_ from _chronic_ articular rheumatism, but
also clearly portrayed the clinical distinctness from both of _muscular_
rheumatism. In so doing, he materially assisted in the differentiation
of these same disorders from _gout_. But at the same time, owing to his
immoderate advocacy of “chill” as the one great cause of _rheumatism_
in all its forms, he undoubtedly retarded progress. For immediately
there arose a cloud of witnesses who claimed a “rheumatic kinship” for a
myriad _visceral_ disorders, the victims of which had suffered exposure.
Thus throughout the seventeenth and eighteenth centuries many of the
conditions now assigned to _irregular gout_ were affiliated instead to
_rheumatism_.
DIFFERENTIATION OF CHRONIC GOUT FROM ARTHRITIS DEFORMANS
Apart from Cullen’s contribution the eighteenth century was unmarked by
any further advance in differentiating the mass of heterogenous joint
affections, indifferently classed as gout and rheumatism. The physicians
of this period, indeed, appear not only to have done little themselves,
but had omitted to utilise the useful indications furnished by their
predecessors.
Thus how much more swiftly would the clinical distinctness of chronic
articular gout from _rheumatoid arthritis_ have been realised had
Sydenham’s dicta in the seventeenth century regarding this intricate
problem been duly appreciated. Up to his time, the clinical descriptions
of rheumatoid arthritis appeared now under gout, now under rheumatism.
As for Sydenham himself, he placed the disorder, nosologically speaking,
under _chronic rheumatism_, of which he believed it to be an _apyretic_
variety. But the importance of his researches resides in this—he pointed
out that it differed essentially from _gout_, but that, in resemblance
thereof, it might endure throughout life, its course diversified by
remissions and exacerbations. Also he tells us that its excruciating
pains, even when of prolonged standing, sometimes cease spontaneously,
noting also that the joints are, so to speak, turned over, and that there
are nodosities, especially on the inside of the fingers.
Nevertheless, if we except Musgrave’s work (1703), “Arthritis ex
Chlorosi,” which included some undoubted examples of _rheumatoid_ or
atrophic arthritis, no note was taken of Sydenham’s contention until
a century afterwards. True, John Hunter in 1759 described the morbid
anatomy of _osteoarthritis_ or the hypertrophic forms of arthritis
deformans, but not until 1868 was the true significance of Sydenham’s
work appreciated, a most generous tribute being then accorded him by the
great French physician Trousseau.
In 1800 Landre Beauvais published his clinical description of
_rheumatoid_ arthritis under the title “goutte asthenique primitif.” That
Beauvais, as Sir Archibald Garrod contends, included under this title
some cases of true _gout_ is beyond doubt. But the words “Doit admettre
une nouvelle espèce de goutte,” go far to justify Charcot in his claim
that Beauvais, despite the title of his brochure, fully realised that the
disease differed from gout.
A few years later (1804-1816), Heberden, in his Commentaries, insisted
on the essential distinctness of rheumatoid arthritis from gout. Thus he
wrote, “The disease called chronical rheumatism, which often passes under
the general name of rheumatism and is sometimes supposed to be _gout_, is
in reality a very different distemper from the genuine gout, and from the
acute rheumatism, and ought to be carefully distinguished from both.” As
to its salient features he noted its afebrile nature, the lack of redness
in the skin over the affected joints, the relative absence of pain,
and that it displayed no special tendency to begin in the feet. It was
further marked by a protracted course involving severe crippling, while
the peculiar nodosities on the fingers are still associated with his name.
In 1805 Haygarth published his classical essay, “A Clinical History
of the Nodosity of the Joints,” the opening sentence of which shows
that, comparably with his successors, he lamented the laxity with which
the term “rheumatism” was invoked and applied “to a great variety of
disorders which beside pain, have but few symptoms that connect them
together.” A purist in nosology, he equally deplored the term “rheumatick
gout” as tending to perpetuate its confusion with gout and rheumatism,
and suggested the term “Nodosities,” in the hope that “as a distinct
genus it will become a more direct object of medical attention.”
Alas, even as late as 1868 Trousseau deplored the retention of the term
“rheumatic gout” by Garrod and Fuller and his own countryman Trastour.
But, in common justice to Garrod, it must be allowed that in the third
edition of his work he definitely applied the term _rheumatoid_ arthritis
to the disorder in question. Nor can we refrain from recording Fuller’s
words that “the natural history of _rheumatic gout_ accords but little
with that of _acute rheumatism_, and is equally inconsistent with that of
true gout.”
CLEAVAGE OF ARTHRITIS DEFORMANS INTO TWO TYPES
In reviewing the researches of the foregoing writers it will be clearly
seen that though they did yeoman service in differentiating broadly
_gout_ from the disorders grouped under _Arthritis Deformans_, there is
little doubt that not for many years afterwards was their distinctiveness
sufficiently realised. This may be in large part attributed to the fact
that they still awaited the next great process of fission as applied to
chronic joint disorders.
I allude in the first place to Charcot’s momentous discovery of the
_nerve arthropathies_, and secondly, to the cleavage of arthritis
deformans into the _rheumatoid_ or _atrophic_, and the _osteoarthritic_
or _hypertrophic_ varieties.
