Apart from the probability of such erroneous relegation to the “gouty” category of non-gouty arthritides, there remains this further consideration, the ease with which tophi, even when superficial, may be overlooked. We look for pearly white concretions, and if none are seen we straightway assume that tophi are absent. This, I am sure, is a very common pitfall. At their inception tophi are neither white nor hard. They are largely fluid and soft to touch. The skin over them may be unchanged in colour or reddened. Only when mature, and the overlying skin is thin, do they assume the ordinary aspects of a tophus. These observations apply not only to tophi in the ears, but to those in the vicinity of the small joints of the hands and feet or elsewhere. I would urge that in the case of all soft localised swellings of dubious nature in the neighbourhood of the phalangeal joints aspiration with a hypodermic syringe will often prove very helpful. If fluid can be withdrawn and the same microscopically examined, it will more often than is supposed reveal the presence of biurate crystals.
More information is badly needed as to the relationship of their formation to acute attacks of gout. Garrod on this point remarks: “The deposits are probably formed during an attack of gout, but occasionally they appear shortly afterwards. In one case, of which I have notes, the ears were carefully examined without result when the patient left the hospital, but within ten days, on re-examination, a deposit was found. Perhaps some fluid was effused during the fit, but being at first transparent, could not be easily distinguished.” Sir Dyce Duckworth, too, observes: “After acute attacks of gout have passed off there may follow renewed pain in the neighbourhood of the joint, and later there is discovered a nodular or soft swelling. In the latter case there may be fluctuation, indicating a liquid collection of urates. This should never be opened. In a few weeks this tumour tends to indurate, grow more compact, and a so-called ‘chalky’ concretion is established.”
Reflection upon the foregoing considerations leads me to the conclusion that not only was Garrod right in his affirmation that “gouty inflammation is invariably attended with the deposition of urate of soda,” but more that examples of true uratic arthritis which lack tophi are exceptional, and that in their absence their diagnosis as such cannot be with certitude established.
We have now, we trust, sufficiently defined our attitude towards the tophus, the salient objective stigma of a “gouty diathesis,” and the indispensable rôle it plays in enabling us to establish the diagnosis of articular gout.
CHAPTER XX
CLINICAL DIAGNOSIS (continued)
Acute Articular Gout—Localised Variety
The nonchalance with which not a few writers dismiss the diagnosis of acute gout when located in the great toe or elsewhere in the foot is, to say the least of it, somewhat remarkable. “It is a very easy matter,” say they, and as an earnest of their good faith are silent as to the many pitfalls that await the unwary. Should they deign to differential diagnosis, they are at pains to discriminate between it and acute articular rheumatism, which re classical outbreaks in the toe seems a little superfluous! But not a word of traumatic lesions, infective processes and static deformities, all infinitely more likely stumbling-blocks.
Did all cases conform to the classic type, acute sthenic gout, it might be held relatively easy. But such are not, to say the least of it, common nowadays. More often than not our examples are, as Garrod terms them, of acute asthenic character. As he observes: “There may be indeed pain and tenderness in the toe, and some amount of swelling, but accompanied with little heat or redness, and all febrile disturbance may be absent; still œdema is generally observed and itching and desquamation follow.”
That diseases, like their victims, alter with environment is but too clear. Who can doubt that the gout of the Regency has to-day assumed a milder clinical facies? Physicians of those days were haunted with the fear of confounding it with erysipelas and phlegmon. Still, while no such fears apparently beset us to-day, it were well to walk circumspectly.