Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

(4) The focal areas of decreased density, usually held due to tophi, are probably very often merely focal areas of absorption of lime salts.

In continuation these authorities have endeavoured to identify the nature of the arthritis that occurs in gout. Like other workers in this sphere, the study of the radiographs obtained of gouty joints reveals that a variety of changes occur in the bones and joints of the hands and feet in gouty subjects. These, they consider, may be classified conveniently as follows:—

(1) Cases marked by focal areas of rarefaction, without any other perceptible change;

(2) Cases presenting, in addition to these translucent areas, minor degrees of lipping at the articular margins;

(3) Cases in which the changes in (1) and (2) are conjoined with either localised atrophy of the bones entering into an affected joint, or with generalised atrophy of all the bones in the affected limb;

(4) In addition to all the above changes, narrowing of certain joint spaces with marked proliferative and atrophic changes occurs.

In reviewing these findings of McCarty and McClure, it is important to recollect that they were found in a series of cases all of which exhibited tophi. Moreover, it will be seen that the radiographic changes in some are reminiscent of atrophic or rheumatoid arthritis, in others of hypertrophic arthritis or osteoarthritis, while, lastly, the appearances typical of infective arthritis are also represented. In addition, if we recall that focal areas of rarefaction, indistinguishable from those met with in gout, also occur in all types of non-gouty arthritis, we at once see how impossible it is to detect anything in the radiographic findings distinctive of gouty as opposed to non-gouty arthritides.

McClure and McCarty, comparing the radiographic changes in gouty as opposed to non-gouty arthritis, observe that, though rarefactive foci occur in all varieties of non-gouty arthritis, they are conjoined with other bony or joint changes. On the other hand, translucent areas unassociated with any bone or joint alterations have been found only in gout. But whether this can be claimed as distinctive of gouty arthritis is, they think, uncertain, since relatively few opportunities for X-ray examination of non-gouty arthritis in its early stages have been forthcoming.

Continuing, of their four radiographic types of gouty arthritis the second resembles osteoarthritis; but the third and especially the fourth group, they consider, “fall into a peculiar class,” this inasmuch as their characters resemble the infective type of non-gouty arthritis. They claim, however, that a differentiation, radiographically speaking, can be effected, this because of the “sharply localised” extreme degree of bony atrophy which occurs in the infective type of non-gouty arthritis. However, as they admit that radiographs of the latter (infective non-gouty arthritis) have been noted which “closely resemble” the “atrophic and proliferative changes occurring in gout,” their final conclusion is that in the skiagrams even of typical gouty arthritis there is nothing in the bony or arthritic changes that is diagnostic of gout.

For myself, I must admit that I have come to the same conclusion as McClure and McCarty, viz., that the skiagraphic findings in gouty and non-gouty arthritis trench so much the one upon the characters of the other that I should be loth indeed to base a diagnosis of gout simply on the revelations of skiagraphy. The chief interest to my mind, as I have previously observed, centres round those examples in which peri-articular tophi are associated with underlying bony and arthritic changes (as revealed by X-rays) indistinguishable from those typical of infective arthritis of non-gouty type.