Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

Sir W. Hale White has some pregnant observations on this point. Many patients, he says, “with chronic arthritis are quite wrongly said to have gout; usually they have osteoarthritis. The presence of bony outgrowths is strongly against gout, though it is not conclusive, for such may occur in true gout either more or less all round the joint or in the form of little nodules, but they never attain the considerable size common in arthritis,” and he adds: “If no urate of soda is visible anywhere the diagnosis may be very difficult.”

To proceed, the general and local phenomena of chronic articular gout are such as scarcely lend themselves to succinct definition, and for their description we would refer the reader to the chapter dealing with its clinical aspects. As that careful observer Sir Alfred Garrod states: “Chronic gout is at times confined to one or two joints, but sometimes numerous articulations are involved.” In other words, chronic articular gout may be mono-, oligo-, or poly-articular in distribution; and naturally the process of differentiation is modified accordingly.

This being so, I purpose dealing in the first instance with chronic monarticular gout, and in succession with the types of oligo- and poly-articular location.

Chronic Monarticular Gout

Occasionally gout in its recurrences clings obstinately to the great toe and tarsal joints. But since the advent of radiography there should be little or no difficulty in differentiating a chronic gouty arthritis of the great toe from the only other arthritic lesion with which it is likely at this stage to be confounded, viz., osteoarthritis. But at the same time we would refer the reader back to the chapter dealing with the differential diagnosis of the localised variety of acute gout, as therein we dealt fully with other possible sources of fallacy, i.e., static deformities, etc. We shall therefore now proceed to discuss those exceptional cases in which chronic gout is located not in one of the small, but in one of the larger, articulations.

Monarticular Gout in Large Articulation a Rarity

Given a chronic arthritis of one of the larger joints, say the ankle, knee, or elbow, we should be careful not to jump too readily to the conclusion that it is of “gouty” nature. The more obscure it appears the more need for caution. Needless to say, if the objective changes be but minimal and the condition be, so to speak, practically a mere arthralgia, there rests upon us the paramount necessity of careful discrimination before labelling it as “gouty” in kind.

Thus, if it be the knee, it may be a referred pain due to hip disorder, e.g., osteoarthritis or tuberculous disease, or it may be symptomatic of an inflammatory process, or, having regard to the usually mature or advanced age of the subject, it may be a neoplasm in the bones.

On the other hand, suppose the subject come complaining not much of pain in his joint, but more troubled because of its enlargements. If now on examination we find also that there is little or no tenderness, but simply a condition of peri-articular thickening or intra-articular effusion, what shall be our method of procedure? Certainly not to leap forthwith to the conclusion that it is gouty. No, not even if he exhibit tophi in his ears.