Bearing in mind the centuries that elapsed before the acute articular forms of gout and rheumatism were dissociated, one ceases to marvel that the task, incomparably more difficult, of discriminating between the chronic forms of these diseases is even now barely accomplished.
“Rheumatissimus agnatus podagræ” said our forefathers, the axiom postulating not the actual identity of the two affections, but a near relationship, and in this non-committal phrase we may, I think, descry the birth of that modern term “L’arthritisme,” so beloved of the French physicians. Even as late as the beginning of the nineteenth century Chomel at the Saltpetrière taught his pupils that gout and rheumatism were but clinical variants of an underlying “arthritic diathesis,” his successor Pidoux being still more insistent that the two disorders sprang from one common root. Even Charcot and Trousseau, convinced as they were of the essential distinctness of the two disorders, nevertheless admitted that at the bedside their chronic manifestations were with difficulty dissociated, the former pointing to the terms “rhumatisme goutteux” and “rheumatic gout” as tacit acknowledgments of our impotence.
Nor did this view that gout and alike rheumatism are the outcome of a basic arthritic diathesis fail of doughty supporters in this country. Thus Hutchinson, in his “Pedigree of Disease,” observes “gout is but rarely of pure breed, and often a complication of rheumatism. It so often mixes itself up with rheumatism, and the two, in hereditary transmission, become so intimately united, that it is a matter of considerable difficulty to ascertain how far rheumatism pure can go ... when this complication exists. It shows its power, we may suspect, by inducing a permanent modification of tissue, and it is to this modification that the peculiarities in the processes (transitory rheumatic pains in joints, fasciæ, and muscles, chronic crippling arthritis, destructive arthritis with eburnation, lumbago, sciatica) are due. Hence the impossibility under many conditions of discriminating between gout and rheumatism.”
Laycock also subscribed to Charcot’s view, and Sir Dyce Duckworth confesses that the conception of “a basic diathetic habit of body called arthritic has well commended itself to my mind,” while as to the clinical commingling of the two disorders Sir Charles Scudamore spoke with no uncertain voice. That an individual may in youth suffer from acute articular rheumatism, and later in life develop gout, is undeniable, as also the reverse, that a gouty subject may be harassed by manifestations of chronic rheumatism or fibrositis. But this mutual trenching of the one upon the clinical territory of the other must not be allowed to impair our views as to the essential distinctness of gout and rheumatism. It is undeniable that the difficulty of differentiating between the chronic forms of these two disorders is great, for not even the revelations of skiagraphy, in the absence of a clinical history, will suffice to effect a discrimination. But to a further consideration of this vexed matter we refer the reader to the coming chapters on Diagnosis.
Identification of Muscular Rheumatism
But to resume our thread, one great step forward we owe to Cullen, who not only differentiated acute from chronic articular rheumatism, but also clearly portrayed the clinical distinctness from both of muscular rheumatism. In so doing, he materially assisted in the differentiation of these same disorders from gout. But at the same time, owing to his immoderate advocacy of “chill” as the one great cause of rheumatism in all its forms, he undoubtedly retarded progress. For immediately there arose a cloud of witnesses who claimed a “rheumatic kinship” for a myriad visceral disorders, the victims of which had suffered exposure. Thus throughout the seventeenth and eighteenth centuries many of the conditions now assigned to irregular gout were affiliated instead to rheumatism.
Differentiation of Chronic Gout From Arthritis Deformans
Apart from Cullen’s contribution the eighteenth century was unmarked by any further advance in differentiating the mass of heterogenous joint affections, indifferently classed as gout and rheumatism. The physicians of this period, indeed, appear not only to have done little themselves, but had omitted to utilise the useful indications furnished by their predecessors.
Thus how much more swiftly would the clinical distinctness of chronic articular gout from rheumatoid arthritis have been realised had Sydenham’s dicta in the seventeenth century regarding this intricate problem been duly appreciated. Up to his time, the clinical descriptions of rheumatoid arthritis appeared now under gout, now under rheumatism. As for Sydenham himself, he placed the disorder, nosologically speaking, under chronic rheumatism, of which he believed it to be an apyretic variety. But the importance of his researches resides in this—he pointed out that it differed essentially from gout, but that, in resemblance thereof, it might endure throughout life, its course diversified by remissions and exacerbations. Also he tells us that its excruciating pains, even when of prolonged standing, sometimes cease spontaneously, noting also that the joints are, so to speak, turned over, and that there are nodosities, especially on the inside of the fingers.
Nevertheless, if we except Musgrave’s work (1703), “Arthritis ex Chlorosi,” which included some undoubted examples of rheumatoid or atrophic arthritis, no note was taken of Sydenham’s contention until a century afterwards. True, John Hunter in 1759 described the morbid anatomy of osteoarthritis or the hypertrophic forms of arthritis deformans, but not until 1868 was the true significance of Sydenham’s work appreciated, a most generous tribute being then accorded him by the great French physician Trousseau.