It is beyond the scope of this volume to outline the methods of differentiating and determining the exact organisms which may be responsible for gouty arthritis. But if we aim at rational as opposed to purely haphazard serum or vaccine therapy, we must effect a differential specific diagnosis in a bacteriological sense. How searching our investigations must be in these cases we learn from Adami’s brilliant address on sub-infection when he laid down the axiom that in all cases “there ought to be routine blood cultures, routine examination and reports on the stools and their predominant bacterial types, blood counts, hæmoglobin examination, in fact the full clinical study of each case, so that nothing is neglected.”
No apology is needed for our insistence on the imperative necessity of routine systematic investigation from all sides of these cases of gouty arthritis. For its origin still remains hidden, and who can doubt that, to remove this long-standing reproach, we must approach our study of these cases in a more catholic attitude of mind, one bent on etiological, not merely nosological, diagnosis?
Clinical Diagnosis
Introductory Remarks
The word gout itself is void of offence, innocent of scientific pretensions, neither expressing nor violating any article of pathological belief. But let us not forget that the term is neither self-explanatory nor final. Derived through the French goutte from the Latin gutta, it but expresses laconically the fanciful doctrine of those who so christened it.
What the old humoralists saw was the tophus, and would that they had clung more steadfastly to this as their sheet anchor in diagnosis! but casting their moorings, they launched forth on the uncharted seas of abstract philosophy. Even in the writings of the nineteenth century physicians we trace the influence of their disquisitions, and we are tempted to think that some even of our day still bide beneath their thrall.
But, with the advance of pathology to the dignity of a natural science, we must assert our independence of misty hypotheses, rendering obeisance only to facts. What then, may we ask, is the outstanding fact of the “gouty diathesis”? It is, in a word, the tophus! Even as the vague and shadowy constitutional warp known as the “rheumatic diathesis” finds expression, or rather becomes incarnate, in fibrous nodule and induration, so also does the equally nebulous “gouty diathesis” become objective, crystallised in the tophus.
The Diagnostic Status of Tophi
This problem calls for more critical consideration than is usually accorded thereto. The tophus is, in truth, the touchstone of gout, yet not a little controversy obtains as to the frequency of its incidence in “gouty” subjects.
At one extreme we find Sir Charles Scudamore maintaining that tophi have occurred in only a few individuals “of particular ‘gouty’ idiosyncrasy,” in, according to him, less than 10 per cent. of the victims. At the other Sir Alfred Garrod, discussing these figures, observes: “From my own experience I consider these numbers far below the real proportion, from their being deposited in parts of the body scarcely to be expected.”