Briefly stated, such is the course of typical, acute articular gout, involving the metatarsal joint of the great toe. Reviewing the indi vidual symptoms, it is evident that pain is the first and most con spicuous phenomenon. It ushers in the attack, and is intolerable before the appearance of redness and swelling. It is felt not so much in the joint between the bones, as in the phalanges themselves—especially upon the lateral borders. In many respects it resembles the throb bing, lancivating pain of a whitlow. It differs from the pain of acute rheumatism by its continuity and its independence of movement and pressure, whereas pain at the beginning of a rheumatic attack is ag gravated by motion and flexure of the joint. Sometimes, even among vigorous subjects, the suffering is quite endurable ; but usually words fail to indicate the agony of the patient. In certain cases the feeling is like that of a dislocation; in others the toe aches as if it had been long immersed in ice-water, or there are sensations as if melted lead or boiling oil were trickling down the calf of the leg. These are sub jective sensations which are not provoked by any form of contact with the limb. If the joint be touched or rubbed or moved, the only feel ing excited is that of intense pain that radiates from the joint through the entire member. The perceptions of heat, cold, and contact are all merged into one common distress.
Swelling is another of the conspicuous phenomena of the attack. Even before its invasion, the superficial veins of the limb become enlarged, and with the outbreak of the paroxysm the joint which is its seat is surrounded by a network of turgid and somewhat varicose vessels. The skin assumes a purple hue, and grows rapidly oedema tons. The cavity of the joint, the neighboring burse and tendinous sheaths are also filled with a serous exudation which acids to the swelling and tension of the part. Even the periosteum in the vicinity of the articulation shares in the universal infiltration. From the toe the swelling extends, in the severest cases, over the upper surface of the foot, sometimes as far as the ankle itself. This is especially true of cases in which the sheaths of the large tendons are involved: the oedema occupies the dorsal and the plantar regions, and sometimes is so great as to cause a sort of fictitious fluctuation along the line of the metatarso-phalangeal articulations. But, ordinarily, the swelling is restricted to the immediate territory of the affected joint.
Pain and swelling are always associated in gouty inflammation, but their incidence is not always simultaneous. Sometimes the joint begins to enlarge before it is painful; in other instances pain is ex perienced for a considerable time before the appearance of swelling. In this respect, the parallel with rheumatism is very close. In cer tain cases there is considerable reduction of suffering as soon as the joint begins to swell.
Another prominent characteristic of acute gout consists in the red ness of the affected joint. The integument is of a dark red or purple
color that is much more pronounced than the coloration of rheumatic swelling. In severe cases of rheumatism there is a rather insignifi cant injection of the skin about the joint and over the sheaths of the large tendons; usually, there is very little change of hue upon the swollen surfaces. But in acute gout the swelling appears tense, and the skin is red and shining, as if an abscess were about to break through its surface. Pressure causes the bright color to disappear for a moment, but it immediately returns as soon as the finger is re moved, and with it comes an aggravation of pain. Quite often the formation of an abscess is still further counterfeited by a deeper red ness and greater degree of swelling upon the lateral surfaces of the great toe. The extent of cutaneous discoloration is conterminous with the swelling in severe cases, and its intensity corresponds with the severity of the attack. But in old chronic cases there is usually very little color, though there may be great and persistent oedema.
Unlike the onset of pain, the color of the inflamed part does not reach its maximum at the beginning of the attack. It first shows itself at the crisis of the initial paroxysm, and only reaches its great est brilliancy during the second night. After the first twenty-four hours the bright tints are transformed into a violet purple hue, which gradually • fades as the nocturnal paroxysms diminish in severity.
The temperature of the inflamed point rises from two to four or five degrees Fahr. during the attack. Thus it is evident that all the classical symptoms of genuine inflammation are exhibited iu the affected part. Another evidence of local cutaneous inflammation is afforded by the exfoliation of the cuticle that follows the subsidence of acute symptoms. The scarf-skin peels off in flakes, and the process, which is accompanied by considerable itching, is sometimes pro longed for more than a week.
The fever that prevails during the attack does not always corre spond with the local symptoms. The pulse often fails to reach one hundred beats in a minute, and the fever-heat seldom rises so high as 102° or 103° F. Excessive temperature and a rapid pulse are the exception rather than the rule. Probably the most constant of the febrile symptoms is the gastric disorder that is associated with the attack. The breath is very offensive ; the tongue is large and flabby, and is covered with a thick yellowish coat; there is an utter disgust for food, but thirst is intense; there is a bitter taste in the mouth; acid eructations and hiccough are very commonly experienced. Vomit ing seldom occurs, but the bowels are constipated. There is consid erable tenderness on pressure over the epigastrium, and the liver is somewhat prominent below the ribs, unless pushed upward by intes tinal flatus.