Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

Now, as Bassett Jones and I have pointed out in a previous work, this condition, symmetrical villous synovitis of the knees, is a very common joint disorder in women at or near the menopause. Frequently they give a history of numerous pregnancies, or of rapidly increasing obesity, while with or without this latter they display a faulty postural attitude, indicative of lowered muscular and ligamentary tone. Following in the wake of these, the subject develops a symmetrical flatfoot, which, according to the stage at which it is seen, may be of flexible or rigid type.

Now, such is the mutual static interdependence of the component parts of the lower limb that this condition of flatfoot promotes or favours the incidence of villous overgrowths in the proximal joints, the knees. As to the modus operandi we have put forward the following explanation: “The everted foot, with its sunken arch, as before stated, determines an alteration in the normal coaptation of the articular surfaces in the knee, and this incongruence is revealed in skiagraphs by the marked prominence laterally of the external tibial tuberosity beneath the external femoral condyle. Coincidently, and for the same reason, additional strain is thrown upon the internal lateral ligament. This in turn favours a state of passive congestion or hyperæmia of the synovial membrane, which becomes relaxed and thrown into folds, especially at its reflexions near the edges of the cartilages. If, as often happens, the individual is the subject of varicose veins or suffers from a general lack of tone in her muscular or ligamentary structures, this tendency to venous engorgement of the knees is much enhanced.”

“Under the influence of these mechanical factors and their associated circulatory disturbances, thickening and enlargement of the synovial fringes ensue. The inflammatory condition thus produced tends to increase automatically, as, owing to the articular incongruence, the enlarged fringes are very prone to become caught between the joint surfaces; in other words, a vicious circle is produced, as with the increasing villous hypertrophy the liability to internal traumatisms increases pari passu.”

Villous Synovitis Static and Non-gouty in Origin

In short, the joint disorder is fundamentally of static or mechanical origin, and, this being so, the results of anti-gouty treatment are open to a further misinterpretation. The victims, as we have said, exhibit very generally a tendency to obesity. Now, Ebstein and many others hold the view that obesity and gout have affinities. Ebstein, moreover, believes that treatment directed to the reduction of body weight will check the appearance of gouty arthritis or ameliorate the same when avowed. What happens is this: these corpulent subjects are placed on a special dietary. Hydrocarbon foodstuffs are limited, bread, amylaceous food and liquids being also restricted. Naturally, pari passu with reduction in their body weight, their overburdened joints become more equal to their office. But those who assume that the chronic arthritis is of gouty origin attribute, and, we think, wrongly, the beneficial results attained to correction of the underlying “gouty” habit.

We prefer to subscribe to the simpler or mechanical theory, and in view of the widespread and, as we believe, erroneous belief in the gouty nature of this arthritis, we take the liberty of appending the salient features of these cases, while adding further a few remarks on the differential diagnosis of other symmetrical affections of the knees which may also be wrongly attributed to gout.

Clinical Symptoms of Villous Synovitis

The onset is gradual and insidious. Stiffness is the salient symptom, but sometimes the subject is more distressed by a sense of weakness, distension and unreliability. Pain is slight or absent, save when during walking pseudo-locking occurs. The mobility of the joints is usually unimpaired, and if any limitation exist it is the power of full extension that is usually restricted.

Objectively the joint shows either general enlargement or swelling localised to the supra- or infra-patellar regions. Intra-articular effusion which comes and goes is a very characteristic feature. On palpation a peculiar soft silken crepitus will be heard and felt as the patient alternately flexes and extends the limb. The enlarged fringes are also easily to be felt as knots or nodules which can be moved up or down on the underlying bone. The ease with which they can be appreciated depends upon the degree of effusion present at the time. Judging from their symptomatology, it seems probable that some of the cases included in Sir Dyce Duckworth’s category, chronic deforming gout, are of this description.