I have more than once hinted at the sameness of some of the states of the gout, and the yellow fever. Who can compare the symptoms and seats of both diseases, and not admit the unity of the remote and immediate causes of fever?
Thus have I enumerated proofs of the gout being a disease of thewholesystem. I have only to add under this proposition, that it affects different parts of the body in different people, according to the nature of their congenital or acquired temperaments, and that it often passes from one part of the body to another in the twinkling of an eye.
The morbid excitement, and actions of the gout, when seated in the ligaments, the blood-vessels, and viscera, and left to themselves, produce effects different in their nature, according to the parts in which they take place. In the viscera they produce congestions composed of all the component parts of the blood. From the blood-vessels whichterminate in hollow cavities and in cellular membrane, they produce those effusions of serum which compose dropsies. From the same vessels proceed those effusions which produce on the skin erysipelas, tetters, and all the different kinds of eruptions. In the ligaments they produce an effusion of coagulable lymph, which by stagnation is changed into what are called chalk-stones. In the urinary organs they produce an effusion of particles of coagulable lymph or red blood, which, under certain circumstances, are changed into sand, gravel, and stone. All these observations are liable to some exceptions. There are instances in which chalk-stones have been found in the lungs, mouth, on the eye-lids, and in the passages of the ears, and a preternatural flux of water and blood has taken place from the kidneys. Pus has likewise been formed in the joints, and air has been found in the cavity of the belly, instead of water.
Sometimes the gout is said to combine with the fevers which arise from cold and miasmata. We are not to suppose from this circumstance, that the system is under a twofold stimulus. By no means. The symptoms which are ascribed to the gout, are the effects of morbid excitement excited by the cold, or miasmata acting upon parts previously debilitated by the usual remote causes of that disease.
A bilious diathesis in the air so often excites the peculiar symptoms of gout, in persons predisposed to it, that it has sometimes been said to be epidemic. This was the case, Dr. Stoll says, in Vienna, in the years 1782 and 1784. The same mixture of gouty and bilious symptoms was observed by Dr. Hillary, in the fevers of Barbadoes.
From a review of the symptoms of the gout, the impropriety of distinguishing it from its various seats, by specific names, must be obvious to the reader. As well might we talk of a yellow fever in the brain, in the nerves, or in the groin, when its symptoms affect those parts, as talk ofmisplacedorretrocedentgout. The great toe, and the joints of the hands and feet, are no more its exclusive seats, than the “stomach is the throne of the yellow fever.” In short, the gout may be compared to a monarch whose empire is unlimited. The whole body crouches before it.
It has been said as a reflection upon our profession, that physicians are always changing their opinions respecting chronic diseases. For a long while they were all classed under the heads of nervous, or bilious. These names for many years afforded a sanctuary for the protection of fraud and error in medicine. They have happily yieldedof late years to the name of gout. If we mean by this disease a primary affection of the joints, we have gained nothing by assuming that name; but if we mean by it a disease which consists simply of morbid excitement, invited by debility, and disposed to invade every part of the body, we conform our ideas to facts, and thus simplify theory and practice in chronic diseases.
I proceed now to treat of theMETHOD OF CURE.
Let not the reader startle when I mention curing the gout. It is not a sacred disease. There will be no profanity in handling it freely. It has been cured often, and I hope to deliver such directions under this head, as will reduce it as much under the power of medicine, as a pleurisy or an intermitting fever. Let not superstition say here, that the gout is the just punishment of folly, and vice, and that the justice of Heaven would be defeated by curing it. The venereal disease is more egregiously the effect of vice than the gout, and yet Heaven has kindly directed human reason to the discovery of a remedy which effectually eradicates it from the constitution. This opinion of the gout being a curable disease, is as humane as it is just. It is calculated to prompt to early application for medical aid, and to prevent that despair of reliefwhich has contributed so much to its duration, and mortality.
But does not the gout prevent other diseases, and is it not improper upon this account to cure it? I answer, that it prevents other diseases, as the daily use of drams prevents the intermitting fever. In doing this, they bring on a hundred more incurable morbid affections. The yellow fever carried off many chronic diseases in the year 1793, and yet who would wish for, or admit such a remedy for a similar purpose? The practice of encouraging, and inviting what has been called a “friendly fit” of the gout as a cure for other diseases, resembles the practice of school boys who swallow the stones of cherries to assist their stomachs in digesting that delicate fruit. It is no more necessary to produce the gout in the feet, in order to cure it, than it is to wait for, or encourage abscesses or natural hæmorrhages, to cure a fever. The practice originated at a time when morbific matter was supposed to be the cause of the gout, but it has unfortunately continued under the influence of theories which have placed the seat of the disease in the solids.
The remedies for the gout naturally divide themselves into the following heads.
I. Such as are proper in its approaching, or forming state.
II. Such as are proper inviolentmorbid action in the blood-vessels and viscera.
III. Such as are proper in afeeblemorbid action in the same parts of the body.
IV. Such as are proper to relieve certain local symptoms which are not accompanied by general morbid action. And
V. Such as are proper to prevent its recurrence, or, in other words, to eradicate it from the system.
I. The symptoms of an approaching fit of the gout are great languor, and dulness of body and mind, doziness, giddiness, wakefulness, or sleep disturbed by vivid dreams, a dryness, and sometimes a coldness, numbness, and prickling in the feet and legs, a disappearance of pimples in the face, occasional chills, acidity and flatulency in the stomach, with an increased, a weak, or a defect of appetite. These symptoms are not universal, but more or less of them usher in nearly every fit of the gout. The reader will see at once their sameness with the premonitory symptoms of fever from coldand miasmata, and assent from this proof, in addition to others formerly mentioned, to the propriety of considering a fit of the gout, as a paroxysm of fever.
