PATHOLOGY. 
organ, inftead of on the joints ; or fuddenly transferred 
from the joints after having fixed there; producing, in 
the internal organ affedted, debility or inflammation ac¬ 
cording to the ftate of the conftitution. 
The gout fometimes comes on fuddenly, without any 
warning of its approach ; but it is generally preceded by 
feveral fymptoms, efpecially by thofe of indigeftion, as 
heart-burn, flatulence, and heavinefs after meals, with 
erudlations of acid or bitter matters, and fome degree o 
languor and torpor of the body; but immediately before 
the fit the appetite is fometimes unufually fliarp. There 
is alfo often an unufual coldnefs of the feet and legs for 
a few days preceding the fit, with the ceffation of the 
perfpiration about the former ; a frequent numbnefs, al¬ 
ternating with a fenfe of prickling, along the whole of 
the lower extremities ; occafional cramps of the mufcles 
of the legs, and an unufual turgefcence of the veins, 
are occafionally obferved. 
The attack is fometimes felt in the evening, but more 
commonly about two or three o’clock in the morning; 
when the patient is awakened from a quiet fleep by a 
pain affecting one foot, generally the ball or firft joint of 
the great toe, but fometimes the other parts of the foot, 
or the ankle. This pain is accompanied with more or 
lefs of chillinefs and (hivering, which, as the pain in- 
creafes, gradually ceafe, and are fucceeded by a hot ftage 
of pyrexia, or fymptomatic fever, which continues du¬ 
ring the fame time as the pain. The pain becomes by 
degrees more and more violent: at firft it is attended 
with a fenfation as if warm water were poured upon the 
membranes affedted, and is faid to refemble the pain of 
a diflocated joint; as it becomes fevere, it is fometimes 
defcribed as refembling the pain of a tenfion or lacera¬ 
tion of the ligaments, fometimes as like that from the 
gnawing of a dog, and fometimes as a feeling of weight 
and conftridtion of the membranes of the part, which be¬ 
comes fo exquifitely tender, as not to endure the weight 
of the bed-clothes, nor even the (baking of the room 
from a perfon walking brifldy in it. Hence, great reft- 
leffnefs of the whole body, and efpecially of the part af¬ 
fected, always accompanies the fit; the patient conftantly 
changing his pofture, with a view to eafe the pain, which, 
neverthelefs, continues fevere all the following day, un¬ 
til midnight, after which it gradually remits : and about 
two or three in the morning, that is, after twenty-four 
hours from the firft attack, it commonly c'eafes almoft 
entirely; and this freedom, with the breaking out of a 
free perfpiration, allows the patient to fall afleep. On 
waking, he finds the pain (light, and the part affedted 
with fome rednefs and fwelling. 
When a paroxyfm has thus come on, although the 
violent pain, after the period of twenty-four hours, be 
confiderably diminifhed, yet the patient is not entirely 
without pain. For fome days he has a return every eve¬ 
ning of pain and fever, which continue, with more or 
lefs violence, till morning. After continuing in this 
manner for feveral days, the difeafe fometimes goes off 
entirely, not to return till after a long interval; and in 
fuch cafes it generally leaves the perfon in very perfedt 
health, enjoying greater eafe and alacrity in the functions 
both of body and mind than he had for a long time be¬ 
fore experienced. 
It often happens, however, that the difeafe does not 
thus fpeedily quit the patient, efpecially when he has pre- 
vioufly fuffered confiderably from its attacks. For, in- 
ftead of ceafing altogether after a few days, it feizes the 
other foot in the fame manner as it did the former, both 
in refpedt to the vehemence and duration of the pain. 
Mod commonly the foot firft affedted becomes quite eafy, 
in fuch a cafe, and even as ftrong and healthy as if it had 
not been difeafed ; but fometimes both feet are affedted 
together, and with equal violence. When this happens, 
the fucceeding exacerbations, as Sydenham remarks, are 
lefs regular, both as to the time of coming on, and as 
to their continuance; but the pain always increafes in 
Vol. XIX. No. 1302. 
