Chapter II: The Pedigree of Gout

Under the vague term “articulorum passio” or “arthritis” the physicians of antiquity handed down to posterity the clinical description of a disease in the varied symptomatology of which we may descry at one time the features of gout and anon those of rheumatism. But centuries had to elapse before gout became differentiated from rheumatism. For there is no doubt that not only the Greek and Roman physicians, but those also of the Græco-Arabian school, confounded these two disorders, or more accurately failed to differentiate rheumatism.

So it is that Charcot, reviewing the antiquity of gout, while he pays a graceful tribute to the ancient physicians for their masterly disquisitions thereon, at the same time deplored their silence on the subject of articular rheumatism.

This absence of allusion thereto is the more remarkable in that the term “rheumatism” or “rheumes” dates from a very remote period. Both words, in truth, were indifferently enlisted to denote all those diseases deemed attributable to the defluxion of some acrid humour upon one or other part of the body. Used by the ancients more in accordance with its etymological sense, the term “rheumes” or “rheumatism,” finds a place even in the writings of Pliny and Ovid. But our modern conception of the disorder differs widely from “the flux of humours” which the Greeks named rheumatism, or “the sharpe and eager flux of fleam” which for them characterised an attack of the “rheumes.”

The early English authors, too, invoked the word as a general term descriptive of various forms of disease. Sir Thomas Elyot, in his “Castel of Health,” so scoffed at by the faculty in his day, inculcates abstemiousness in those afflicted with the “rheumes,” and in “Julius Caesar,” Brutus is warned by Portia not to tempt “the rheumy unpurged ayre of night,” a clear indication that the term was used as a synonym for fluxions, humours and catarrhs of all sorts. But as to the malign _articular_ forms of the affection, never a word; and this almost inexplicable silence led Sydenham, Haecker and Leupoldt to surmise that articular rheumatism was a modern disease unknown amongst the ancients.

ISOLATION OF ACUTE ARTICULAR RHEUMATISM FROM GOUT

Hallowed by tradition, this erroneous conception of the identity of gout and rheumatism endured until 1642, when Baillon, in his treatise “De Rheumatismo et Pleuritide,” effected a cleavage, at any rate between the acute varieties of these two diseases.

Dissociating the term “rheumatism” from its primitive interpretation, Baillon restricted its usage to that particular group of symptoms we now call _acute articular rheumatism_. In the same century Sydenham, in his “Classical Observations,” materially clarified the existing clinical confusion, defining with his customary lucidity the essential differences between the two disorders.

TARDY DISSOCIATION OF CHRONIC GOUT FROM CHRONIC RHEUMATISM

Bearing in mind the centuries that elapsed before the _acute_ articular forms of gout and rheumatism were dissociated, one ceases to marvel that the task, incomparably more difficult, of discriminating between the _chronic_ forms of these diseases is even now barely accomplished.

“Rheumatissimus agnatus podagræ” said our forefathers, the axiom postulating not the actual identity of the two affections, but a near relationship, and in this non-committal phrase we may, I think, descry the birth of that modern term “_L’arthritisme_,” so beloved of the French physicians. Even as late as the beginning of the nineteenth century Chomel at the Saltpetrière taught his pupils that gout and rheumatism were but clinical variants of an underlying “arthritic diathesis,” his successor Pidoux being still more insistent that the two disorders sprang from one common root. Even Charcot and Trousseau, convinced as they were of the essential distinctness of the two disorders, nevertheless admitted that at the bedside their _chronic_ manifestations were with difficulty dissociated, the former pointing to the terms “rhumatisme goutteux” and “rheumatic gout” as tacit acknowledgments of our impotence.

