In 1800 Landre Beauvais published his clinical description of rheumatoid arthritis under the title “goutte asthenique primitif.” That Beauvais, as Sir Archibald Garrod contends, included under this title some cases of true gout is beyond doubt. But the words “Doit admettre une nouvelle espèce de goutte,” go far to justify Charcot in his claim that Beauvais, despite the title of his brochure, fully realised that the disease differed from gout.
A few years later (1804-1816), Heberden, in his Commentaries, insisted on the essential distinctness of rheumatoid arthritis from gout. Thus he wrote, “The disease called chronical rheumatism, which often passes under the general name of rheumatism and is sometimes supposed to be gout, is in reality a very different distemper from the genuine gout, and from the acute rheumatism, and ought to be carefully distinguished from both.” As to its salient features he noted its afebrile nature, the lack of redness in the skin over the affected joints, the relative absence of pain, and that it displayed no special tendency to begin in the feet. It was further marked by a protracted course involving severe crippling, while the peculiar nodosities on the fingers are still associated with his name.
In 1805 Haygarth published his classical essay, “A Clinical History of the Nodosity of the Joints,” the opening sentence of which shows that, comparably with his successors, he lamented the laxity with which the term “rheumatism” was invoked and applied “to a great variety of disorders which beside pain, have but few symptoms that connect them together.” A purist in nosology, he equally deplored the term “rheumatick gout” as tending to perpetuate its confusion with gout and rheumatism, and suggested the term “Nodosities,” in the hope that “as a distinct genus it will become a more direct object of medical attention.”
Alas, even as late as 1868 Trousseau deplored the retention of the term “rheumatic gout” by Garrod and Fuller and his own countryman Trastour. But, in common justice to Garrod, it must be allowed that in the third edition of his work he definitely applied the term rheumatoid arthritis to the disorder in question. Nor can we refrain from recording Fuller’s words that “the natural history of rheumatic gout accords but little with that of acute rheumatism, and is equally inconsistent with that of true gout.”
Cleavage of Arthritis Deformans into Two Types
In reviewing the researches of the foregoing writers it will be clearly seen that though they did yeoman service in differentiating broadly gout from the disorders grouped under Arthritis Deformans, there is little doubt that not for many years afterwards was their distinctiveness sufficiently realised. This may be in large part attributed to the fact that they still awaited the next great process of fission as applied to chronic joint disorders.
I allude in the first place to Charcot’s momentous discovery of the nerve arthropathies, and secondly, to the cleavage of arthritis deformans into the rheumatoid or atrophic, and the osteoarthritic or hypertrophic varieties.
It is to Vidal that we are indebted for the first clinical description of the atrophic type. Charcot in his lectures refers to it as the “Atrophic form of Vidal,” noting that in this variety “induration of the skin, a sort of scleroderma develops, the cutaneous covering is cold, pale, smooth, polished, and will not wrinkle, adding also that in such cases atrophy of the bones and muscles accompanies the wasting of the soft tissues.”
Notwithstanding this, Charcot, to our mind, unquestionably refers to the category of chronic articular gout certain of these examples of Vidal’s atrophic type of arthritis deformans. The reasons he adduces for their gouty nature are, to say the least of it, both conflicting and unconvincing. On the one hand, he admits that they are clinically indistinguishable from Vidal’s type, in respect of their pronounced atrophic changes; on the other, he postulates them as gouty even though the uratic deposits “either do not exist at all, or only mere traces of them, or when only the articular cartilages are invaded by the urate of soda.” It must be conceded that chronic articular gout and rheumatoid or atrophic arthritis are totally distinct affections.
Now as to the hypertrophic variety, or osteoarthritis, which, of the twain, more closely resembles gout, and whose confusion therewith is far from infrequent even at the present time. Sir Dyce Duckworth, while he recognises with Charcot a tophaceous form of chronic articular gout, postulates the existence of another type, arthritis deformans uratica. Unlike Charcot, however, he seems only to have included under this term instances of the osteoarthritic or hypertrophic variety. But like Charcot, his claim that this particular variety is of gouty nature seems to rest on equally frail foundations, as witness his statement that they “may be complicated with visible or invisible tophaceous deposits!”