In acute asthenic forms great contrasts appear. Pain and tenderness in the toe may be moderate, but there may be little local heat or redness and no pyrexia. But œdema is generally in evidence, and the usual desquamation of skin follows.
Tophus Formation.—To the local changes that mark their eruption at ab-articular sites we have already alluded. Here we would only reiterate that their formation follows the local joint inflammation. Consequently if a few days after the attack local pain or tenderness, with or without swelling in the vicinity of the joint, should be complained of, it should not be dismissed as of no account, but the affected parts should be scrutinised carefully and, where possible, at short intervals. This in the interests of diagnosis of a joint affection which may at the time have been of doubtful nature, more especially if the primary attack occur elsewhere than at the classical site. Some observations of Trousseau are well worth quotation: “Physicians who have watched the progress of the evolution of tophus believe that it is formed during the paroxysm of gout. They are mistaken: the deposit appears during the interval between attacks, or at least when the attacks have not been of long duration, and when they do not recur in such rapid succession as to run into one another, in which cases their secretion has commenced during the preceding and continued during the succeeding attack.”
CHAPTER XVII
CLINICAL ACCOUNT (continued)
Acute Generalised Gout
While gout may throughout its life history confine its ravages to the foot, if not solely to the toe joints, it may, even in the initial attack, involve many articulations. Such cases usually, if not always, occur in persons of marked gouty heredity. In its simplest forms the orthodox monarticular seizure is simply exchanged for a sequential implication of each big toe joint. If so, as Trousseau pointed out, the joint that is the last to be involved is least affected, and the soonest to get well again, while the accompanying œdema is of shorter duration. But in more severe cases not only the big toe, but the tarsal joints, the knee and the hand, may be invaded in the first attack. Occasionally, too, the disorder displays concomitantly its tendency to involve other structures, tendons and aponeuroses, e.g., the tendo Achillis, plantar fascia. Such widespread initial involvement is usually preceded by prodromal phenomena of unusual severity and prolonged duration. These initial attacks of polyarticular distribution are extremely rare.
Far more commonly acute gouty polyarthritis supervenes after several attacks of classic location have been suffered. The gouty inflammation in these cases invades the joints after a serial fashion. But each joint as it becomes involved goes through the same painful cycle. Thus, for five or six days the pain goes on increasing, then abates, and finally the wished-for crisis comes. So it happens that the gout may be raging simultaneously in several articulations, though in each at different stages of evolution. Consequently the symptoms do not pursue an even tenor, but are made up rather of a series of little attacks—series et catena paroxysmulorum, to invoke Sydenham’s expression.
Frequently periods of apparent recovery take place. The temperature remains normal for some days, and welcome convalescence seems established, when, to the victim’s despair, the temperature again rises, and the same weary cycle, though perhaps shorter, is yet to be endured. Running this chequered career, the disorder may last for six weeks or two or three months.
In such attacks not only the feet, knees, hands, and elbows, may be promiscuously involved, but often also the ligaments, bursæ, tendon sheaths, and aponeuroses. The suddenness with which the disorder shifts its seat from one joint to another, or from joints to bursæ or muscles, often leads to its confusion with acute rheumatism. In other words, that fixity distinctive of gout in its monarticular forms is here exchanged for mobility, that specific quality of acute rheumatism.