CLINICAL DIAGNOSIS (_continued_)
ACUTE ARTICULAR GOUT—LOCALISED VARIETY
The nonchalance with which not a few writers dismiss the diagnosis of
_acute gout_ when located in the _great toe_ or elsewhere in the foot
is, to say the least of it, somewhat remarkable. “It is a very easy
matter,” say they, and as an earnest of their good faith are silent
as to the many pitfalls that await the unwary. Should they deign to
_differential_ diagnosis, they are at pains to discriminate between it
and _acute articular rheumatism_, which _re_ classical outbreaks in the
_toe_ seems a little superfluous! But not a word of _traumatic_ lesions,
_infective_ processes and _static_ deformities, all infinitely more
likely stumbling-blocks.
Did all cases conform to the classic type, _acute sthenic gout_, it might
be held relatively easy. But such are not, to say the least of it, common
nowadays. More often than not our examples are, as Garrod terms them, of
acute _asthenic_ character. As he observes: “There may be indeed pain and
tenderness in the toe, and some amount of swelling, but accompanied with
little heat or redness, and all febrile disturbance may be absent; still
œdema is generally observed and itching and desquamation follow.”
That diseases, like their victims, alter with environment is but too
clear. Who can doubt that the gout of the Regency has to-day assumed a
milder clinical _facies_? Physicians of those days were haunted with the
fear of confounding it with _erysipelas_ and _phlegmon_. Still, while no
such fears apparently beset us to-day, it were well to walk circumspectly.
Thus, recently a friend of mine came across an instance of what he deemed
_acute gout_ in a _metacarpo-phalangeal_ joint. Its failure to respond to
colchicum and the growing intensity and extent of the local inflammation
suggested incision, when, lo, pus issued, to the subject’s comfort, but
to his own chastening!
There are, however, many more likely sources of fallacy, these, too, of
the most diverse type, inasmuch as they differ according to the exact
location in the foot of the assumed gouty process. For while the _big
toe_ is the _site of predilection_ for the _initial_ manifestation, it
is not always so. The _primary_ outbreak may be located in any of the
smaller joints of the foot, or outside them in related structures: in
the _heel_, the _sole_, or the _tendo Achillis_. These vagaries greatly
enhance the difficulties of diagnosis. For the process of differentiation
will vary according to the particular joint or structure involved, the
predilections of certain infective processes, not to mention the marked
liability of the foot to painful disturbances of static origin.
DIFFERENTIAL DIAGNOSIS
Inasmuch as the primary outbreak may be located in any part of the foot,
we purpose, for reasons just cited, dealing _seriatim_ with gout in (1)
the big toe; (2) the instep; (3) the heel; (4) the sole.
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_.
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.
_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.”
GOUT IN THE HEEL
In some instances the first manifestations of gout occur in the heel,
while in others the sheath of the neighbouring tendo Achillis is the part
first invaded. Probably there is no region of the foot in which there
exist more pitfalls, and doubly careful should we be before concluding
that any painful or inflammatory condition thereof is one of “gout.”
_Referred Pain._—Pain in the heel affords many loopholes for
misinterpretation. It may, as Sir James Paget pointed out many years
ago, be symptomatic of a _renal calculus_. In my own experience it is
sometimes complained of by the subjects of _internal hæmorrhoids_, the
pain waxing and waning with the variations in the rectal trouble, and
only disappearing permanently when the piles have been radically treated.
It is, again, a symptom sometimes complained of by the victims of
_enlarged prostate_.
LOCAL SOURCES OF FALLACY
If the pain and tenderness be located on the _under_-surface of the os
calcis, there are several misconceptions possible.
(1) Careful examination may reveal a tendency to flatfoot, the
pain being referable to strain on the posterior insertion of
the plantar fascia.
(2) The root of the trouble may be a gonococcal inflammation of
the plantar fascia, or of the periosteum covering the os calcis.
(3) A skiagram may show the existence of a bony spur on the
inferior surface of the os calcis.
(4) The bursa under the os calcis may be inflamed.
(5) Also, as Tubby has pointed out, pain in the heel may be
referable to shortening of one leg or constant standing, and
more rarely to tuberculous disease of the os calcis.
If the pain and tenderness be located on the _posterior_ surface of the
os calcis, or in the tendo Achillis, the following should be excluded
before assigning the trouble to “gout”:—
(1) _Post-calcaneal Bursitis._—Inflammation of the bursa lying
between the os calcis and the tendo Achillis is not uncommon.
It may be uni- or bi-lateral, and in the majority of instances
is attributable to violent exercise, or chafing of the heel
by ill-fitting boots. The local swelling and tenderness at
the site of the inflamed bursa and its aggravation by plantar
flexion of the foot will afford a clue to its true nature. (An
exostosis projecting from the hinder surface is sometimes a
cause of post-calcaneal bursitis.)
(2) _Synovitis of the Tendo Achillis._—Symptoms very similar to
those above described have been met with in a teno-synovitis
of the tendo Achillis, as evidenced by swelling of the sheath,
tenderness, and silky crepitus.