The system, during the existence of these symptoms, is in a state of morbid depression. The disease is as yet unformed, and may easily be prevented by the loss of a few ounces of blood, or, if this remedy be objected to, by a gentle doze of physic, and afterwards by bathing the feet in warm water, by a few drops of the spirit of hartshorn in a little sage or camomile tea, by a draught of wine whey, or a common doze of liquid laudanum, and, according to a late Portuguese physician, by taking a few doses of bark.
It is worthy of notice, that if these remedies are omitted, all the premonitory symptoms that have been mentioned disappear as soon as the arthritic fever is formed, just as lassitude and chilliness yield to a paroxysm of fever from other causes.
II. Of the remedies that are proper in cases of great morbid action in the blood-vessels and viscera.
I shall begin this head by repudiating the notion of a specific cure for the gout existing in any single article of the materia medica. Every attempt to cure it by elixirs, diet-drinks, pills, or boluses, which were intended to act singly on the system, has been as unsuccessful as the attempts to cure the whooping cough by spells, or tricks of legerdemain.
The first remedy that I shall mention for reducing great morbid action in the blood-vessels and viscera, isblood-letting. I was first taught the safety of this remedy in the gout by reading the works of Dr. Lister, above thirty years ago, and I have used it ever since with great advantage. It has the sanction of Dr. Hoffman, Dr. Cullen, and many others of the first names in medicine in its favour.
The usual objections to bleeding as a remedy, have been urged with more success in the gout, than in any other disease. It has been forbidden, because the gout is said to be a disease of debility. This is an error. Debility is not a disease. It is only its predisposing cause. Disease is preternatural strength in the state of the system now under consideration, occasioned by the abstraction of excitement from one part, and the accumulation of it in another part of the body. Every argument infavour of bleeding in a pleurisy applies in the present instance, for they both depend upon the same kind of morbid action in the blood-vessels. Bleeding acts moreover alike in both cases by abstracting the excess of excitement from the blood-vessels, and restoring its natural and healthy equality to every part of the system.
It has been further said, that bleeding disposes to more frequent returns of the gout. This objection to the lancet has been urged by Dr. Sydenham, who was misled in his opinion of it, by his theory of the disease being the offspring of morbific matter. The assertion is unfounded, for bleeding in a fit of the gout has no such effect, provided the remedies to be mentioned hereafter are used to prevent it. But a fit of the gout is not singular in its disposition to recur after being once cured. The rheumatism, the pleurisy, and the intermitting fever are all equally disposed to return when persons are exposed to their remote and exciting causes, and yet we do not upon this account consider them as incurable diseases, nor do we abstain from the usual remedies which cure them.
The inflammatory or violent state of the gout is said most commonly to affect the limbs. But this is far from being the case. It frequently makesits first attack upon the head, lungs, kidneys, stomach, and bowels. The remedies for expelling it from the stomach and bowels are generally of a stimulating nature. They are as improper in full habits, and in the recent state of the disease, as cordials are to drive the small-pox from the vitals to the skin. Hundreds have been destroyed by them. Bleeding in these cases affords the same speedy and certain relief that it does in removing pain from the stomach and bowels in the first stage of the yellow fever. Colonel Miles owes his life to the loss of 60 ounces of blood in an attack of the gout in his bowels, in the winter of 1795, and major Butler derived the same benefit from the loss of near 30 ounces, in an attack of the gout in his stomach in the spring of 1798.
I could add many more instances of the efficacy of the lancet in the gout when it affects the viscera, from my own experience, but I prefer mentioning one only from sir John Floyer, which is more striking than any I have met with in its favour. He tells us, sir Henry Coningsby was much disposed to the palsy from the gout when he was 30 years old. By frequent bleedings, and the use of the cold bath, he recovered, and lived to be 88. During his old age, he was bled every three months.
I have said, in the history of the symptoms of the gout, that it sometimes appeared in the form of a hectic fever. I have prescribed occasional bleedings in a case of this kind accompanied with a tense pulse, with the happiest effects. It confined the disease for several years wholly to the blood-vessels, and it bid fair in time to eradicate it from the system.
The state of the pulse, as described in another place[61], should govern the use of the lancet in this disease. Bleeding is required as much in its depressed, as in its full and chorded state. Colonel Miles's pulse, at the time he suffered from the gout in his bowels, was scarcely perceptible. It did not rise till after a second or third bleeding.
Some advantage may be derived from examining the blood. I have once known it to be dissolved; but for the most part I have observed it, with Dr. Lister, to be covered with the buffy coat of common inflammation.
The arguments made use of in favour of bleeding in the diseases of old people in a former volume, apply with equal force to its use in the gout.The inflammatory state of this disease frequently occurs in the decline of life, and bleeding is as much indicated in such cases as in any other inflammatory fever. The late Dr. Chovet died with an inflammation in his liver from gout, in the 86th year of his age. He was twice bled, and his blood each time was covered with a buffy coat.
Where the gout affects the head with obstinate pain, and appears to be seated in the muscles, cupping and leeches give great relief. This mode of bleeding should be trusted in those cases only in which the morbid action is confined chiefly to the head, and appears in a feeble state in the rest of the arterial system.
The advantages of bleeding in the gout, when performed under all the circumstances that have been mentioned, are as follow:
1. It removes or lessens pain.
2. It prevents those congestions and effusions which produce apoplexy, palsy, pneumonia notha, calculi in the kidneys and bladder, and chalk-stones in the hands and feet. The gravel and stone are nine times in ten, I believe, the effects of an effusion of lymph or blood from previous morbid actionin the kidneys. If this disease were narrowly watched, and cured as often as it occurs, by the loss of blood, we should have but little gravel or stone among gouty people. A citizen of Philadelphia died a few years ago, in the 96th year of his age, who had been subject to the strangury the greatest part of his life. His only remedy for it was bleeding. He lived free from the gravel and stone; and died, or rather appeared to fall asleep in death, from old age. Dr. Haller mentions a similar case in his Bibliotheca Medicinæ, in which bleeding had the same happy effects.
