Now as to these distinguished physicians, who shall doubt that of the twain Garrod stood on firmer ground than his predecessor? In arriving at their diagnoses of gout, Scudamore rested on clinical “instinct,” Garrod on clinical “observation.” To the more scientific mind of the latter the tophus appealed with all the insistence of a fact, while the former was yet in bondage to abstract philosophy, dominated too much by crude and unproven hypotheses.
Given the presence of tophi, the diagnosis of a “gouty diathesis” is assured; in their absence it is but speculative.
It is upon this dictum that we would take our stand, and this without depreciating in any way the pioneer researches of Garrod. For it must be recognised that the increasing differentiation of joint diseases has proceeded apace. How many are now affiliated to specific germs, not to mention the undreamt-of light thrown on their inward characters by X-rays! Scudamore’s work appeared exactly a century ago, Garrod’s in 1876. The conclusion then seems inevitable that many of their alleged cases of gout—at any rate, those unattested by tophi—would now be relegated to widely different categories.
But this zeal for infinite cleavage and subdivision, so characteristic of the modern school, far from diminishing, does but accentuate, the diagnostic valency of the tophus. It still remains the infallible criterion of diagnosis, and, for myself, I feel convinced that infinitely more good than harm would ensue if we refuse to recognise any individual as being of the “gouty diathesis” unless he exhibit these objective stigmata thereof.
Of course to some such a rigid attitude will spell anathema. I hear them say in oracular tones: “Never forget gout, or awful indeed will be your awakening.” More harm, say they, is wrought by failure to recognise gout than by diagnosing gout where none is. Doubtless they are right in counselling us not to forget gout, but not to the exclusion of all else. For, at issue with them, I hold it better to miss gout than to miss syphilitic, gonorrhœal, and other forms of arthritis.
“A name being so readily found for an obscure disease, the practitioner considers himself as excused from the difficult task of nicer discrimination.” Thus wrote Scudamore a century since, a rebuke and a warning for all time.
Tophi in Relation to Arthritis
How elated we are, and rightly, when in an obscure form of arthritis we pounce on these objective criteria of gout, how apt to deem our diagnostic quest as ended, and with what fatal glibness the time-worn “gout” slips from our lips, sure, alas, of ready and almost complaisant acceptance. Fallacious inference, all too prevalent, that the presence of tophi stamps any concomitant arthritis as “gouty.”
True, tophi are pathognomonic of gout, but their existence does not confer on their host immunity from all other forms of arthritis. In view of the increasing light shed upon joint disorders, who can doubt that (and this not only for our forefathers) the tophus has too often proved a veritable snare, allaying all diagnostic doubts, lulling us into false security? For an individual may, for example, exhibit auricular tophi and be the victim also of an arthritis, but the latter is not inevitably “gouty.” All that can be assumed at sight is merely that the joint disorder, whatever its nature, has ensued in a subject of “gouty diathesis.”
For it may be of specific infective origin, gonococcal, syphilitic, pneumococcal, etc. Quâ a concomitant arthritis, then, the diagnostic significance of tophi, at any rate when of ab-articular site, must not be overrated. It is at once a beacon and a warning. In other words, the diagnosis of a co-existent arthritis as “gouty” should not be entertained pending the exclusion of all other forms of arthritis.