Chronic Gout of Polyarticular Distribution
The clinical portrait of tophaceous gout when of widespread distribution is one of the most striking to be met with in the whole domain of medicine, but for the broad outlines of the picture presented we would refer the reader to the chapter dealing with the clinical description of chronic articular gout.
In these polyarticular forms the most distinctive joint deformities are those met with in the hands or feet, more particularly the former. The excrescences produced are the outcome of successive uratic deposits. These latter when massive can scarcely be confused with any other disorder, for the superjacent skin, distended by the ever-increasing underlying uratic deposits, becomes thinned and purplish red in hue, and occasionally ulcerates. I have at present in my wards a case of this nature, and the subject hoards up the exuding “chalk” in a small bottle.
Fortunately such marked examples are relatively rare, though easily recognised; but it is the less marked types that occasion difficulty in diagnosis. The point at issue of course is the differentiation of moderate-sized or small tophaceous swellings from bony outgrowths. Frequently the task is impossible of achievement without resorting to puncture, when, if anything can be withdrawn, microscopic examination may reveal the presence of biurate crystals.
For the rest, attention to the following points will prove helpful in enabling us to differentiate clinically between gouty arthritis and other chronic joint disorders attended by deformities:—
(1) Tophi when of recent incidence are soft, and when of long standing are never so dense or so hard as bony outgrowths.
(2) The overlying skin is thin, and through its substance the subjacent white concretions may sometimes be discerned. It may be adherent, or the seat of ulcers.
(3) Uratic deposits are not located exactly at the level of the articulation. They do not adapt themselves to the contour or shape of the bone-ends.
(4) Unlike osseous growths, they may be slightly movable in lateral directions.
(5) Tophi may soften or disappear after exacerbations of arthritis.