It is to Vidal that we are indebted for the first clinical description
of the _atrophic_ type. Charcot in his lectures refers to it as the
“Atrophic form of Vidal,” noting that in this variety “induration of the
skin, a sort of scleroderma develops, the cutaneous covering is cold,
pale, smooth, polished, and will not wrinkle, adding also that in such
cases atrophy of the bones and muscles accompanies the wasting of the
soft tissues.”
Notwithstanding this, Charcot, to our mind, unquestionably refers to
the category of _chronic articular gout_ certain of these examples of
Vidal’s _atrophic_ type of _arthritis deformans_. The reasons he adduces
for their _gouty_ nature are, to say the least of it, both conflicting
and unconvincing. On the one hand, he admits that they are clinically
indistinguishable from Vidal’s type, in respect of their pronounced
_atrophic_ changes; on the other, he postulates them as _gouty_ even
though the _uratic deposits_ “either do not exist at all, or only mere
traces of them, or when only the articular cartilages are invaded by the
urate of soda.” It must be conceded that _chronic articular gout_ and
_rheumatoid_ or _atrophic arthritis_ are totally distinct affections.
Now as to the _hypertrophic_ variety, or osteoarthritis, which, of the
twain, more closely resembles gout, and whose confusion therewith is far
from infrequent even at the present time. Sir Dyce Duckworth, while he
recognises with Charcot a _tophaceous_ form of chronic articular gout,
postulates the existence of another type, _arthritis deformans uratica_.
Unlike Charcot, however, he seems only to have included under this term
instances of the osteoarthritic or _hypertrophic_ variety. But like
Charcot, his claim that this particular variety is of _gouty_ nature
seems to rest on equally frail foundations, as witness his statement that
they “may be complicated with visible or invisible tophaceous deposits!”
That osteoarthritis and gout may coexist in the same individual is
certain, and equally sure is it that uratic deposits may supervene in
joints the seat of osteoarthritis. But it is now, I think, generally
conceded that, despite these coincidences, _gouty arthritis_ and
_osteoarthritis_ are wholly distinct disorders, of wholly different
origin.
At this period of our historical _résumé_ we see that by the withdrawal
of these three great groups—_rheumatism_, the _nerve arthropathies_ and
_arthritis deformans_—the domain of gout has, through these several
allotments, undergone substantial shrinkage.
ELIMINATION OF THE INFECTIVE ARTHRITIDES
Yet again was the territory of gout destined to undergo further
restriction, and this largely owing to the rise of the science of
_bacteriology_. For in light of recent improvements in _diagnostic_
methods, who can escape the conviction that under the term “gout” had
been wrongfully included many forms of arthritis, now known to be due to
_specific infections_. What, for example, of Hippocrates’ aphorism that
gout was unknown in youths—_ante usum veneris_—who can doubt that some of
his reputed cases of gout were examples of _gonococcal_ or _syphilitic_
arthritis?
What, too, of all the other infective arthritides—_influenzal_,
_pneumoccocal_, _scarlatinal_, _typhoidal_, _meningococcal_—to mention
only those actually affiliated to some specific organism. For gout, be
it noted, confers no exemption from other arthritic diseases, but how in
time past were such to be differentiated therefrom?
Again, gouty subjects, as has been recently emphasised, are notoriously
prone to _pyorrhœa alveolaris_, and how difficult, given the supervention
of an _arthritis_ in such to define the causal agent—_gout_ or _sepsis_,
which? Small wonder then, that the clinical content of gout, not only to
ancient, but also to latter day physicians, loomed large, swollen as it
undoubtedly was by the inclusion of infective arthritides, not to mention
those of _traumatic_ or _static_ origin.
That more of these alien joint disorders—_les pseudo-rheumatismes
infectieux_, as M. Bouchard terms them, were relegated to the “rheumatic”
than to the “gouty” category, may perhaps be allowed, but still gout
was undoubtedly allotted its full share and to boot. Moreover, if to
“rheumatism” was wrongly affiliated the lion’s share of the _infective
arthritides_, on the other hand to “gout” accrued a host of unrelated
_visceral_ disorders, not to mention affections of the _nervous_ and
_vascular_ structures, etc.
In endeavouring to summarise the results of our brief retrospect, the
somewhat chastening fact emerges, viz., that the isolation of articular
gout has been achieved not so much by an increase in our knowledge as
to what _is_ gout, but through our growing perception of what is _not_
gout. For of the _causa causans_ of gout we are still as ignorant as
in the days of Sydenham. But, in contrast, our enlightenment as to the
clinical and pathological features of other forms of arthritis has
steadily progressed. In this way, shorn of many alien joint disorders,
gouty arthritis has slowly but surely asserted itself as a specific joint
affection, distinct both from rheumatism and arthritis deformans.
In the course of our sketch, too, we have traced the evolution of the
modern opinion that at least two separate conditions, “rheumatoid
arthritis” and “osteoarthritis,” are comprised under arthritis deformans.
This most tardily arrived at differentiation has done more than any other
to clarify our conceptions as to what constitutes true “gouty arthritis.”
If to this be added the further differentiation, not only of the _nerve
arthropathies_, but also of the _infective arthridites_—both specific and
undifferentiated forms—it will be seen that the term “gouty arthritis,”
once the most comprehensive perhaps in all medical nomenclature, has now
been brought within, at any rate, reasonable distance of more or less
exact definition.