Leaving aside these rare instances of acute gout complicated by acute phlebitis, I think there is a too flippant tendency to regard any phlebitis occurring in middle-aged or elderly subjects as being of this nature, this often in the absence of any evidence, hereditary or other, of a gouty element in the case. Frequently, too, the subjects are women with varicose veins of long standing, and ipso facto potentially liable to phlebitis. But why, in the absence of ancestral or acquired gout, dub such cases forthwith as “gouty”? We may, it is true, as in Paget’s classical instance, elicit a familial tendency to phlebitis, but even so I doubt the legitimacy of the inference that the phlebitis is necessarily “gouty.” Is it not equally true that the tendency to varicose veins is hereditary, and ergo predicates an enhanced liability to phlebitis?
Cutaneous Disorders
The incidence of tophi in the skin naturally engendered the conception that gout was responsible for many and diverse types of cutaneous affections. In accordance with this, every effort was made to prove that they were the outcome of uratic infiltrations, but in vain.
Objective proof of this nature being lacking, the older clinicians found their justification in the alternation of arthritic attacks with cutaneous disorders, and their alternation in inheritance was laid great stress upon, this especially by French dermatologists, notably Bazin, but at the present day Jacquet’s non-committal pronouncement is probably representative of the attitude of the French school as a whole towards “arthritic” affections of the skin: “Le lien admis entre le groupe de maladies dites arthritiques est très mal connu dans son essence, mais il serait tout aussi contraire à l’esprit scientifique de le nier avec rigueur que de l’affirmer avec presomption.”
As to the skin disorders associated with acute types of gout, perhaps the most interesting and well ascertained is herpes. It may precede an acute attack, may alternate with it, or be a sequel thereof. Rendu noted that acne, boils, and carbuncles also might occur prior to, in alternation with, or in sequence to acute attacks, and Scudamore noted the same in respect of erysipelas.
The noteworthy liability of the gouty to these disorders is but another proof that gout predisposes its victims to infections. The fact that acute gouty arthritis might follow acne, boils, etc., lends colour to our contention that the same may be of infective origin. But unfortunately the suspicion also intrudes that some of the arthritides occurring in such association may, on insufficient grounds, have been diagnosed as “gouty,” this especially if the joint disorder were located anywhere save at its classic site, the big toe.
Passing to skin affections associated with chronic gout, it must be admitted that as a whole the contention that they are “gouty” in origin is, to say the least of it, doubtful. French dermatologists claimed that the cutaneous eruptions of the “gouty” might be recognised by their polymorphism, circumscribed location, etc., but these are no more distinctive peculiarities than the concomitant pricking, hyperæsthesia, and hyperalgesia upon which Bazin laid such emphasis in their diagnosis.
In short, sequences, coincidences, and alternations are the basis of much that has been written upon so-called “gouty” cutaneous affections, criteria all of them fruitful sources of fallacy.
As to psoriasis, I have met with it so frequently in association with non-gouty arthritides that I have never felt justified in claiming any example as “gouty.” So-called “gouty” pruritis and prurigo, these when they occur in the “gouty” are frequently referable to an associated glycosuria, and when this is not the case, it is frequently a senile prurigo. The claim that urticaria is “gouty” may be dismissed without comment.
As to frequency of incidence in the “gouty,” eczema undoubtedly must be awarded the palm. But whether the scaliness of skin on extensor surfaces of arms and legs and back of neck, which ultimately, under the influence of skin infection through scratching, develops into a dermatitis which assumes the character of eczema, can be, strictly speaking, held as of “gouty” origin, is questionable. Certainly, whatever be the origin of the pruriginous scaliness of the skin, there can be no doubt that the later dermatitis is the outcome of infection by skin organisms. Frequently the presumption that the eczema is “gouty” rests upon general rather than specific grounds, on “goutiness” rather than “gout.” Accordingly I think it would be wiser to regard eczema as an occasional complication of gout rather than an integral element thereof.