Nor did this view that _gout_ and alike _rheumatism_ are the outcome of a _basic arthritic diathesis_ fail of doughty supporters in this country. Thus Hutchinson, in his “Pedigree of Disease,” observes “gout is but rarely of pure breed, and often a complication of rheumatism. It so often mixes itself up with rheumatism, and the two, in hereditary transmission, become so intimately united, that it is a matter of considerable difficulty to ascertain how far rheumatism pure can go ... when this complication exists. It shows its power, we may suspect, by inducing a permanent modification of tissue, and it is to this modification that the peculiarities in the processes (transitory rheumatic pains in joints, fasciæ, and muscles, chronic crippling arthritis, destructive arthritis with eburnation, lumbago, sciatica) are due. Hence the impossibility under many conditions of discriminating between gout and rheumatism.”

Laycock also subscribed to Charcot’s view, and Sir Dyce Duckworth confesses that the conception of “a basic diathetic habit of body called _arthritic_ has well commended itself to my mind,” while as to the clinical commingling of the two disorders Sir Charles Scudamore spoke with no uncertain voice. That an individual may in youth suffer from _acute articular rheumatism_, and later in life develop _gout_, is undeniable, as also the reverse, that a gouty subject may be harassed by manifestations of chronic rheumatism or _fibrositis_. But this mutual trenching of the one upon the clinical territory of the other must not be allowed to impair our views as to the essential distinctness of _gout_ and _rheumatism_. It is undeniable that the difficulty of differentiating between the _chronic_ forms of these two disorders is great, for not even the revelations of _skiagraphy_, in the absence of a clinical history, will suffice to effect a discrimination. But to a further consideration of this vexed matter we refer the reader to the coming chapters on Diagnosis.

IDENTIFICATION OF MUSCULAR RHEUMATISM

But to resume our thread, one great step forward we owe to Cullen, who not only differentiated _acute_ from _chronic_ articular rheumatism, but also clearly portrayed the clinical distinctness from both of _muscular_ rheumatism. In so doing, he materially assisted in the differentiation of these same disorders from _gout_. But at the same time, owing to his immoderate advocacy of “chill” as the one great cause of _rheumatism_ in all its forms, he undoubtedly retarded progress. For immediately there arose a cloud of witnesses who claimed a “rheumatic kinship” for a myriad _visceral_ disorders, the victims of which had suffered exposure. Thus throughout the seventeenth and eighteenth centuries many of the conditions now assigned to _irregular gout_ were affiliated instead to _rheumatism_.

DIFFERENTIATION OF CHRONIC GOUT FROM ARTHRITIS DEFORMANS

Apart from Cullen’s contribution the eighteenth century was unmarked by any further advance in differentiating the mass of heterogenous joint affections, indifferently classed as gout and rheumatism. The physicians of this period, indeed, appear not only to have done little themselves, but had omitted to utilise the useful indications furnished by their predecessors.

Thus how much more swiftly would the clinical distinctness of chronic articular gout from _rheumatoid arthritis_ have been realised had Sydenham’s dicta in the seventeenth century regarding this intricate problem been duly appreciated. Up to his time, the clinical descriptions of rheumatoid arthritis appeared now under gout, now under rheumatism. As for Sydenham himself, he placed the disorder, nosologically speaking, under _chronic rheumatism_, of which he believed it to be an _apyretic_ variety. But the importance of his researches resides in this—he pointed out that it differed essentially from _gout_, but that, in resemblance thereof, it might endure throughout life, its course diversified by remissions and exacerbations. Also he tells us that its excruciating pains, even when of prolonged standing, sometimes cease spontaneously, noting also that the joints are, so to speak, turned over, and that there are nodosities, especially on the inside of the fingers.

Nevertheless, if we except Musgrave’s work (1703), “Arthritis ex Chlorosi,” which included some undoubted examples of _rheumatoid_ or atrophic arthritis, no note was taken of Sydenham’s contention until a century afterwards. True, John Hunter in 1759 described the morbid anatomy of _osteoarthritis_ or the hypertrophic forms of arthritis deformans, but not until 1868 was the true significance of Sydenham’s work appreciated, a most generous tribute being then accorded him by the great French physician Trousseau.