3. It prevents the system from wearing itself down by fruitless pain and sickness, and thereby inducing a predisposition to frequent returns of the disease.
4. It shortens the duration of a fit of gout, by throwing it, not into the feet, but out of the system, and thus prevents a patient's lying upon his back for two or three months with a writhing face, scolding a wife and family of children, and sometimes cursing every servant that comes near enough to endanger the touch of an inflamed limb. Besides preventing all this parade of pain and peevishness, it frequently, when assisted with other remedies to be mentioned presently, restores a man to his businessand society in two or three days: a circumstance this of great importance in the public as well as private pursuits of men; for who has not read of the most interesting affairs of nations being neglected or protracted, by the principal agents in them being suddenly confined to their beds, or chairs, for weeks or months, by a fit of the gout?
2. A second remedy in the state of the gout which has been mentioned, ispurging. Sulphur is generally preferred for this purpose, but castor oil, cream of tartar, sena, jalap, rhubarb, and calomel, may all be used with equal safety and advantage. The stomach and habits of the patient should determine the choice of a suitable purge in every case. Salts are generally offensive to the stomach. They once brought on a fit of the gout in Dr. Brown.
3.Vomitsmay be given in all those cases where bleeding is objected to, or where the pulse is only moderately active. Mr. Small, in an excellent paper upon the gout, in the 6th volume of the Medical Observations and Inquiries, p. 205, containing the history of his own case, tells us that he always took a vomit upon the first attack of the gout, and that it never failed of relieving all its symptoms. The matter discharged by this vomitindicated a morbid state of the liver, for it was always a dark greenish bile, which was insoluble in water. A British lieutenant, whose misfortunes reduced him to the necessity of accepting a bed in the poor-house of this city, informed the late Dr. Stuben, that he had once been much afflicted with the gout, and that he had upon many occasions strangled a fit of it by the early use of an emetic. Dr. Pye adds his testimony to those which have been given in favour of vomits, and says further, that they do most service when they discharge an acid humour from the stomach. They appear to act in part by equalizing the divided excitement of the system, and in part by discharging the contents of the gall-bladder and stomach, vitiated by the previous debility of those organs. Care should be taken not to exhibit this remedy where the gout attacks the stomach with symptoms of inflammation, or where it has a tendency to fix itself upon the brain.
4.Nitremay be given with advantage in cases of inflammatory action, where the stomach is not affected.
5. A fifth remedy iscoolorcold air. This is as safe and useful in the gout as in any other inflammatory state of fever. The affected limbsshould be kept out of bed,uncovered. In this way Mr. Small says he moderated the pains of the gout in his hands and feet[62]. I have directed the same practice with great comfort, as well as advantage to my patients. Even cold water has been applied with good effects to a limb inflamed by the gout. Mr. Blair M'Clenachan taught me the safety and benefit of this remedy, by using it upon himself without the advice of a physician. It instantly removed his pain, nor was the gout translated by it to any other part of his body. It was removed in the same manner, Dr. Heberden tells us, by the celebrated Dr. Harvey from his own feet. Perhaps it would be best in most cases to prefer cool, or cold air, to cold water. The safety and advantages of both these modes of applying cold to the affected limbs, show the impropriety of the common practice of wrapping them in flannel.
6.Diluting liquors, such as are prescribed in common inflammatory fevers, should be given in such quantities as to dispose to a gentle perspiration.
7.Abstinence from wine, spirits, and malt liquors, also from such aliments as afford much nourishmentor stimulus, should be carefully enjoined. Sago, panada, tapioca, diluted milk with bread, and the pulp of apples, summer fruits, tea, coffee, weak chocolate, and bread soaked in chicken water or beef tea, should constitute the principal diet of patients in this state of the gout.
8.Blistersare an invaluable remedy in this disease, when used at a proper time, that is, after the reduction of the morbid actions in the system by evacuations. They should be applied to the joints of the feet and wrists in general gout, and to the neck and sides, when it attacks the head or breast. A strangury from the gout is no objection to their use. So far from increasing this complaint, Dr. Clark and Dr. Whytt inform us, that they remove it[63]. But the principal advantage of blisters is derived from their collecting and concentrating scattered and painful sensations, and conveying them out of the system, and thus becoming excellent substitutes for a tedious fit of the gout.
9.Fearandterrorhave in some instances cured a paroxysm of this disease. A captain of a British ship of war, who had been confined for several weeks to his cabin, by a severe fit of the gout inhis feet, was suddenly cured by hearing the cry of fire on board his ship. This fact was communicated to me by a gentleman who was a witness of it. Many similar cases are upon record in books of medicine. I shall in another place insert an account of one in which the cure effected by a fright, eradicated the disease from the system so completely, as ever afterwards to prevent its return.
Thus have I enumerated the remedies which are proper in the gout when it affects the blood-vessels and viscera with great morbid action. Most of those remedies are alike proper when the morbid actions are seated in the muscular fibres, whether of the bowels or limbs, and whether they produce local pain, or general convulsion, provided they are of a violent nature.
There are some remedies under this head of a doubtful nature, on which I shall make a few observations.
Sweatinghas been recommended in this state of the gout. All the objections to it in preference to other modes of depletion, mentioned in another place[64], apply against its use in the inflammatorystate of the gout. It is not only less safe than bleeding, purging, and abstinence, but it is often an impracticable remedy. The only sudorific medicine to be trusted in this state of the disease is the Seneka snake-root. It promotes all the secretions and excretions, and exerts but a feeble stimulus upon the arterial system.
Many different preparations ofopiumhave been advised in this state of the gout. They are all hurtful if given before the morbid action of the system is nearly reduced. It should then be given in small doses accommodated to the excitability of the system.
