Unquestionably many cases of acute gouty polyarthritis have been confounded with acute articular rheumatism, and vice versâ. Garrod on this point remarks: “That many cases of acute gout have been mistaken for acute rheumatism I do not doubt, and, on the other hand, that some few cases of acute rheumatism have been regarded as of a gouty nature I am no less certain. I may refer to the oft-quoted case related by Dr. Haygarth in which gout was supposed to have been transferred from the extremities to the heart as an example of the latter error.”
It is only, of course, with that type of acute gouty polyarthritis accompanied by pyrexia, and not the afebrile variety, that confusion with acute articular rheumatism is possible. What then are the points of discrimination?
| Acute Articular Rheumatism. | Acute Gouty Polyarthritis. | |
|---|---|---|
| Age and sex | Most common between ages of fourteen and thirty. Predominance of males after twenty. | Maturity and old age. Males. Females markedly exempt. |
| Heredity | Very disputable. | Very pronounced. |
| Onset | Usually abrupt and often with tonsillitis. | Insidious, with premonitory gastro-intestinal symptoms. |
| General symptoms | High fever, sometimes hyperpyrexia. Profuse acid sweats. | Moderate pyrexia. Marked daily remissions. |
| Distribution of lesions | Preference for large joints and markedly mobile. | Small joints, hand or foot often involved. Fixity typical. |
| Local characters | Joints exhibit slight reddish flush. No subsequent desquamation. No residual change. | Scarlet hue and œdema with later peeling of cuticle and itching. Tendency to involvement of bursæ and tendons. |
| Pain | Chiefly evoked by movement. | Spontaneous, more intense. |
| Duration | Twenty to thirty days, sometimes longer. | Six weeks to three months. |
| Associated phenomena | Cardiac lesions common. | Tophi. Occasionally glycosuria and albuminuria. |
| Therapeutic test | Salicylates a specific. | Not so in gout, but colchicum takes this rôle. |
Acute Gonococcal Arthritis
This disorder, as we know, is sometimes of oligo- or poly-articular distribution. Moreover, as the attendant pyrexia may be slight or absent, it may readily be confounded with the afebrile variety of acute gouty polyarthritis. Osier, discussing diagnosis of the latter condition, observes: “A patient with three or four joints red, swollen, and painful in acute rheumatism has fever, and while pyrexia may be present, and often is, in gout, its absence is, I think, a valuable diagnostic sign.”
This is of course true, but it still remains necessary, for reasons above cited, to eliminate acute gonorrhœal arthritis. The tendency to such confusion has been emphasised by Sir Rose Bradford and Sir William Roberts, and I would urge the necessity of being alive to this possibility even in middle-aged men. One thing is certain, viz., we should be extremely chary of pronouncing any coincident urethral discharge to be a so-called “gouty urethritis”; nor should we translate any coincident conjunctivitis or iritis as further evidence of the articular affection being “gouty.” It is far more likely to be gonococcal. Apart from these inflammatory ocular affections, the relics also of previous attacks—viz., irregularity in contour or inequality in size of the pupils—have before now put me on the right track in obscure types of polyarthritis.
To sum up, the following are distinctive characters of generalised gonorrhœal arthritis:—
Etiology.—History or presence of urethral discharge and isolation of the gonococcus.
Onset.—Insidious, seldom acute.
General Symptoms.—Absent or slight relatively to extent and severity of joint mischief. Pyrexia, low grade or absent.