27 L 
the evening and remits in the morning; and what is 
called a Jit of the gout, which goes off fooner or later, 
according to the age and conftitution of the patient, is 
made up of a number of tliefe little fits. For, when this 
difeafe lafts two or three months, it is not to be efteetned 
one continued fit, but rather a feries or affemblage of 
fmall fits, the laft of which proves milder and (horter, 
until the whole is terminated. In ftrong conftitutions, 
and fuch as have the gout feldom, the attack is common¬ 
ly finilhed in fourteen days ; but in thofe of advanced 
life, or who have frequent returns of the difeafe, thefe 
feries of fits will continue for two months ; and in fuch 
perfons as are more debilitated, either by ag® or the 
long continuance of the diforder, it will not go off till 
the fummer advances, (beginning, as is mod common, 
in January, or early in February,) which feems to drive 
it away. 
When the fit is going off, a violent itching feizes the 
foot, efpecially between the toes ; and the cuticle peels 
off. The appetite and ftrength return fooner or later, 
according to the greater or lefs feverity of the preceding 
fit, and the-interval of health between the paroxyfms is 
generally nearly in the fame ratio ; i. e. longer in propor¬ 
tion to the greater violence of the laft fit. At the begin¬ 
ning of the difeafe, Dr. Cullen obferves, the returns of 
it are fometimes only once in three or four years ; but af¬ 
ter fome time the intervals become (horter, and the at¬ 
tacks become annual; afterwards they come twice each 
year, and at length recur feveral times during the whole 
courfeof autumn, winter, and fpring ; and as it happens 
that, when the fits are frequent, the paroxyfms become 
alfo longer, fo, in the advanced ftate of the difeafe, the 
patient is hardly ever tolerably free from it, except, per¬ 
haps, for two or three months in fummer. 
Before the difeafe becomes thus inveterate, however, 
it has gradually aftumed other appearances, and attacked 
other parts of the body. At firft it commonly affedts 
one foot only; but afterwards every paroxyfm affedts 
both feet, the one after the other, and then both toge¬ 
ther ; and its changes of place as it continues to recur, 
are not only from one foot to the other, but alfo from 
the feet into other joints, as the hands, wrifts, elbows, 
knees, &c. fo that there is fcarcely a joint in the body 
that is not, on one occafion or other, affedted. It fome¬ 
times feizes on two different joints at the fame time; but 
more commonly it is fevere in a (ingle joint only, and 
paffes fucceflively from one joint to another; fo that the 
patient’s affliction is often protradted for a long time. 
The pains, indeed, are commonly lefs violent, in this 
ftate of the difeafe, than they were at firft ; but, in addi¬ 
tion to them, lofs of appetite, (icknefs, and other fymp¬ 
toms of the atonic gout, now alflidt him. Befides, in the 
intervals between the firft paroxyfms of the diforder, the 
joints which had been affedted were entirely reftored to 
their former fupplenefs and ftrength, and were free from 
pain or uneafinefs, and all thefundtions of life were well 
performed. But in this protradted condition of the dif¬ 
eafe, the joints remain not only weak and (tiff after the 
termination of the fit, but they become at length fo con¬ 
tracted and difabled, that, although the patient can (land, 
and perhaps walk a little, yet it is very (lowly, and 
with great lamenefs and difficulty, fo that he is fcarcely 
able to move from room to room; and fometimes the 
joints lofe their motion altogether. 
In many perfons, though not in all, when the difeafe 
has frequently recurred, this immobility of the joints is 
farther increafed by the formation of concretions, of a 
chalky appearance, upon the outfide of them, and for 
the moft part immediately under the (kin. The fecretion 
or depofition of this matter is charadteriftic of the difeafe, 
being the confequence of gouty inflammation alone. It 
feems to be depofited at firft in a fluid form, but after¬ 
wards becomes dry and firm ; in which ftate the concre¬ 
tions have the appearance of a friable earthy fubftance, 
and have been called chalk-Jlones, which fee, vol. iv. p. 75,. 
4 A From 
