[39] In this connection the tendency of gouty glycosurics to exhibit boils and sometimes carbuncles should not be forgotten.
[40] Max Strunsky, of New York, discussing the frequency with which by the older physicians gouty forms of arthritis were confused with gonorrhœal, syphilitic, and other undifferentiated forms of infective arthritis, makes the following observation: “Also flatfeet must have added herds of cases, for this pathological entity was as yet unknown. The rich man in pursuit of his pleasure and the poor man from prolonged standing at his labour strained their arches then as they do now, and women by their ultra-fashionable shoes, which fashion decreed upon them in certain periods of history, produced painful feet which were undoubtedly mistaken for gout. That patients with local foot trouble were treated for gout the writer can speak from experience. A typical case is of a woman who came to his office two years ago. She had broken-down anterior arches. Hallux valgus, hammer-toes, and bunions were present, and the heels were small and undeveloped. Her feet were one mass of pain, and they looked infantile, reminding one of a Chinese woman. All her adult life she wore high-heeled, narrow, pointed, tight shoes. She said that for twenty years she had been treated for gout.”
[41] In support of this contention, I would note that Charcot, while he gives us an inimitable account of the tophaceous variety of gout, introduces also another variant, as he deems it, of chronic articular gout. The joint changes in this latter are marked by what he terms “a thorough atrophy,” including the superjacent skin, which “is pale, shining and polished.” With this are associated ankyloses, angular deflections, and partial dislocations. The joints, he states, “may be absolutely free from swelling, for example when the extra-articular urate deposits either do not exist at all, or only mere traces of them, or when only the articular cartilages are invaded by the urate of soda.” It cannot, we think, be doubted that the clinical content of this group is largely made up of rheumatoid or atrophic arthritis. The evidence that these examples, quâ uratic deposits, are of “gouty” nature, is obviously very slender.
Reverting to Sir Dyce Duckworth, this authority also recognises two varieties of chronic articular gout: (a) tophaceous gout; (b) chronic deforming gout, with as its synonym arthritis deformans uratica. As to the clinical content of this latter group he writes: “The fingers, hands, and wrists show various deformities depending on over-growth of articulating ends of bone, cartilage, ligaments, and bursæ. These may be complicated with visible or invisible tophaceous deposits.” As to these anatomical alterations, Duckworth regards them as “similar to, but not the same as, those induced by rheumatic disease.” But he adds: “It is very rare for the deformities of true gout to attain the gross characters peculiar to chronic rheumatic arthritis; they are altogether of lesser degree in the majority of the worst instances.” From a careful study of their anatomical characters, I cannot avoid the conclusion that they were in the main examples of the hypertrophic variety of arthritis deformans, viz., osteoarthritis.
[42] As Sir W. Hale White has pointed out, “pads” not uncommonly develop on the dorsal aspects of the mid-phalangeal joints. They range in size from a split pea to a hazel nut. Histologically they are the outcome of an excessive overgrowth of fibrous tissue beneath the corium. They in no way involve the joints, but, according to Hale White, they have been confused with osteoarthritis. Their frequent association with Dupuytren’s contracture might conceivably lead to their confusion with gout also, inasmuch as that deformity is so widely attributed to a “gouty” habit.
[43] Sir Spencer Wells in his “Practical Observations on Gout and its Complications and on the Treatment of Joints stiffened by Gouty Deposits.”
“Of the many cases related by authors as anonymous disease by far the greater portion were connected with a gouty diathesis, as indicated both by the formation of calculi, by the occurrence of regular paroxysms of gout, and by the descent of the individual from gouty ancestors; they are cases, in fact, which would have been better understood and better treated if they had been termed ‘anomalous gout’; but as the subjects are young females, they are of course set down as ‘anomalous hysteria.’”—Laycock: “Nervous Diseases of Women.”
[44] “Diseases of the Eye” (1918), p. 258.
[45] “Diseases of the Eye” (1919).
[46] “Diseases and Injuries of the Eye” (1913).