Applications of various kinds to the affected limbs have been used in a fit of the gout, and some of them with success. The late Dr. Chalmers of South-Carolina used to meet the pain of the gout as soon as it fixed in any of his limbs, with a blister, and generally removed it by that means in two or three days. I have imitated this practice in several cases, and always with success, nor have I ever seen the gout thrown upon any of the viscera by means of this remedy. Caustics have sometimes been applied to gouty limbs with advantage. The moxa described and used by sir William Temple, which is nothing but culinary fire, has often notonly given relief to a pained limb, but carried off a fit of the gout in a few hours. These powerful applications may be used with equal advantage in those cases in which the gout by falling upon the head produces coma, or symptoms of apoplexy. A large caustic to the neck roused Mr. John M. Nesbit from a coma in which he had lain for three days, and thereby appeared to save his life. Blisters, and cataplasms of mustard, had been previously used to different parts of his body, but without the least effect. In cases of moderate pain, where a blister has been objected to, I have seen a cabbage leaf afford considerable relief. It produces a moisture upon the part affected, without exciting any pain. An old sea captain taught me to apply molasses to a limb inflamed or pained by the gout. I have frequently advised it, and generally with advantage. All volatile and stimulating liniments are improper, for they not only endanger a translation of the morbid excitement to the viscera, but where they have not this effect, they increase the pain and inflammation of the part affected.
The sooner a patient exercises his lower limbs by walking, after a fit of the gout, the better. “I made it a constant rule (says Mr. Small) to walk abroad as soon as the inflammatory state of the gout was past, and though by so doing, I oftensuffered great pain, I am well convinced that the free use I now enjoy of my limbs is chiefly owing to my determined perseverance in the use of that exercise; nor am I less persuaded that nine in ten of gouty cripples owe their lameness more to indolence, and fear of pain, than to the genuine effects of the gout[65].” Sir William Temple confirms the propriety of Mr. Small's opinion and practice, by an account of an old man who obviated a fit of the gout as often as he felt it coming in his feet, by walking in the open air, and afterwards by going into a warm bed, and having the parts well rubbed where the pain began. “By following this course (he says) he was never laid up with the gout, and before his death recommended the same course to his son if ever he should fall into that accident.” Under a conviction of the safety of this practice the same author concludes the history of his own case in the following words: “I favoured it [viz. the swelling in my feet] all this while more than I needed, upon the common opinion, that walking too much might draw down the humour, which I have since had reason to conclude is a great mistake, and that if I had walked as much as I could from the first daythe pain left me, the swelling might have left me too in a much less time[66].”
III. I come now to mention the remedies which are proper in that state of the gout in which afeeblemorbid action takes place in the blood-vessels and viscera.
I shall begin this head, by remarking, that this state of the gout is often created, like the typhus state of fever, by the neglect, or too scanty use of evacuations in its first stage. When the prejudices which now prevent the adoption of those remedies in their proper time, are removed, we shall hear but little of the low state of the arthritic fever, nor of the numerous diseases from obstruction which are produced by the blood-vessels disorganizing the viscera, by repeated and violent attacks of the disease.
To determine the character of a paroxysm of gout and the remedies proper to relieve it, the climate, the season of the year, the constitution of the atmosphere, and the nature of the prevailing epidemic, should be carefully attended to by a physician.But his principal dependence should be placed upon the state of the pulse. If it do not discover the marks which indicate bleeding formerly referred to, but is weak, quick, and soft, the remedies should be such as are calculated to produce a more vigorous, and equable action in the blood-vessels and viscera. They are,
1.Opium.It should at first be given in small doses, and afterwards increased, as circumstances may require.
2.MadeiraorSherry winealone, or diluted with water, or in the form of whey, or rendered more cordial by having any agreeable spice infused in it. It may be given cold or warm, according to the taste of the patient, or the state of his stomach. If this medicine be rejected in all the above forms,
3.Portershould be given. It is often retained when no other liquor will lie upon the stomach. I think I once saved the life of Mr. Nesbit by this medicine. It checked a vomiting, from the gout, which seemed to be the last symptom of his departing life. If porter fail of giving relief,
4.Ardent spiritsshould be given, either alone, or in the form of grog, or toddy. Cases have occurredin which a pint of brandy has been taken in the course of an hour with advantage. Great benefit has sometimes been found from Dr. Warner's tincture, in this state of the gout. As these observations may fall into the hands of persons who may not have access to Dr. Warner's book, I shall here insert the receipt for preparing it.
Of raisins, sliced and stoned, half a pound.
Rhubarb, one ounce.
Sena, two drachms.
Coriander and fennel seeds, of each one drachm.
Cochineal, saffron, and liquorice root, each half a drachm.
Infuse them for ten days in a quart of French brandy, then strain it, and add a pint more of brandy to the ingredients, afterwards strain it, and mix both tinctures together. Four table spoons full of this cordial are to be taken every hour, mixed with an equal quantity of water, until relief be obtained.
Ten drops of laudanum may be added to each dose in those cases in which the cordial does not produce its intended effects, in two or three hours. If all the different forms of ardent spirits which have been mentioned fail of giving relief,
5. From 30 drops to a tea spoonful ofæthershould be given in any agreeable vehicle. Also,
6.Volatile alkali.From five to ten grains of this medicine should be given every two hours.
7.Aromatic substances, such as alspice, ginger, Virginia snake-root, cloves, and mace in the form of teas, have all been useful in this state of the gout.
All these remedies are indicated in a more especial manner when the gout affects the stomach. They are likewise proper when it affects the bowels. The laudanum in this case should be given by way of glyster. After the vomiting was checked in Mr. Nesbit by means of porter, he was afflicted with a dull and distressing pain in his bowels, which was finally removed by two anodyne glysters injected daily for two or three weeks.
8. Where the gout produces spasmodic or convulsive motions, theoil of ambermay be given with advantage. I once saw it remove for a while a convulsive cough from the gout.
