306 THE TREATMENT OF DISEASES. 



sometimes it is preceded by some disorder of the stomach, such as diminished appe- 

 tite, flatulence, heartburn, or nausea. As a rule, the patient who may have gone 

 to bed and to sleep in his usual health, and without any suspicion of the sufferings 

 in store for him, awakes about three in the morning with a severe pain in the 

 foot, usually in the ball of the big toe. He attempts to get out of bed, but 

 finds that he cannot put his foot to the ground, or if he succeeds in so doing, the 

 act is accompanied with very great pain. On examining the affected joint, it is 

 found to be hot, red, swollen, and exquisitely tender. The veins proceeding from 

 the toe are turgid with blood, and the joint is stiff. The pain is so great that 

 the weight of the bed-clothes is insupportable, and the mere vibration of the room 

 causes discomfort. The pain is usually spoken of as being of a most agonising 

 description. It is described as a grinding, crushing, wrenching pain, and is some- 

 times likened to a red-hot iron being suddenly thrust into the joint. The pain 

 is attended with great restlessness, and the patient in his vain search for relief is- 

 perpetually shifting his foot from place to place, and from posture to posture. 



There may be no constitutional disturbance, but usually the pain is ushered in 

 by more or less cold shivering, followed by heat of skin, perspiration, thirst, loss 

 of appetite, a white furred tongue, and confined bowels. The urine is small in 

 quantity, high-coloured, and deposits on cooling a pinkish or reddish sediment. 



If moderate precautions are taken, and the foot kept up on the bed or couch, 

 the inflammation subsides in the early part of the day, but it usually gets worse 

 towards evening, and for the greater part of the night the patient is kept awake 

 by the pain, which, however, again subsides as morning advances. 



In a few days relief is obtained, and the tension and swelling are diminished, 

 as well as the heat and redness. The skin usually peels oft" in the neighbourhood of 

 the joint, occasionally in flakes of considerable size, the process being attended with 

 troublesome itching. The duration of the joint inflammation varies considerably 

 in different cases, and is much influenced by the diet and mode of treatment adopted. 

 Occasionally it lasts ten days, or even longer, but if care be taken it may usually 

 be got rid of in from four to five days. After the attack is over the patient not 

 uncommonly feels all the better for it, and says it has done him good. He very 

 frequently enjoys greater ease and alacrity in the functions both of body and mind 

 than he had for a long time previously experienced. 



The disorder which has thus departed almost inevitably returns. At first it 

 may not recur oftener than once in every three or four years, but after a time the 

 intervals get gradually shorter and shorter, till the attacks become annual, happen- 

 ing about the same time every year, and finally they return several times during 

 the course of the autumn, winter, and spring. As the fits increase in frequency 

 their duration becomes protracted, so that in an advanced state of the disease the 

 patient is, with the exception of a few months in the summer, scarcely ever free 

 from it. 



As we have already said, the ball of the great toe is commonly selected as the 

 first seat of the disease, but occasionally this joint escapes altogether. An old 

 injury to a joint, as, for example, a stiff knee resulting from a fall from a horse, 

 will attract gout to the damaged part, and will moreover cause it to linger there 