In 1800 Landre Beauvais published his clinical description of _rheumatoid_ arthritis under the title “goutte asthenique primitif.” That Beauvais, as Sir Archibald Garrod contends, included under this title some cases of true _gout_ is beyond doubt. But the words “Doit admettre une nouvelle espèce de goutte,” go far to justify Charcot in his claim that Beauvais, despite the title of his brochure, fully realised that the disease differed from gout.

A few years later (1804-1816), Heberden, in his Commentaries, insisted on the essential distinctness of rheumatoid arthritis from gout. Thus he wrote, “The disease called chronical rheumatism, which often passes under the general name of rheumatism and is sometimes supposed to be _gout_, is in reality a very different distemper from the genuine gout, and from the acute rheumatism, and ought to be carefully distinguished from both.” As to its salient features he noted its afebrile nature, the lack of redness in the skin over the affected joints, the relative absence of pain, and that it displayed no special tendency to begin in the feet. It was further marked by a protracted course involving severe crippling, while the peculiar nodosities on the fingers are still associated with his name.

In 1805 Haygarth published his classical essay, “A Clinical History of the Nodosity of the Joints,” the opening sentence of which shows that, comparably with his successors, he lamented the laxity with which the term “rheumatism” was invoked and applied “to a great variety of disorders which beside pain, have but few symptoms that connect them together.” A purist in nosology, he equally deplored the term “rheumatick gout” as tending to perpetuate its confusion with gout and rheumatism, and suggested the term “Nodosities,” in the hope that “as a distinct genus it will become a more direct object of medical attention.”

Alas, even as late as 1868 Trousseau deplored the retention of the term “rheumatic gout” by Garrod and Fuller and his own countryman Trastour. But, in common justice to Garrod, it must be allowed that in the third edition of his work he definitely applied the term _rheumatoid_ arthritis to the disorder in question. Nor can we refrain from recording Fuller’s words that “the natural history of _rheumatic gout_ accords but little with that of _acute rheumatism_, and is equally inconsistent with that of true gout.”

CLEAVAGE OF ARTHRITIS DEFORMANS INTO TWO TYPES

In reviewing the researches of the foregoing writers it will be clearly seen that though they did yeoman service in differentiating broadly _gout_ from the disorders grouped under _Arthritis Deformans_, there is little doubt that not for many years afterwards was their distinctiveness sufficiently realised. This may be in large part attributed to the fact that they still awaited the next great process of fission as applied to chronic joint disorders.

I allude in the first place to Charcot’s momentous discovery of the _nerve arthropathies_, and secondly, to the cleavage of arthritis deformans into the _rheumatoid_ or _atrophic_, and the _osteoarthritic_ or _hypertrophic_ varieties.

It is to Vidal that we are indebted for the first clinical description of the _atrophic_ type. Charcot in his lectures refers to it as the “Atrophic form of Vidal,” noting that in this variety “induration of the skin, a sort of scleroderma develops, the cutaneous covering is cold, pale, smooth, polished, and will not wrinkle, adding also that in such cases atrophy of the bones and muscles accompanies the wasting of the soft tissues.”

Notwithstanding this, Charcot, to our mind, unquestionably refers to the category of _chronic articular gout_ certain of these examples of Vidal’s _atrophic_ type of _arthritis deformans_. The reasons he adduces for their _gouty_ nature are, to say the least of it, both conflicting and unconvincing. On the one hand, he admits that they are clinically indistinguishable from Vidal’s type, in respect of their pronounced _atrophic_ changes; on the other, he postulates them as _gouty_ even though the _uratic deposits_ “either do not exist at all, or only mere traces of them, or when only the articular cartilages are invaded by the urate of soda.” It must be conceded that _chronic articular gout_ and _rheumatoid_ or _atrophic arthritis_ are totally distinct affections.