9. In cases where the stomach will bear thebark, it should be given in large and frequent doses. Itdoes the same service in this state of gout, that it does in the slow, or low states of fever from any other cause. Where the gout appears in the form of an intermittent, the bark affords the same relief that it does in the same disease from autumnal exhalations. Mr. Small found great benefit from it after discharging the contents of his stomach and bowels by a dose of tartar emetic. “I do not call (says this gentleman) a fit of the gout a paroxysm, for there are several paroxysms in the fit, each of which is ushered in with a rigour, sickness at stomach, and subsequent heat. In this the gout bears a resemblance to an irregular intermittent, at least to a remitting fever, and hence perhaps the efficacy of the bark in removing the gout[67].”
10. Thewarm bathis a powerful remedy in exciting a regular and healthy action in the sanguiferous system. Where the patient is too weak to be taken out of bed, and put into a bathing tub, his limbs and body should be wrapped in flannels dipped in warm water. In case of a failure of all the above remedies,
11. Asalivationshould be excited as speedily as possible, by means of mercury. Dr. Cheynecommends it in high terms. I have once used it with success. The mercury, when used in this way, brings into action an immense mass of latent excitement, and afterwards diffuses it equally through every part of the body.
12. Besides these internal remedies, frictions with brandy, and volatile liniment, should be used to the stomach and bowels. Blisters should be applied to parts in which congestion or pain is seated, and stimulating cataplasms should be applied to the lower limbs. The flour of mustard has been justly preferred for this purpose. It should be applied to the upper part of the foot.
The reader will perceive, in the account I have given of the remedies proper in the feeble state of chronic fever, that they are the same which are used in the common typhus, or what is called nervous fever. There is no reason why they should not be the same, for the supposed two morbid states of the system are but one disease.
It is agreeable in medical researches to be under the direction of principles. They render unnecessary, in many instances, the slow and expensive operations of experience, and thus multiply knowledge, by lessening labour. The science of navigationhas rested upon this basis, since the discovery of the loadstone. A mariner who has navigated a ship to one distant port, is capable of conducting her to every port on the globe. In like manner, the physician who can cure one disease by a knowledge of its principles, may by the same means cure all the diseases of the human body, for their causes are the same. Judgment is required, only in accommodating the force of remedies to the force of each disease. The difference in diseases which arises from their seats, from age, sex, habit, season, and climate, may be known in a short time, and is within the compass of very moderate talents.
IV. Were I to enumerate all the local symptoms of gout which occur without fever, and the remedies that are proper to relieve them, I should be led into a tedious digression. The reader must consult practical books for an account of them. I shall only mention the remedies for a few of them.
The theory of the gout which has been delivered, will enable us to understand the reason why a disease which properly belongs to the whole system, should at any time be accompanied only with local morbid affection. The whole body is a unit, and hence morbid impressions which are resisted bysound parts are propagated to such as are weak, where they excite those morbid actions we call disease.
Thehead-achis a distressing symptom of the gout. It yields to depleting or tonic remedies, according to the degree of morbid action which accompanies it. I have heard an instance of an old man, who was cured of an obstinate head-ach by throwing aside his nightcap, and sleeping with his bare head exposed to the night air. The disease in this case was probably attended with great morbid action. In this state of the vessels of the brain, cupping, cold applications to the head, purges, a temperate diet, and blisters behind the ears, are all proper remedies, and should be used together, or in succession, as the nature of the disease may require. Many persons have been cured of the same complaint by sleeping in woollen nightcaps. The morbid action in these cases is always of a feeble nature. With this remedy, tonics, particularly the bark and cold bath, will be proper. I have once known a chronic gouty pain in the head cured by an issue in the arm, after pounds of bark, and many other tonic remedies, had been taken to no purpose.
Theophthalmiafrom gout should be treated with the usual remedies for that disease when it arises from other causes, with the addition of such local applications to other and distant parts of the body, as may abstract the gouty action from the eyes.
Dull but constant pains in the limbsyield to frictions, volatile liniments, muslin and woollen worn next to the skin, electricity, a salivation, and the warm and cold bath. A gentleman who was afflicted with a pain of this kind for three years and a half in one of his arms, informed me, that he had been cured by wearing a woollen stocking that had been boiled with sulphur in water, for two weeks upon the affected limb. He had previously worn flannel upon it, but without receiving any benefit from it. I have known wool and cotton, finely carded, and made into small mats, worn upon the hips, when affected by gout, with great advantage. In obstinate sciatic pains, without fever or inflammation, Dr. Pitcairn's remedy, published by Dr. Cheyne, has performed many cures. It consists in taking from one to four tea-spoons full of the fine spirit of turpentine every morning, for a week or ten days, in three times the quantity of honey, and afterwards in drinking a large quantity of sack whey, to settle it on the stomach, and carry it intothe blood. An anodyne should be taken every night after taking this medicine.
Agouty diarrhœashould be treated with the usual astringent medicines of the shops. Blisters to the wrists and ankles, also a salivation, have often cured it. I have heard of its being checked, after continuing for many years, by the patient eating large quantities of alspice, which he carried loose in his pocket for that purpose.
Theangina pectoris, which I have said is a symptom of the gout, generally comes on with fulness and tension in the pulse. After these are reduced by two or three bleedings, mineral tonics seldom fail of giving relief.
Spasms in the stomach, andpains in the bowels, often seize gouty people in the midst of business or pleasure, or in the middle of the night. My constant prescription for these complaints is ten drops of laudanum every half hour, till relief be obtained. If this medicine be taken in the forming state of these pains, a single dose generally removes the disease. It is preferable to spiced wine and spirits, inasmuch as it acts quicker, and leaves no disposition to contract a love for it when it is not required to ease pain.
Thepain in the rectumwhich has been described, yields to the common remedies for the piles. Cold water applied to the part, generally gives immediate relief.
For apreternatural secretion and excretion of bile, gentle laxatives, and abstinence from oily food, full meals, and all violent exercises of the body and mind, are proper.