GOUT IN THE SOLE
There is a wide disposition to regard all painful or unpleasant
sensations in the sole of the foot as evidences of “goutiness.” It may
be recalled that Strabo, according to Plutarch, apostrophised heat or
itching of the feet at night as “the lisping of the gout.” Duckworth,
too, emphasised the frequency of this symptom in the gouty, and Sir
Charles Scudamore also held heat and dryness of the sole as frequent
harbingers of acute attacks. Now, did we but confine our hazards as
to gout only to cases marked by heat or itching in the sole, possibly
little harm might result; but unfortunately there is a flippant readiness
to relegate all obscure pains or abnormal sensations in the sole to
the “gouty” category. Needless to say, this is quite unjustifiable. We
need not reiterate the bounden necessity of excluding all static foot
deformities, but we should in addition recall the various types of
_plantar neuralgia_.
_Plantar Neuralgia._—Occasionally, as we have pointed out elsewhere,
the pain is of almost unendurable severity. It constitutes one of the
types of so-called _partial sciatica_, the pain and paræsthesia being
confined to the plantar nerves. Indeed, pain, numbness, hyperæsthesia,
or sweating of the sole are often symptomatic of a definite neuritis.
Such may follow typhoid fever or caisson disease, and in this latter be
of aggravated type. When we realise that the pain in these cases may be
limited to the tips of the toes or the _ball of the great toe_, we see
how readily it may be confused with “gout.” Fortunately plantar neuralgia
is exceptionally rare; but even after exclusion of the foregoing causes
we should, before pronouncing any such neuralgia to be “gouty,” recollect
that plantar neuralgia or hyperæsthesia is very common in _alcoholism_
and _hysteria_.
_Erythromelalgia._—Among the exceptional cases that find their way to
spas are examples of this rare disorder. Almost invariably they come
under the diagnosis of “gout” or “rheumatism.” When we reflect that in
the majority of instances the initial burning pain typical of the disease
is located in some part of the sole of one foot, and that the associated
redness and vascularity may be delimited to the _ball of the great toe_,
the heel, or outer or inner side of the foot, we see the danger of its
being too easily referred to “gout.”
If seen at the zenith of an attack, the severe pain, the local heat,
the intense purplish redness, the distension of the veins, and in some
instances œdema, how close the resemblance to gout! Precisely also, as
in gout, the simulation of a deep-seated inflammatory process is very
pronounced. Indeed, in not a few examples of erythromelalgia fruitless
incisions have been made. Accordingly in all cases of pain, redness, and
swelling in the sole of the foot, we should canvass the possibility that
we may be face to face with an instance of erythromelalgia, a disorder
which, like gout, is most frequently met with in men of middle age.
In drawing to a close our remarks on the diagnosis of _acute gout_ in
the _foot_, we would emphasise the fact that in all such cases the
bare feet should be thoroughly examined. For, apart from _infective_
and _traumatic_ lesions, the frequency with which the various _static
foot deformities_ are confused with “gout” is incredibly common. That
_gout may co-exist with hallux valgus_ or other distortion we readily
admit, but this does not absolve us of our responsibility—correction of
the static deformity. Combine this, if you will, with constitutional
treatment if there be evidence, _i.e._, tophi, of a “gouty” diathesis,
but, we repeat, correct the mechanical defect. For gout may come and go,
but static errors remain. In so doing, the victim will be saved much
preventable suffering, and, for aught known to the contrary, the removal
of irritation and local congestion may haply minimise the chances of
subsequent gouty outbreaks.
ANOMALOUS SITES FOR INITIAL OUTBREAKS
While _primary_ attacks are in the vast majority of instances localised
to the _foot_, if not actually to the _toe_, it is well to recollect
that very rarely the _knee_, the _wrist_, _elbow_, or _ankle_ may be the
chosen spot. In such cases there is need for exceptional caution before
committing oneself to a diagnosis of _gout_. Certainly not until all
other known causes of _acute arthritis_ of _monarticular_ type have been
excluded.
If in the _knee_ or _wrist_, any possibility of _injury_ or _strain_
should be thoroughly canvassed. To make assurance doubly sure, a
radiograph should always be taken. Specific infective forms of arthritis
then call for careful elimination—_i.e._, gonococcal, etc. If there be no
history of such, a painstaking search should be made for any local foci
of infection, _e.g._, mouth and accessory cavities. If any be found, they
should be radically treated, as it is much more likely that the arthritis
is due thereto than to gout.
If, notwithstanding a meticulously careful investigation, no cause can be
assigned, we may entertain the possibility of its being _gout_, the more
legitimately if the subject be a middle-aged man coming of gouty ancestry
and exhibiting himself tokens of this diathesis, _i.e._, _tophi_. It
would be confirmatory, too, if, apart from its exceptional localisation,
the joint disorder in its course conformed to that typical of gout in the
toe, in other words if it was of sudden nocturnal onset, showed marked
daily remissions in temperature and pain, responded swiftly to the action
of colchicum, and was not protracted beyond the usual week or ten days.
Sir Hale White, discussing the diagnosis of acute gout of unusual
localisation, remarks: “The real difficulty in acute cases comes when
it is suggested that an acute arthritis with pyrexia and swelling and
redness of a joint other than that of the great toe is caused by gout.
I have recently seen the difficulty in one patient in the wrist, in
another in the knee. Such cases, if they are not gout, are some bacterial
arthritis.”