Acute Articular Gout—Localised Variety
The nonchalance with which not a few writers dismiss the diagnosis of acute gout when located in the great toe or elsewhere in the foot is, to say the least of it, somewhat remarkable. “It is a very easy matter,” say they, and as an earnest of their good faith are silent as to the many pitfalls that await the unwary. Should they deign to differential diagnosis, they are at pains to discriminate between it and acute articular rheumatism, which re classical outbreaks in the toe seems a little superfluous! But not a word of traumatic lesions, infective processes and static deformities, all infinitely more likely stumbling-blocks.
Did all cases conform to the classic type, acute sthenic gout, it might be held relatively easy. But such are not, to say the least of it, common nowadays. More often than not our examples are, as Garrod terms them, of acute asthenic character. As he observes: “There may be indeed pain and tenderness in the toe, and some amount of swelling, but accompanied with little heat or redness, and all febrile disturbance may be absent; still œdema is generally observed and itching and desquamation follow.”
That diseases, like their victims, alter with environment is but too clear. Who can doubt that the gout of the Regency has to-day assumed a milder clinical facies? Physicians of those days were haunted with the fear of confounding it with erysipelas and phlegmon. Still, while no such fears apparently beset us to-day, it were well to walk circumspectly.
Thus, recently a friend of mine came across an instance of what he deemed acute gout in a metacarpo-phalangeal joint. Its failure to respond to colchicum and the growing intensity and extent of the local inflammation suggested incision, when, lo, pus issued, to the subject’s comfort, but to his own chastening!
There are, however, many more likely sources of fallacy, these, too, of the most diverse type, inasmuch as they differ according to the exact location in the foot of the assumed gouty process. For while the big toe is the site of predilection for the initial manifestation, it is not always so. The primary outbreak may be located in any of the smaller joints of the foot, or outside them in related structures: in the heel, the sole, or the tendo Achillis. These vagaries greatly enhance the difficulties of diagnosis. For the process of differentiation will vary according to the particular joint or structure involved, the predilections of certain infective processes, not to mention the marked liability of the foot to painful disturbances of static origin.