"After some hours of this excruciating pain, some relief is obtained, comina gradually or quite suddenly, perspiration occurs, and sleep follows. On the follow ing day the affected joint is found swelled, red, tense, shining, and tender. Some pain continues all the day, and toward evening it becomes aggravated, reaching almost the same intensity as in the preceding night." The temperature is somewhat elevated; it reaches 102° F., but seldom higher; the pulse varies from SO to inn For some days the symptoms may recur in the same manner, then some cedema appears around the affected joint, and successively increases to the fourth or fifth day, when the pain finally commences to decline; the swelling of the affected joint then diminishes, and this is commonly followed by cracking and peeling of of the cuticle: a process accompanied by intense itching. When the great toe-joint or similar small artic ulations are affected no effusion in the joint can be felt; when larger articula tions, such as the knee-joint, are at tacked, this sign is frequently observed.
During the attack there is commonly thirst, but no appetite; the patient feels even aversion to solid food and some nausea; vomiting very rarely occurs; the tongue is furred and the bowels consti pated, or there may be some pale and offensive stools. The urine is scanty, concentrated, and a copious sediment of urates and uric-acid crystals is precipi tated.
When the attack has passed away, the patient often feels better than before it; some weakness, tenderness, and stiffness of the affected joint remains for some days, then complete recovery is estab lished. The duration of the whole at tack varies from six to ten days, and may even reach some weeks; in that case there are numerous remissions and exacerba tions of the attack.
All attacks of acute gout do not, how ever, pass of suddenly; they may super vene gradually and increase in severity until they reach the true classical form. Sometimes the first attack is more vio lent, but as the malady progresses the accesses become more prolonged and are not so painful; at first the attack gener ally comes on once a year,—in the spring; then twice a year,—in spring and au tumn; afterward at more irregular inter vals. Only rarely does the malady show itself by one attack only; that may occur when the patient alters his whole manner of life, renounces the use of alcoholic stimulants, lives on very frugal diet, etc.
As the attacks become more frequent, asthenia increases, the pain is less vio lent, the duration of the access is longer, the stiffness of the affected joints does not completely disappear, and they re main enlarged, red, and tender even after the attack has passed away; smaller or larger hard nodules (tophi) are found in the tissues around the joints and else where,—the case is passing over in the chronic stage.
As already stated, the first attack of acute gout ordinarily affects the meta tarso-phalangeal articulation of the great toe; in some cases the knee or the elbow joint is attacked at the onset. Garrod and other authors state that an injury, such as a sprain or a contusion, may deter mine the localization of the gouty proc ess to the injured joint. Charcot ob served that the articulations of paralyzed extremities were particularly liable to be involved by gout.