548 DISEASES OF THE ORGANS OF LOCOMOTION. 



SYMPTOMS AND COURSE. Most gouty patients have shown, by 

 their appearance or sensations, some other results of high living before 

 the first attack of gout. They have usually become fat ; the face, 

 particularly the nose, is reddened, from the development of varicose 

 vessels ; they have haemorrhoids j we cannot, however, say that these, 

 and other signs which occur in various modifications, are premonitory 

 tokens of this disease. 



But, besides the above symptoms, the first attack, as well as the 

 subsequent ones, is usually preceded by true premonitory constitu- 

 tional symptoms, arthritis imperfecta, or status arthriticus. The 

 patients feel languid, their sleep is restless ; the appetite is impaired, 

 and they have indigestion ; they complain of palpitation of the heart 

 and constriction of the chest ; they sweat profusely, and frequently 

 pass small amounts of concentrated urine. Careless patients do not 

 generally pay much attention to these premonitions, say nothing about 

 them to their physician, and continue their previous mode of life. 



Hence the attack of gout almost always comes unexpectedly, in 

 spite of the premonitions, and surprises the patient like a thief in 

 the night. After he has gone to bed, without dreaming of the com- 

 ing evil, and has gone quietly to sleep, he is awakened, generally soon 

 after midnight, by a severe burning piercing pain in the metatarso- 

 phalangeal articulation of the great toe. The pain rapidly becomes 

 unbearable. The patient feels as if the affected joint were in a vice ; he 

 sighs, moans, throws himself around in bed ; the leg or even the entire 

 body trembles with pain. Soon after the commencement of the attack, 

 the skin covering the affected joint begins to swell and redden, and 

 there is fever, with a full, bounding pulse, dry skin, intense thirst, con- 

 centrated urine, and great mental excitement. Toward morning there 

 is a remission, and in the course of the following day the state of the 

 patient generally becomes endurable, although the pains have not 

 entirely disappeared, and the ball of the affected toe is more swollen, 

 shining, and very red, and the whole leg is slightly swollen by cedema. 

 The next night the scene of the past one is repeated with equal or some- 

 what less severity ; the following day brings another remission, and so 

 passable days alternate with bad nights for about a week, rarely 

 onger, at least in the first attack ; then the patient is temporarily free 

 from his trouble. After the redness and swelling have gradually sub- 

 sided from the ball of the great toe, there is a desquamation of the 

 cuticle, and the parts return to their normal state. The first attack of 

 gout hardly ever leaves any deformity. It does not often affect any 

 joint but the first one of the great toe; in other words, it is rare for 

 the first attack, instead of being a podagra, to be a chiragra, gonagra, 

 or omagra. After the patient has recovered from his pain and sleep 



