During the acute paroxysm the urine presents the ordinary char acteristics of febrile urine; it is scanty, high-colored, but does not contain bile-pigment. Usually it contains orates and uric acid in considerable quantity, though the amount is generally less than is discharged during the intermissions. Sometimes; when the attack is severe, there may be a trace of albumin in the urine, but this is a transient febrile phenomenon, and it disappears in the course of a few days without damage to the kidneys. As the attacks decline, the secretion of urine becomes more profuse, and sometimes assumes for a few days the character of a veritable polyuria.
Convalescence in the case of a young and vigorous subject, especially after a first attack, is usually rapid and leads to perfect recovery. The inflamed joints exhibit their original flexibility, with out any trace of swelling or other impediment to motion. In many instances the general health is greatly improved, and various ailments that have been mentioned among the forerunners of an attack of gout are now completely relieved.
But, on the other hand, there are patients who are less fortunate.
oedema sometimes persists for a long period after the disappearance of other inflammatory symptoms. In other cases, though there be no swelling nor mineral deposit, the joint remains stiffened, and inordinately sensitive to changes of temperature. Many individuals even after a brief attack are greatly debilitated, as if they had been ill for weeks or months. Sometimes there is considerable emaciation, and the muscles on the proximal side of the affected joint may undergo atrophy, just as they may dwindle after a severe attack of rheuma tism, or after a traumatic inflammation of a joint. In a certain num ber of cases, the attack degenerates into chronic gout; the joints remain permanently enlarged, and a uratic deposit rapidly makes its appearance in the peri-articular tissues.
The tendency to localization in the great toe is one of the most notable facts in connection with the first attack acute gout. Garrod was of the opinion that not more than five per cent. of cases escaped without an initial inflammation of the joints of the great toe. Of forty cases reported by Braun, there were only two in which the inflammation did not begin in the toe or in the metatarsal region. Scudamore collected a total of five hundred and sixteen cases, in which the joint of the great toe was attacked in three hundred and seventy-three instances, while both toes were simultaneously inflamed in twenty-seven cases. Occasionally, however, any one or all of the
principal joints may be involved, while the great toe escapes entirely. In such cases, however, it is sometimes possible to identify a cause for such an irregular localization : the occurrence of a previous injury, a sprain, a bruise, an unusual degree of exercise in walking, may de termine the outbreak of inflammation in the ankle, the knee, the wrist, or the elbow. Thus, an elderly prelate of my acquaintance, finding himself at an out-of-the-way station in the country, without means of conveyance, was obliged to walk for several miles to the church where he was to officiate. An attack of gout in the knee-joints fol lowed this unusual exertion. In this respect, the manifestation of gout sometimes follows the same course that has been often observed in the localization of articular rheumatism and of syphilis. Occa sionally, after a general shock or injury, such as may be produced by a fall or a concussion, the localization of an attack of gout is widely diffused, and many of the joints are simultaneously inflamed. In such cases it may be very difficult to distinguish the case from an attack of rheumatism, hut in the majority of instances it will be found, on careful inquiry, that the patient had suffered with one or more previous attacks in which the great toe alone, or in association with other joints, had been involved.
The manner in which an attack of gout is localized upon one or upon several joints is not without importance in its relation to the prognosis. When one articulation alone is attacked, and when the severity of the paroxysms is great and sharply defined, the course of the disease is much more rapid, and recovery is more complete than when several joints are tardily involved. The intensity of the suffer ing that is experienced varies much according to the temperament of the individual. Nervous and excitable patients suffer more than those who are dull and phlegmatic. Recurrent attacks also serve to reduce the power of reaction, so that with return of the disease the onset is less acute, and the pain is less severe. But, even among the victims of chronic gout, it is not unusual to witness the occasional recurrence of an acute attack that is marked by a considerable por tion of the vivacity of the original paroxysms.