He goes to bed happy, and is awakened after a
few hours' sleep, usually between one and four
in the morning, with pain in the ball of one
great toe, which increases with a sense of burning
and throbbing, and he finds next morning
that his toe is swollen with a deep red shining
skin. Moreover, it is so exquisitely tender,
that during the height of the attack he cannot
bear the weight of the bedclothes or the shaking
of the bed by footsteps in the room. There
are a series of such attacks. Then the swelling
abates. In a few days the skin itches and
peels off, and there is in the joint only some
little remaining tenderness. That is the form
of a brisk first attack in a man otherwise healthy.
Gout has a partiality for gnawing at a man's
great toe. Of five hundred and sixteen cases
of gout observed by Sir C. Scudamore, three
hundred and fourteen seized on the great toe of
one foot only, twenty-seven fastened upon both
the great toes, but only two fastened upon the
thumb, only fifteen touched in any way the
hand or wrist. In not more than five cases in
a hundred, in fact, is any joint affected with
true gout where the great toe has not been, or
is not, also a sufferer, and in those cases there
has usually been some local injury to cause the
gout to appear first in some other than its
natural place. As for the pain, "Screw your
joint," said a Frenchman, "in a vice till you can
no longer bear the pressure, that is rheumatism;
then give the vice another twist, that's gout."
Gout having once seized on its chosen outwork,
has a tendency to fight its way upward, first
storming the ankles, then making an ugly rush
upon the knee, then taking possession of the
hands and elbows. There used to be a
superstition that gout lengthens life, and Cullen
endorsed the maxim that the only remedy for it
was "patience and flannel." But he would not
now be considered a wise man who should
resign himself thus to the mercy of an enemy
that can deal fatal blows, though it does usually
kill when it has made death welcome by depriving
life of all its pleasure. A man otherwise
healthy who is careful of diet, may, indeed, live
beyond his eightieth year after suffering from
gout for more than half a century; he may
remain free from chalkstones, stiffness, and
deformity, and suffer only few and slight attacks
in his old age. But with many, the gout
remains long enough in a joint to destroy its
flexibility, or to deposit chalkstones, which
were so called when people supposed them so
to be. They are not chalk, and they may
contain no particle of lime, but they contain a large
proportion of a salt—urate—of soda.
Chalkstones are much more commonly absent than
present; or they are not very often present as
visible disfigurement. In a slight degree they
are often to be found, and if they occur
anywhere in any degree, they are found usually on
the ear, commonly near the thin upper edge, as
little pearly spots, or a single spot that may be
smaller than a pin's head; they give out, when
pricked, a milky fluid; or such a spot may be as
large as a split pea, and, when hard, is firmly
fastened to the gristle of the ear. These testify
to the altered condition of the blood, the difference
being that while it may retain all other
natural constituents in just proportion, it has two
constituents, always there but properly only in
small proportion, combined as urate of soda,
and existing in unnatural excess. It is the
business of the kidneys to remove all but a very
little of the urate of soda formed within the
body. When they fail to do that, and it
accumulates, its irritation causes gout. Dr. Garrod,
whose book on the subject, representing the
researches of seventeen years, is the standard
professional authority, has contrived an ingenious
way of discovering whether a man has gouty
blood. He puts into a flat glass dish, about a
teaspoonful of the serum or fluid part of the
blood to be tested, adds a few drops of acetic
acid, and then puts into the mixture one or two
fine but rough ultimate fibres from a piece of
unwashed huckaback or other linen. After
standing undisturbed two or three days—the
time varying with the state of the atmosphere—
if there be too much uric acid in the blood, it
will have crystallised like sugar-candy round
the linen fibre, and its crystals will easily be
recognised under the microscope. These facts,
apparently so simple, represent a marked recent
advance in medical knowledge. Apart from the
different course of symptoms, the presence of
an excess of this acid in the blood, as shown by
the thread test, emphatically prevents all
possible confusion between gout and rheumatism.
Where the serum of freshly-drawn blood will
show it, it will be shown also by the fluid that
a blister draws, if it be not a blister placed over
an inflamed surface.

But if urate of soda in the blood give men
the gout, what gives them the urate of soda?
Is it all the doing of old crusty port?
Certainly not. In the first place, there is a
hereditary tendency so strong that Dr. Cullen
even thought all gout hereditary. In three
cases out of five, or at any rate in more than
half the cases, gout may be traced back to
parents or grandparents. It is part of many a
man's rich inheritance. "A few years since,"
says Dr. Garrod, "I was consulted by a gentleman
labouring under a severe form of gout,
with chalkstone, and, although not more than
fifty years old, he had suffered from the disease
for a long period. On inquiry, I ascertained
that for upwards of four centuries the eldest
son of the family had invariably been afflicted
with gout when he came into possession of the
family estate."

And so when a man sets up for himself a
gout that he has not inherited, he has
something at any rate which he will probably
leave to his children. A first attack of gout
is seldom seen in a patient younger than twenty
or older than sixty-six, the greater number of
such attacks occur between the thirtieth and
fortieth year; but inherited gout sometimes
appears very early. When a man sets up gout
for himself, he gets it by use of fermented
drinks. Had there been no fermented drinks,