Theitching in the anus, which I have supposed to be a symptom of gout, has yielded in one instance that has come within my knowledge to mercurial ointment applied to the part affected. Dr. Lettsom recommends fomenting the part with a decoction of poppy heads and hemlock, and advises lenient purges and a vegetable diet as a radical cure for the disease[68].
For theitching in the vaginaI have found a solution of the sugar of lead in water to be an excellent palliative application. Dr. Lettsom recommends as a cure for it, the use of bark in delicate habits, and occasional bleeding, with a light and moderate diet, if it occur about the time of the cessation of the menses.
Obstinatecutaneous eruptions, which are the effects of gout, have been cured by gentle physic, a suitable diet, issues, and applications of the unguentum citrinum to the parts affected.
Thearthritic gonorrhœashould be treated with the same remedies as a gonorrhœa from any other cause.
In the treatment of all the local symptoms that have been enumerated, it will be of great consequence to inquire, before we attempt to cure them, whether they have not succeeded general gout, and thereby relieved the system from its effects in parts essential to life. If this have been the case, the cure of them should be undertaken with caution, and the danger of a local disease being exchanged for a general one, should be obviated by remedies that are calculated to eradicate the gouty diathesis altogether from the system. The means for this purpose, agreeably to our order, come next under our consideration. Before I enter upon this head, I shall premise, that I do not admit of the seeds of the gout remaining in the body to be eliminated by art after a complete termination of one of its paroxysms, any more than I admit of the seeds of a pleurisy or intermitting fever remaining in the body, after they have been cured by blood-lettingor bark. A predisposition only remains in the system to a return of the gout, from its usual remote and exciting causes. The contrary idea took its rise in those ages of medicine in which morbific matter was supposed to be the proximate cause of the gout, but it has unfortunately continued since the rejection of that theory. Thus in many cases we see wrong habits continue long after the principles have been discarded, from which they were derived.
I have known several instances in which art, and I have heard and read of others in which accidental suffering from abstinence, pain, and terror have been the happy means of overcoming a predisposition to the gout. A gentleman from one of the West-India islands, who had been for many years afflicted with the gout, was perfectly cured of it by living a year or two upon the temperate diet of the jail in this city, into which he was thrown for debt by one of his creditors. A large hæmorrhage from the foot, inflamed and swelled by the gout, accidentally produced by a penknife which fell upon it, effected in an Irish gentleman a lasting cure of the disease. Hildanus mentions the history of a gentleman, whom he knew intimately, who was radically cured of a gout with which he had been long afflicted, by the extreme bodily pain he sufferedinnocently from torture in the canton of Berne. He lived to be an old man, and ever afterwards enjoyed good health[69]. The following letter from my brother contains the history of a case in which terror suddenly eradicated the gout from the system.
“Reading,July 27th, 1797.
“DEAR BROTHER,
“WHEN I had the pleasure of seeing you last week, I mentioned an extraordinary cure of the gout in this town, by means of afright. In compliance with your request, I now send an exact narration of the facts.
“Peter Fether, the person cured, is now alive, a householder in Reading, seventy-three years of age, a native of Germany, and a very hearty man. The first fit of the gout he ever had, was about the year 1773; and from that time till 1785, he had a regular attack in the spring of every year. His feet, hands, and elbows were much swollen and inflamed; the fits lasted long, and were excruciating. In particular, the last fit in 1785 was so severe, as to induce an apprehension, that it wouldinevitably carry him off, when he was suddenly relieved by the following accident.
“As he lay in a small back room adjoining the yard, it happened that one of his sons, in turning a waggon and horses, drove the tongue of the waggon with such force against the window, near which the old man lay stretched on a bed, as to beat in the sash of the window, and to scatter the pieces of broken glass all about him. To such a degree was he alarmed by the noise and violence, that he instantly leaped out of bed, forgot that he had ever used crutches, and eagerly inquired what was the matter. His wife, hearing the uproar, ran into the room, where, to her astonishment, she found her husband on his feet, bawling against the author of the mischief, with the most passionate vehemence. Fromthatmoment, he has been entirely exempt from the gout, has never had the slightest touch of it, andnowenjoys perfect health, has a good appetite, and says he was never heartier in his life. This is probably the more remarkable, when I add, that he has always been used to the hard work of a farm, andsincethe year 1785 has frequently mowed in his own meadow, which I understand is low and wet. I am well informed, in his mode of living, he has been temperate, occasionallyindulging in a glass of wine, after the manner of the German farmers, but not to excess.
“To you, who have been long accustomed to explore diseases, I leave the task of developing the principles, on which this mysterious restoration from the lowest decrepitude and bodily wretchedness, to a state of perfect health, has been accomplished. I well know that tooth-achs, head-achs, hiccoughs, [**AMP]c. are often removed by the sudden impression of fear, and that they return again. But to see a debilitated gouty frame instantly restored to vigour; to see the whole system in a moment, as it were, undergo a perfect and entire change, and the most inveterate and incurable diseaseradicallyexpelled, is surely adifferentthing, and must be acknowledged a very singular and marvellous event. If an old man, languishing under disease and infirmity, haddiedof mere fright, nobody would have been surprised at it; but that he should be absolutely cured, and his constitution renovated by it, is a most extraordinary fact, which, while I am compelled to believe by unexceptionable evidence, I am totally at a loss to account for.
I am your sincerelyaffectionate brother,JACOB RUSH.”
These facts, and many similar ones which might be mentioned, afford ample encouragement to proceed in enumerating the means which are proper to prevent the recurrence of the gout, or, in other words, to eradicate it from the system.
V. I shall first mention the means of preventing the return of that state of the disease which is accompanied withviolentaction, and afterwards take notice of the means of preventing the return of that state of it, in which afeeblemorbid action takes place in the blood-vessels. The means for this purpose consist in avoiding all the remote, exciting, and predisposing causes of the gout which have been mentioned. I shall say a few words upon the most important of them, in the order that has been proposed.
