Hallux Rigidus.—This deformity is but too often overlooked, and if marked by pain and more or less rigidity of the first metatarso-phalangeal joint, it may, in lack of adequate examination, be flippantly dismissed as “gout,” this more particularly in its later stages, when, in addition to pain and stiffness therein, the joint is swollen, tender to the touch, and the bony ends actually enlarged. Here again local examination, if carefully carried out, will suffice to obviate such errors, while the quick response to rest and appropriate applications, with correction of the frequently associated sunken arch, will sufficiently attest its true nature.
Metatarsalgia.—As pointed out in our previous work on Fibrositis, “this painful condition is more often than not confused with rheumatism or gout.” We have known subjects wander to nearly every spa on the Continent under such a misconception. Not to mention the financial expense, the dietetic penances imposed, the consequences of such faulty diagnosis, are by no means trivial, for the intensity of the suffering may reduce the walking capacity to a minimum.
The neuralgic pain radiates into the toes and often upwards into the leg, usually comes on while walking, and is relieved by the removal of the boot. For its detection any altered relationship in the position of the third, fourth, and fifth metatarsals, especially their displacement to a lower level than normal, should be noted, and any limitation of the power of dorsal flexion of the foot likewise estimated. The presence of callosities under the heads of the metatarsals is very suggestive of this painful condition.
Gout in the Instep
Next to the metatarso-phalangeal joints, the tarsal articulations are the most frequent site of initial attacks of gout. Here again we would insist on the necessity of excluding infections of the tarsal joints or shafts and even more important, static foot deformities.
Gonococcal Arthritis.—In a table compiled by Garrod from those of Foucart, Brandes, Rollet, and Fournier, the relative frequency of the implication of individual joints in gonorrhœal arthritis shows that out of a total of 119 the tarsus and metatarsus were attacked in five instances. In the more acute cases the periarticular swelling, local heat, and pink blush may be confused with acute gout. The resemblance is enhanced in that, as in gout, the overlying tendon sheaths are liable to become inflamed and distended with fluid.
Tuberculous and Syphilitic Disease of the Tarsal Joints or the Related Joints.—In cases of obscure pain and inflammatory trouble in the instep the possibility of arthritic and bony lesions of this nature should not be overlooked, especially if there be suggestive lesions elsewhere, or if the history afford evidence of the possibility of such contingencies.
Pes Planus.—In all cases of pain and swelling, with or without redness, in the instep, it is well to recollect that, though flatfoot may for a long time exist without giving rise to symptoms, it frequently happens that, in sequence to some unusual strain on the plantar arch, the static disturbance in the foot enters quite abruptly on a painful phase. Congestion and swelling of the foot is common, and actual teno-synovitis of the tibial and peroneal muscles is not infrequent. Tenderness, too, at points of ligamentary strain is almost always present, and more or less constant pain.[40]
The frequency with which the local and referred pains of flatfoot are misinterpreted as “gout” and dietetic restrictions and other useless and uncalled-for methods of therapy enjoined is well exemplified by a case which has just left our consulting room.
The subject, a middle-aged spinster of lean kind, came to Bath for treatment of her supposed gout, and for which indeed she had previously received spa therapy. Her feet when bared showed a condition of double hallux valgus with related bursal thickenings. The occasional inflammation of these latter structures and the recital of doubtful ancestral proclivities were the sole evidence on which was based the diagnosis of gout. In addition, as is so frequent in hallux valgus, there was associated therewith a bilateral flatfoot, and it may be added that in the left foot a hammer-toe had been removed some years since. Unfortunately the neglected symmetrical flatfoot had, as so frequently happens, initiated, through the erroneous deflection of a body weight, a condition of chronic villous synovitis in both knees. This again was misinterpreted as but another proof of her assumed “gouty” diathesis. Reflecting upon human nature, how curious the reluctance with which such subjects elect to part with their “gout.” Women especially hold tenaciously thereto, even those of austere type, clinging to the taint handed down to them from some far-off ancestor whose “superfluity of naughtiness” was a by-word among his generation. To exchange gout, morbus dominorum, for “flatfoot” and inflamed “bunions,” savours of degradation, and to couple it with aspersions on their footgear is well-nigh insupportable. Nor are the “lords of creation,” we fear, exempt from this failing. We recall during the War being consulted by a highly placed officer who complained of gout. A well-preserved man of nigh sixty years of age, he obviously prided himself on being immaculately booted. As such patients frequently do, he brought his own diagnosis of “gout.” Removing his footgear, manifestly too small, his crucified toes stood out with bunions in a state of hot resentment. But impeachment of his boots was too much for him. Persuasion and argument were futile, and I doubt not he walks to-day stiff, a martyr to his vanity. “Il faut souffrir pour être belle.”