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longer than in other localities. It is often said the gout differs from rheumatism 

 in implicating the smaller joints of the body. This is true, if reference be made 

 solely to the earlier attacks, but after a time the larger and smaller joints are indis- 

 criminately affected. In severe cases there may be scarcely a joint which has not 

 been attacked at some time or another. The hips and shoulders are the least liable 

 to be attacked, but even they do not always escape. After the earlier attacks the 

 joints soon recover their former strength and pliancy, but when the disorder has 

 recurred again and again, they are not so readily nor so completely restored to their 

 previous condition, but remain weak and stiff, and sometimes they lose at length 

 their capacity for motion altogether. It is a curious and at the same time a for- 

 tunate circumstance, that however active the inflammation may be, it never runs 

 on to the formation of matter. The only exception to this is in cases where there 

 has been a chalky deposit in the joint, and then the matter arises from the irri- 

 tation caused by the presence of the foreign body, and is not directly owing to 

 the gout. 



As we have said, an attack of gout is sometimes ushered in by irritability of the 

 stomach. In many gouty people, however, irritability of the temper is a more 

 common symptom. You often hear a wife say of her gouty husband that she 

 knows he is going to have one of his bad attacks, for "he has been like a bear with a 

 sore head for the last day or two." Palpitation of the heart is experienced by some 

 people on the eve of a gouty seizure, whilst others suffer from a kind of asthma- 

 It is not uncommon to find some derangement of the bowels, and this may take the 

 form either of diarrhoea or constipation. 



The amount of fever, or in other words elevation of temperature, which accom- 

 panies the actual attack is always in direct proportion to the number of joints 

 affected. It is always secondary, occurring as the result of the inflammation. 



In old long-standing cases of gout, " chalk-stones " not unfrequently make their 

 appearance around the joints. This chalk-like matter is deposited at first in a half- 

 fluid state resembling cream or soft mortar, and it then gradually becomes dry 

 and hard. These concretions are not really composed of chalk, but of a substance 

 known as urate of soda. It is often deposited around the knuckles, and it is said 

 that people who are inclined to make the best of a bad job have been known to 

 utilise their affected joints to chalk or score the game upon the table whilst playing 

 cards. These chalky deposits not uncommonly cause such deformity of the hands, 

 that their natural shape is completely lost, and they are for all ordinary purposes of 

 life practically useless. Sometimes the fingers are swollen to such an extent that 

 they look for all the world like a bunch of carrots with their heads forwards, tht 

 nails taking the place of the stalks. When these deposits are seen, no doubt can 

 ever exist as to the nature of the complaint from which the patient is suffering. 

 Curiously enough, a little chalk-stone is not uncommonly found on the ear just at 

 the margin. In all doubtful cases of gout it is as well to examine this region, for if 

 this deposit is detected, the nature of the complaint is clear. 



There are several varieties of what is called " irregular " gout, and of these the 

 most common is gout in the stomach. The attack usually commences in the ordinary 

 way with inflammation of one of the joints, but the pain which is never very 



