The redness in its intensity attains its zenith in from twenty-four to forty-eight hours, and then in hue becomes more violaceous. On the other hand, the _œdema_ may go on increasing for some days. At first, owing to tension, the presence of œdema may not readily be elicited. But with the subsidence of inflammation the swollen parts readily pit on pressure. It is scarcely possible to detect _intra-articular effusion_ unless it be the ankle joint that is involved. According to Duckworth, in the more _sthenic_ forms there may be local _ecchymoses_. With the crisis the redness, œdema, and venous turgescence die down. The previously distended skin becomes wrinkled, and with complete subsidence of inflammation _desquamation_ ensues. This process is generally attended with troublesome _itching_. It is most noticeable about the _feet_ and _hands_, but more rare at other sites. Scudamore said that in seventy-eight out of 234 cases no peeling occurred, but, as Garrod observed, it may readily be overlooked unless especially sought for. The exquisite sensitiveness of the parts, as before noted, gives way to _numbness_. The diminished sensibility, coupled with _stiffness_ of the joint, renders walking difficult for some days, and, indeed, a month or more may elapse before the joint, even in favourable cases, recovers its customary mobility. 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