Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

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.

Static Foot Deformities

Hallux Valgus with Inflamed Bunion.—Scudamore in his “Treatise on Gout” observes that “the bursal disease over the first joint of the great toe, which is familiarly known as bunion, is a very common complaint with gouty persons.” In view of the fact that no reference is made in the context to the absence or presence in such cases of a condition of hallux valgus, one is led to believe that Scudamore overlooked the deformity and regarded the local bursitis as the outcome of a gouty inflammation of this structure.

Bradford and Lovatt, discussing hallux valgus, observe: “There may be pain and irritability in the great toe joint, and in severe cases extreme pain and difficulty in walking, which is usually attributed by the patient to gout.” We would only qualify this statement by the fact that the local heat, redness, and swelling that in this condition so often follow slight injuries or excessive walking is not only so interpreted by the patient, but far too frequently also by his medical attendant.

Routine examination of the bare foot will minimise the chance of such a fallacy, though of course it must be borne in mind that a gouty subject may present this deformity. But when we recollect that hallux valgus of slight degree “is almost universally present after middle childhood,” we see that, given the presence of this static foot deformity, any inflammatory process in the superjacent structures is infinitely more likely to be due to an inflammatory bursitis than to a gouty arthritis.

Given an inflamed bursa with cellulitis spreading over the dorsum of the foot, confusion with acute sthenic gout is all too easy. But in our experience, mirabile dictu, the ordinary more or less chronic circumscribed redness over the bunion is but too commonly misinterpreted as gout, this particularly in women, despite the rarity with which gout attacks their toe and the frequency with which their footgear is precisely adapted to produce hallux valgus. Given therefore the presence of this static foot deformity, we should in the absence of objective stigmata of gout, viz., tophi, suspend our diagnosis pending observation of the results obtained by local treatment of the displaced toe.