General Symptoms.—Continuous low grade pyrexia, quick pulse, and rapid emaciation, and commonly concomitant gastro-intestinal derangements.
Distribution of Lesions.—Polyarticular. Beginning in the small joints, it spreads centripetally, with a tendency to symmetry. No migrant trend, but a steady, progressive involvement of joint after joint, including temporo-maxillary and cervical articulations.
Local Characters.—Overlying skin of affected joint white or semi-asphyxial in tint. Contour spindle-shaped, but in terminal stages shrinkage from atrophy of articular structures sets in. Muscular wasting and contracture conspicuous features.
Associated Phenomena.—Trophic and vasomotor changes prominent, but no tendency to cardiac lesions.
Infective Arthritis of Undifferentiated Type
It were well in approaching any acute polyarthritis of obscure nature to bear in mind the axiom that any or all infections may be complicated by arthropathies, also that if the said polyarthritis does not respond quickly to colchicum or salicylate of soda we are almost certainly dealing with an infective arthritis either of specific or undifferentiated type. The specific forms of infective arthritis, as far as seems necessary, have been dealt with, but those rarer forms not referred to, viz., influenzal, pneumococcal, dysenteric, meningococcal, etc., have also to be borne in mind, if the history reveal any recent occurrence of these disorders.
Still far more common than any of these are the acute infective arthritides of undifferentiated type. As we before remarked, an extraordinary general clinical resemblance obtains between these types of joint disorder and acute gouty polyarthritis. Indeed, in the absence of tophi, their differentiation is well-nigh impossible. Even the blood picture in both types of the disorder is strikingly similar in the matter of leucocytosis and secondary anæmia.
Recently Dr. Henry A. Christian, lecturing at a clinic of the Harvard Medical School, emphasised this clinical similarity and the difficulty of discriminating between these two types of joint disorder. As he rightly says, “while there is a definite acute gouty polyarthritis (as evidenced by external tophi or deposits in bone or cartilage with variations in uric acid output) and also an equally definite infective arthritis, yet between those two there is a very considerable number of cases that present some of the factors suggestive of gout and other factors suggestive of an infectious arthritis, and there is where the difficulty comes.”
This is precisely the state of affairs, and one may well ask where gout ends and infection begins. Let us take an example. A man exhibiting tophi, the subject also of pyorrhœa alveolaris, develops an acute polyarthritis. What then is the nature of the joint disorder? There is a gouty element in his case, as attested by tophi, also an infective element, as evidenced by oral sepsis.
Now are we to regard such a case as one of infective arthritis of undifferentiated type occurring in a gouty subject, or are we to proceed on the assumption that the presence of tophi negatives the possibility of infection and forthwith to class it as a case of acute gouty polyarthritis of so-called metabolic origin?