I. The first remedy for obviating theviolentstate of gout is,
1.Temperance.This should be regulated in its degrees by the age, habits, and constitution of the patient. A diet consisting wholly of milk, vegetables, and simple water, has been found necessary to prevent the recurrence of the gout in some cases. But, in general, fish, eggs, the white meats and weak broths may be taken in small quantities oncea day, with milk and vegetables at other times. A little salted meat, which affords less nourishment than fresh, may be eaten occasionally. It imparts vigour to the stomach, and prevents dyspepsia from a diet consisting chiefly of vegetables. The low and acid wines should be avoided, but weak Madeira or sherry wine and water, or small beer, may be drunken at meals. The latter liquor was the favourite drink of Dr. Sydenham in his fits of the gout. Strong tea and coffee should not be tasted, where there is reason to believe the habitual use of them has contributed to bring on the disease.
From the disposition of the gout to return in the spring and autumn, greater degrees of abstinence in eating and drinking will be necessary at those seasons than at any other time. With this diminution of aliment, gentle purges should be taken, to obviate an attack of the gout. In persons above fifty years of age, an abstemious mode of living should be commenced with great caution. It has sometimes, when entered upon suddenly, and carried to its utmost extent, induced fits of the gout, and precipitated death. In such persons, the abstractions from their usual diet should be small, and our dependence should be placed upon other means to prevent a return of the disease.
2.Moderate labourandgentle exercisehave frequently removed that debility and vibratility in the blood-vessels, on which a predisposition to the gout depends. Hundreds of persons who have been reduced by misfortunes to the necessity of working for their daily bread, have thrown off a gouty diathesis derived from their patents, or acquired by personal acts of folly and intemperance. The employments of agriculture afford the most wholesome labour, and walking, the most salutary exercise. To be useful, they should be moderate. The extremes of indolence and bodily activity meet in a point. They both induce debility, which predisposes to a recurrence of a fit of the gout. Riding in a carriage, and on horseback, are less proper as a means of preventing the disease than walking. Their action upon the body is partial. The lower limbs derive no benefit from it, and on these the violent state of gout generally makes its first attack. In England, many domestic exercises have been contrived for gouty people, such as shuttle-cock, bullets, the chamber-horse, and the like, but they are all trifling in their effects, compared with labour, and exercise in the open air. The efficacy of the former of those prophylactic remedies will appear in a strong point of light, when we consider, how much the operation of the remote and exciting causes of the gout which actmore or less upon persons in the humblest ranks of society, are constantly counteracted in their effects, by the daily labour which is necessary for their subsistence.
3. To prevent the recurrence of the gout, cold should be carefully avoided, more especially when it is combined with moisture. Flannel should be worn next to the skin in winter, and muslin in summer, in order to keep up a steady and uniform perspiration. Fleecy hosiery should be worn in cold weather upon the breast and knees, and the feet should be kept constantly warm and dry by means of socks and cork-soaled shoes. It was by wetting his feet, by standing two or three hours upon the damp ground, that colonel Miles produced the gout in his stomach and bowels which had nearly destroyed him in the year 1795.
4. Great moderation should be used by persons who are subject to the gout in the exercise of their understandings and passions. Intense study, fear, terror, anger, and even joy, have often excited the disease into action. It has been observed, that the political and military passions act with more force upon the system, than those which are of a social and domestic nature; hence generals and statesmen are so often afflicted with the gout, and that too,as was hinted in another place, in moments the most critical and important to the welfare of a nation. The combination of the exercises of the understanding, and the passion of avarice in gaming, have often produced an attack of this disease.
These facts show the necessity of gouty people subjecting their minds, with all their operations, to the government of reason and religion. The understanding should be exercised only upon light and pleasant subjects. No study should ever be pursued till it brings on fatigue; and, above all things, midnight, and even late studies should be strictly avoided. A gouty man should always be in bed at an early hour. This advice has the sanction of Dr. Sydenham's name, and experience proves its efficacy in all chronic diseases.
5. The venereal appetite should be indulged with moderation. And,
6. Costiveness should be prevented by all persons who wish to escape a return of violent fits of the gout. Sulphur is an excellent remedy for this purpose. Dr. Cheyne commends it in high terms. His words are, “Sulphur is one of the best remedies in the intervals of the gout. In the whole extent of the materia medica, I know not a moresafe and active medicine[70].” Two cases have come within my knowledge, in which it has kept off fits of the gout for several years, in persons who had been accustomed to have them once or twice a year. Rhubarb in small quantities chewed, or in the form of pills, may be taken to obviate costiveness, by persons who object to the habitual use of sulphur. Dr. Cheyne, who is lavish in his praises of that medicine as a gentle laxative, says, he “knew a noble lord of great worth and much gout, who, by taking from the hands of a quack a drachm of rhubarb, tinged with cochineal to disguise it, every morning for six weeks, lived in health, for four years after, without any symptom of it[71].”
I have said that abstinence should be enjoined with more strictness in the spring and autumn, than at any other time, to prevent a return of the gout. From the influence of the weather at those seasons in exciting febrile actions in the system, the loss of a pint of blood will be useful in some cases for the same purpose. It will be the more necessary if the gout has not paid its habitual visits to the system. The late Dr. Gregory had been accustomed to an attack of the gout every spring. Two seasonspassed away without his feeling any symptoms of it. He began to flatter himself with a hope that the predisposition to the disease had left him. Soon afterwards he died suddenly of an apoplexy. The loss of a few ounces of blood at the usual time in which the gout affected him, would probably have protracted his life for many years. In the year 1796, in visiting a patient, I was accidentally introduced into a room where a gentleman from the Delaware state had been lying on his back for near six weeks with an acute fit of the gout. He gave me a history of his sufferings. His pulse was full and tense, and his whole body was covered with sweat from the intensity of his pain. He had not had his bowels opened for ten days. I advised purging and bleeding in his case. The very names of those remedies startled him, for he had adopted the opinion of the salutary nature of a fit of the gout, and therefore hugged his chains. After explaining the reason of my prescriptions, he informed me, in support of them, that he had escaped the gout but two years in twenty, and that in one of these two years he had been bled for a fall from his horse, and, in the other, his body had been reduced by a chronic fever, previously to the time of the annual visit of his gout.
