Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

Gout in the Big Toe

Infections.—There is no â priori reason why any of the infections may not find a nidus in the first metatarso-phalangeal joint. Thus, Garrod, as we know, held gouty subjects specially liable to pyæmia. In rare instances, the primary focus has been in or near the great toe, and has consequently been mistaken for gout. The rapid progress of the disease would of course soon clear up the nature of the case. But if the subject has previously suffered from gout, such a diagnostic error at first sight is quite excusable. Accordingly, as a safeguard in all doubtful cases, inquiry should be made as to the existence of bladder troubles, piles, etc., especially any recent operation in this or other regions.

Again, while gout in its articular form is rarely, if ever, met with in children, it must be recalled, on the authority of Sir James Goodhart, that rheumatism in their instance is occasionally limited to one joint. Moreover, this distinguished physician actually saw it localised in the great toe, “in a case in which the subsequent course of the disease showed that it was acute rheumatism.”

Acute Gonococcal Arthritis.—We may recall that Van Swieten, a disciple of Boerhaave, held that sometimes a wife while nursing her gouty husband had contracted the same disorder. A tribute, we fear, to Van Swieten’s diplomacy rather than to his clinical acumen—an euphemism for gonorrhœal rheumatism!

Of course in adolescents or in young adults monarticular pain, with or without swelling, heat, or redness, should not suggest “gout,” but an infective disorder either in the joint or the related bone-ends. At the same time middle-aged men enjoy no immunity from gonorrhœa, and we may add that gonococcal infection of the metatarso-phalangeal joints is not so uncommon. When located in that of the great toe, it is easy to see how readily the acute arthritis may be confused with gout. But, unlike the latter, its duration is measured by months or weeks rather than by days. It is well to recollect, too, that “gouty” persons are more prone to develop arthritis following gonococcal infection. Given therefore a history even remote, we should in doubtful cases recall the longevity of the organism, its persistence in the prostatic recesses, and the need for bacteriological investigation.

Traumatic Lesions.—Its exposed situation renders the big toe very liable to trauma. Often, too, the injury being slight, and not followed by any immediate consequences, the connection may easily be overlooked. A blow or a fall may readily bruise the synovial membrane without at first any external sign. But given trivial hæmorrhage into the cavity or subjacent tissues, an acute synovitis with effusion is induced.

Again, joint disorder following injury is usually monarticular, whereas the same when the outcome of so-called “constitutional” causes is generally oligo- or poly-articular. The relevancy of this is obvious when we recall that initial attacks of gout are monarticular. Accordingly, given a history of definite injury to the toe joint, the question arises, Is it acute gout or acute traumatic arthritis? this especially if the subject has not had a previous attack of gout at this site.

Here I would lay stress on the fact that indirect rather than direct traumatisms are more common antecedents or determinants of gout, viz., sprains or strains. Moreover, in reviewing the writings of the older physicians one is driven to the conclusion that frequently a septic cellulitis, synovitis, or a frankly traumatic arthritis was confused with acute gout.

The following examples cited by Scudamore are, we contend, susceptible of such an explanation: “A gentleman much subject to gout, when considering himself unusually well, underwent the slight operation of having the nail of the great toe cut on account of its improper growth. The toe was much pressed, and gouty inflammation was the immediate consequence.” In another case “the patient, never before having suffered the gout, tore off a broken portion of the thumb-nail, so as to make the part tender. Very soon the thumb and part of the hand put on a swollen and shiny appearance, and was exquisitely painful. A poultice was applied. Suddenly on the third evening the pain quitted the thumb and seized the toe, next the ankle, then the knee, and lastly the great toe of the other foot. Throughout he secured ease and sleep till the first light of the morning appeared, and hence facetiously observed that the gout in this respect assumed all the behaviour of a ghost.” Was not this probably a case of septic absorption with cellulitis and a mild degree of sapræmia, evoking arthralgic pains?

In conclusion, without denying the potentialities of trauma, whether direct or indirect, in determining an outbreak of gout, we would submit that its diagnosis under such circumstances should not be hastily arrived at, but by the slower process of elimination, this especially if the trauma has involved slight abrasions with the possibility of sepsis. A quick response to colchicum would of course be highly suggestive of gout.

Acute Osteoarthritis.—It is perhaps not so widely recognised as it should be that osteoarthritis not uncommonly attacks the metatarso-phalangeal joint of the great toe. It becomes enlarged owing to the hypertrophy of the articular ends. Like similar lesions in the small joints of the hand, the big toe joint from time to time undergoes exacerbation, with increased vascularity and local heat, which, though of minor degree, may by a superficial examiner be readily misinterpreted as gout. The parts are painful, somewhat swollen, hot, and tender, but the local symptoms are never intense, and constitutional disturbance is lacking. The presence of osteoarthritic lesions elsewhere and the revelations of skiagraphy will suffice for differentiation of such cases from asthenic articular gout.