Chronic Articular Gout
If the diagnosis of acute types of articular gout often presents difficulties, these same are, if anything, accentuated when we approach its chronic manifestations. For, apart from uratic deposits, the anatomical lesions that ensue in joints the seat of long-continued gout have no specific character. In short, there is nothing pathognomonic of gout in the changes produced, and which, as a matter of fact, we know to be capable of production, by many different morbid agencies. Surely this lack of specificity in its structural lesions should make us very chary of admitting to the category of chronic articular gout any examples of arthritis destitute of uratic deposits.
In our chapter on classification we emphasised the desirability of restricting the usage of the term chronic articular gout to that type long since known as tophaceous gout, this because there is little, if any, doubt that that variety known as chronic deforming gout (syn. arthritis deformans uratica) is largely made up of examples of rheumatoid or atrophic arthritis and hypertrophic arthritis or osteoarthritis.[41]
As to osteoarthritis, I do not for a moment deny that uratic deposits may be met with in its victims. One frequently meets with patients, the subjects of osteoarthritis of the hip, who at the same time exhibit tophi in the ears.
But such to our mind are to be regarded as merely instances of osteoarthritis occurring in subjects of “gouty diathesis.” This apparent blending of the two disorders must not be allowed to impair the clarity of our conception as to the essential distinctness of gouty arthritis and osteoarthritis.
Sir W. Hale White has some pregnant observations on this point. Many patients, he says, “with chronic arthritis are quite wrongly said to have gout; usually they have osteoarthritis. The presence of bony outgrowths is strongly against gout, though it is not conclusive, for such may occur in true gout either more or less all round the joint or in the form of little nodules, but they never attain the considerable size common in arthritis,” and he adds: “If no urate of soda is visible anywhere the diagnosis may be very difficult.”
To proceed, the general and local phenomena of chronic articular gout are such as scarcely lend themselves to succinct definition, and for their description we would refer the reader to the chapter dealing with its clinical aspects. As that careful observer Sir Alfred Garrod states: “Chronic gout is at times confined to one or two joints, but sometimes numerous articulations are involved.” In other words, chronic articular gout may be mono-, oligo-, or poly-articular in distribution; and naturally the process of differentiation is modified accordingly.
This being so, I purpose dealing in the first instance with chronic monarticular gout, and in succession with the types of oligo- and poly-articular location.