134 GOUT 



tory but aseptic course, which is strikingly similar to an erysipelatous inflam- 

 mation. Corresponding to the intensity of the inflammatory process, there 

 is as a rule extraordinarily severe pain. Most patients declare it to be as 

 though the affected parts of the body were tightly screwed in a vise. The 

 skin is intensely red (purplish red or bluish red), sometimes even permeated 

 by small hemorrhages ; it appears as though suppuration were developing, and 

 is tender on pressure, glistening, and swollen. The swelling is the consequence 

 of edema; upon pressure there is pitting of the skin which only very slowly 

 disappears when the pressure is relaxed. In the most severe cases active 

 motion is impossible, and upon attempting passive movement of the painful 

 Joints, the patients resist. Under these circumstances, the patient is early 

 confined to his bed. 



Apart from these local pathologic phenomena, we also observe in acute 

 paroxysms of gout disturbances of the general constitution. Especially note- 

 worthy are the fever and the symptoms dependent upon this. In the milder 

 attacks, fever may be absent. We note from Observation I that, in the same 

 individual, it was present in some attacks and absent in others. Occasionally 

 there is a slight rise of temperature only in the first days, so that if the patient, 

 for instance, comes under observation only upon the third day of the attack 

 there may be no fever. Usually, the fever is moderate, a rise above 102.3° P. 

 being rarely reached at the height of the paroxysm. During the exacerbations 

 so frequently observed in attacks of gout, the temperature rarely exceeds 

 101.3° P., and when remission occurs, as a rule it at once falls to normal. 

 The age of the patient seems to have some influence upon the temperature 

 curve during the paroxysm, as, under otherwise similar conditions, the highest 

 temperatures occur in young robust patients. Nevertheless, in the aged, dur- 

 ing acute attacks, rises in temperature are by no means absent. 



The further course of the gouty inflammation in the affected part of the 

 body is generally typical. After the para-articular phlegmons have existed for 

 a few days, or several weeks and longer with remissions and exacerbations, the 

 latter being sometimes so severe that an extensive joint suppuration seems 

 imminent, the inflammatory symptoms ameliorate, the pain usually subsides, 

 and the affected joint in many cases returns apparently to its normal condi- 

 tion. As in erysipelas, the skin becomes pale and desquamates. Neverthe- 

 less, decided sensitiveness to pressure may be noted in the affected joints, and 

 this increases upon active and passive movement. 



As a rule, the first attacks of gout are limited to one or several small joints 

 of an extremity; rarely, for example, is the knee-joint implicated in the first 

 attack of gout. Effusions, which are not at all rare in the gouty paroxysm, 

 localize usually in the joints, and often they last for a long time. This causes 

 the condition so frequently noted in the later course of the gouty process, in 

 which two or more joints are attacked, one after the other, and thus the par- 

 oxysm is decidedly prolonged. An illustration of this and of the fact that in 

 the course of gout numerous joints are always implicated may here be given. 



Obsebvation II. — X., a lawyer from B., forty-six years of age, consulted me on the 

 0th of July, 1896, on account of gout. His father — now over eighty years of age — and 

 his younger brother are both said to have had an attack of gout. His mother died at 



