Tophi, I contend, notwithstanding, are essential for the diagnosis of gout. In their absence, the designation of an arthritis as “gouty” is unjustifiable. Either tophi are, or tophi are not the sole pathognomonic feature of gout. If the latter, then gout ceases to exist as a clinically recognisable entity.
Holding tophi indispensable for the diagnosis of gout, I maintain that Charcot and Duckworth’s plea for the recognition of a chronic type of articular gout, apart from the tophaceous variety, is untenable. Fraught, moreover, with risk, as I am satisfied that their so-called, “deforming” type is largely made up of the atrophic and hypertrophic forms of arthritis deformans.
Suggested Classification of Articular Gout
For myself, as to the classification of the articular types of gout, I would divide them into:
- (1) Acute articular gout.
- (2) Chronic articular gout.
Under the first group I would place not only the acute localised type, but also those acute varieties of polyarticular distribution. As to the second category, I would exclude therefrom, for the reasons cited, the so-called “deforming” varieties of chronic articular gout, recognising only the so-called tophaceous form. But I would place a different interpretation on this term in opposition to that generally accepted; for, by most writers the word tophaceous is apparently limited in its application to examples which, so to speak, exhibit tophi of phenomenal size or number. Scudamore was the chief offender in this respect. As a consequence, he found tophi in only 10 per cent. of his cases of gout. Accordingly, he went so far as to postulate for such victims as did present this peculiarity an idiosyncratic tendency to chalk-stones! In other words, he would seem to suggest that there is a gout within gout, that one displays chalk-stones, the other not. By inference, Duckworth and his followers, by differentiating tophaceous gout, tacitly concur, and so “confusion twice confounded” results.
This usage of the term “tophaceous” is unjustifiable and misleading. The significance of tophi is qualitative not quantitative. One tophus bespeaks the “gouty diathesis” as surely as a myriad concretions. Solitary though it be, the same, given elimination of all other sources of arthritis, will suffice to establish the “gouty” nature of an associated joint disorder. It is in this more catholic sense that I would translate the term “tophaceous gout.” The conclusion, then, to my mind, is obvious—there is but one form of articular gout, and one only, viz., an arthritis, the victim of which exhibits uratic deposits in situ or elsewhere in his body. On this and on no other grounds can a chronic arthritis, with any show of certitude, be certified as truly “uratic” or “gouty.”
This rigid attitude may not commend itself to some, but I feel convinced that, only by holding on grimly to the tophus, shall we steer a safe course through all the pitfalls that beset the diagnosis of the chronic arthritides. Only in this way, too, can we preserve for ourselves a clear conception of gouty arthritis as a specific disorder, the which otherwise loses its identity, submerged in a medley of joint diseases. Prior to the differentiation of gout, on the one hand, from rheumatism and arthritis deformans, and on the other from the nerve arthropathies and the infective arthritides, such laxity might be condonable, but not, we think, in the present stage of our knowledge.
In drawing to a close my remarks on the classifications of articular gout, it will be noted that I have made no reference to that variety known as retrocedent gout, but to this I shall allude at a more favourable juncture, viz., in the chapter devoted to the clinical account of articular gout. Conformably, too, it will, I think, be more convenient, to defer any criticisms of the term “irregular gout” to the chapter I purpose devoting to consideration of the varied clinical content of the same.