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.