Indeed, it is well recognised that, whatever the nature of the prodromal phenomena, they all tend to cease just before the oncoming attack. Occasionally a pre-existing depression gives way to a feeling of exuberant health or well-being. We recall the instance of a celebrated physician whose lectures always just prior to an attack took on an added brilliance.
Reverting to more definite harbingers, it has been noted that the urine becomes scanty, and its content of uric acid much diminished, some three or four days before the paroxysm, though such is not invariable. Easier of note and widely recognised is the fact that in those exhibiting tophi pricking pains or tenderness are experienced at their site. Scudamore, Garrod, and Duckworth are all agreed on this point. Another sign noted by Sydenham was that the veins of the part about to be affected become engorged—a feature confirmed by Trousseau and others.[30]
The Acute Paroxysm
A brief interlude, lasting a few hours or a day, frequently intervenes between cessation of the prodromal discomforts and the onset of the attack. This delusive sense of well-being deceives none but the uninitiated, for to the old time sufferer it is but the truce before the threatened assault.[31]
Still the subject feels better and more placid than his wont, seeks his bed, and sinks to sleep (“sanus lecto somnoque committur”). But suddenly, more commonly an hour or two after midnight, he awakes to a pain in the foot, usually in the ball of the great toe, though more rarely in the heel, instep, or ankle. Simultaneously he becomes chilly, shivers, or has a rigor. But as the pain, at first bearable, grows in intensity, these feelings lapse, giving way to feverish restlessness. Posture after posture is renounced, but, toss as he will, he strives in vain to find a place of ease for the tortured limb. Even the pressure of the bedclothes is intolerable. But towards morning (“sub galli cantu”) the pain remits as suddenly as it began. Anon the sufferer breaks into a gentle sweat, falls asleep, and wakes to find the painful part red, swollen, tense, and shiny, surrounded with œdema and turgid veins.
The same series of events recurs, though often in mitigated form, for some days and nights. During the day his pain is lulled, but towards evening it gathers in intensity to cease or diminish towards morning. The cycle continues from eight to ten days; then pain ceases, redness fades, œdema subsides, and the inflamed cuticle peels, with itching. The temperature meanwhile has sunk to normal, the local tenderness and stiffness gradually pass off, and health is restored. “Gout is the cure of the gout,” said Mead long since, and certainly recovery from the first attack of gout is usually speedy and complete. A renewed sense of bien-être ensues, free from the discomforts that led up to the outbreak. Indeed, in exceptionally rare instances the disease seemingly exhausts itself in a single paroxysm, or decades may pass before another visitation. Sir William Roberts tells of a Yorkshire squire who sustained a classical attack in his twenty-seventh year, the next in his eighty-ninth year. Frequently a second attack may not occur for one, two, or even three years. But the tendency to recurrence usually becomes more and more pronounced as the years roll on, and eventually the gouty man resigns himself to the doleful expectation of an attack once or twice a year, during spring or fall, with some approach to periodic regularity.
Initial attacks of gout are usually monarticular, but consideration of the polyarticular variety will best be postponed until we come to consider acute gouty polyarthritis. Also we think it will be more convenient for us to defer discussion of retrocedent gout to the chapter dealing with the irregular or anomalous types of the disorder. Meanwhile we will now proceed to detailed description of the individual phenomena that make up the clinical content of acute gout.
Detailed Consideration of Phenomena
Onset.—From Sydenham’s classical account it might be inferred that the onfall of gout is always fulminant. But this is far from being the case. For I find myself in agreement with Hilton Fagge that in many, if not the majority of instances, even the initial outbreak of the disorder is installed in a far less dramatic manner. Certainly in not a few cases its manner of approach is insidious, not to say stealthy. At onset then the nature of the case is therefore frequently misinterpreted both by victim and physician. The free liver, fearing that Nemesis has overtaken him, is fertile in suggestion. He has overwalked, his boot pinched him, or it is a sprain. Local appearances may be non-committal. There may be no swelling nor redness, and no access of pain at night. Still there is discomfort when he walks. The so-called sprain lingers, and one morning the great toe, instep, or ankle, is swollen, tender, flushed, and the victim’s fears and the physician’s suspicions are converted into certainty: it is gout!
Still in this matter of the onset I must not overlook the findings of my colleague James Lindsay. In 569 cases, the onset was sudden in 458, and in the remaining 111 examples gradual. It was noted that only 14·5 per cent. of the male cases were of gradual onset. But no less than 47·1 per cent. of the female cases developed after this fashion.