Now as to the _hypertrophic_ variety, or osteoarthritis, which, of the twain, more closely resembles gout, and whose confusion therewith is far from infrequent even at the present time. Sir Dyce Duckworth, while he recognises with Charcot a _tophaceous_ form of chronic articular gout, postulates the existence of another type, _arthritis deformans uratica_. Unlike Charcot, however, he seems only to have included under this term instances of the osteoarthritic or _hypertrophic_ variety. But like Charcot, his claim that this particular variety is of _gouty_ nature seems to rest on equally frail foundations, as witness his statement that they “may be complicated with visible or invisible tophaceous deposits!”

That osteoarthritis and gout may coexist in the same individual is certain, and equally sure is it that uratic deposits may supervene in joints the seat of osteoarthritis. But it is now, I think, generally conceded that, despite these coincidences, _gouty arthritis_ and _osteoarthritis_ are wholly distinct disorders, of wholly different origin.

At this period of our historical _résumé_ we see that by the withdrawal of these three great groups—_rheumatism_, the _nerve arthropathies_ and _arthritis deformans_—the domain of gout has, through these several allotments, undergone substantial shrinkage.

ELIMINATION OF THE INFECTIVE ARTHRITIDES

Yet again was the territory of gout destined to undergo further restriction, and this largely owing to the rise of the science of _bacteriology_. For in light of recent improvements in _diagnostic_ methods, who can escape the conviction that under the term “gout” had been wrongfully included many forms of arthritis, now known to be due to _specific infections_. What, for example, of Hippocrates’ aphorism that gout was unknown in youths—_ante usum veneris_—who can doubt that some of his reputed cases of gout were examples of _gonococcal_ or _syphilitic_ arthritis?

What, too, of all the other infective arthritides—_influenzal_, _pneumoccocal_, _scarlatinal_, _typhoidal_, _meningococcal_—to mention only those actually affiliated to some specific organism. For gout, be it noted, confers no exemption from other arthritic diseases, but how in time past were such to be differentiated therefrom?

Again, gouty subjects, as has been recently emphasised, are notoriously prone to _pyorrhœa alveolaris_, and how difficult, given the supervention of an _arthritis_ in such to define the causal agent—_gout_ or _sepsis_, which? Small wonder then, that the clinical content of gout, not only to ancient, but also to latter day physicians, loomed large, swollen as it undoubtedly was by the inclusion of infective arthritides, not to mention those of _traumatic_ or _static_ origin.

That more of these alien joint disorders—_les pseudo-rheumatismes infectieux_, as M. Bouchard terms them, were relegated to the “rheumatic” than to the “gouty” category, may perhaps be allowed, but still gout was undoubtedly allotted its full share and to boot. Moreover, if to “rheumatism” was wrongly affiliated the lion’s share of the _infective arthritides_, on the other hand to “gout” accrued a host of unrelated _visceral_ disorders, not to mention affections of the _nervous_ and _vascular_ structures, etc.

In endeavouring to summarise the results of our brief retrospect, the somewhat chastening fact emerges, viz., that the isolation of articular gout has been achieved not so much by an increase in our knowledge as to what _is_ gout, but through our growing perception of what is _not_ gout. For of the _causa causans_ of gout we are still as ignorant as in the days of Sydenham. But, in contrast, our enlightenment as to the clinical and pathological features of other forms of arthritis has steadily progressed. In this way, shorn of many alien joint disorders, gouty arthritis has slowly but surely asserted itself as a specific joint affection, distinct both from rheumatism and arthritis deformans.

In the course of our sketch, too, we have traced the evolution of the modern opinion that at least two separate conditions, “rheumatoid arthritis” and “osteoarthritis,” are comprised under arthritis deformans. This most tardily arrived at differentiation has done more than any other to clarify our conceptions as to what constitutes true “gouty arthritis.”

If to this be added the further differentiation, not only of the _nerve arthropathies_, but also of the _infective arthridites_—both specific and undifferentiated forms—it will be seen that the term “gouty arthritis,” once the most comprehensive perhaps in all medical nomenclature, has now been brought within, at any rate, reasonable distance of more or less exact definition.