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.