As a proof of the efficacy of active, or passive depletion, in preventing the gout, it has been found that persons who sweat freely, either generally or partially, or who make a great deal of water, are rarely affected by it.
An epitome of all that has been said upon the means of preventing a return of the gout, may be delivered in a few words. A man who has had one fit of it, should consider himself in the same state as a man who has received the seeds of a malignant fever into his blood. He should treat his body as if it were a Florence flask. By this means he will probably prevent, during his life, the re-excitement of the disease.
Areissuesproper to prevent the return of the violent state of gout? I have heard of an instance of an issue in the leg having been effectual for this purpose; but if the remedies before-mentioned be used in the manner that has been directed, so unpleasant a remedy can seldom be necessary.
Arebittersproper to prevent a return of this state of gout? It will be a sufficient answer to this question to mention, that the duke of Portland's powder, which is composed of bitter ingredients,excited a fatal gout in many people who used it for that purpose. I should as soon expect to see gold produced by the operations of fire upon copper or lead, as expect to see the gout prevented or cured by any medicine that acted upon the system, without the aid of more or less of the remedies that have been mentioned.
II. We come now, in the last place, to mention the remedies which are proper to prevent a return of that state of gout which is attended with afeeblemorbid action in the blood-vessels and viscera.
This state of gout generally occurs in the evening of life, and in persons of delicate habits, or in such as have had their constitutions worn down by repeated attacks of the disease.
The remedies to prevent it are,
1. Agently stimulating diet, consisting of animal food well cooked, with sound old Madeira or sherry wine, or weak spirit and water. Salted, and even smoked meat may be taken, in this state of the system, with advantage. It is an agreeable tonic, and is less disposed to create plethora than fresh meat. Pickles and vinegar should seldom be tasted. They dispose to gouty spasms in the stomach andbowels. Long intervals between meals should be carefully avoided. The stomach, when overstretched or empty, is always alike predisposed to disease. There are cases in which the evils of inanition in the stomach will be prevented, by a gouty patient eating in the middle of the night.
2. The use ofchalybeate medicines. These are more safe when used habitually, than bitters. I have long been in the practice of giving the different preparations of iron in large doses, in chronic diseases, and in that state of debility which disposes to them. A lady of a weak constitution informed Dr. Cheyne, that she once asked Dr. Sydenham how long she might safely take steel. His answer was, that “she might take it for thirty years, and then begin again if she continued ill[72].”
Water impregnated with iron, either by nature or art, may be taken instead of the solid forms of the metal. It will be more useful if it be drunken in a place where patients will have the benefit of country air.
3. The habitual use of thevolatile tincture of gum guiacum, and of other cordial and gently stimulatingmedicines. A clove of garlic taken once or twice a day, has been found useful in debilitated habits predisposed to the gout. It possesses a wonderful power in bringing latent excitement into action. It moreover acts agreeably upon the nervous system.
Mr. Small found great benefit from breakfasting upon a tea made of half a drachm of ginger cut into small slices, in preventing occasional attacks of the gout in his stomach. Sir Joseph Banks was much relieved by a diet of milk, with ginger boiled in it. The root of the sassafras of our country might probably be used with advantage for the same purpose. Aurelian speaks of certain remedies for the gout which he calls “annalia[73].” The above medicines belong to this class. To be effectual, they should be persisted in, not for one year only, but for many years.
4.Warmth, uniformly applied, by means of suitable dresses, and sitting rooms, to every part of the body.
5. Thewarm bathin winter, and thetemperate, orcold bathin summer.
6.Exercise.This may be in a carriage, or on horseback. The viscera being debilitated in this state of predisposition to the gout, are strengthened in a peculiar manner by the gentle motion of a horse. Where this or other modes of passive exercise cannot be had, frictions to the limbs and body should be used every day.
7.Costivenessshould be avoided by taking occasionally one or two table spoons full of Dr. Warner's purging tincture prepared by infusing rhubarb, orange peel, and caraway seeds, of each an ounce, for three days in a quart of Madeira, or any other white wine. If this medicine be ineffectual for opening the bowels, rhubarb may be taken in the manner formerly mentioned.
8. The understanding and passions should be constantly employed in agreeable studies and pursuits. Fatigue of mind and body should be carefully avoided.
9. A warm climate often protracts life in persons subject to this state of gout. The citizens of Rome who had worn down their constitutions by intemperance, added many years to their lives, by migrating to Naples, and enjoying there, in a warmer sun, the pure air of the Mediterranean, and sirWilliam Temple says the Portuguese obtain the same benefit by transporting themselves to the Brazils, after medicine and diet cease to impart vigour to their constitutions in their native country.
Thus have I enumerated the principal remedies for curing and preventing the gout. Most of them are to be met with in books of medicine, but they have been administered by physicians, or taken by patients with so little regard to the different states of the system, that they have in many instances done more harm than good. Solomon places all wisdom, in the management of human affairs, in finding out the proper times for performing certain actions. Skill in medicine, consists in an eminent degree in timing remedies. There is a time to bleed, and a time to withhold the lancet. There is a time to give physic, and a time to trust to the operations of nature. There is a time to eat meat, and there is a time to abstain from it. There is a time to give tonic medicines, and a time to refrain from them. In a word, the cure of the gout depends wholly upon two things, viz.properremedies, in their propertimes, andplaces.
I shall take leave of this disease, by comparing it to a deep and dreary cave in a new country, in which ferocious beasts and venomous reptiles, withnumerous ghosts and hobgoblins, are said to reside. The neighbours point at the entrance of this cave with horror, and tell of the many ravages that have been committed upon their domestic animals, by the cruel tenants which inhabit it. At length a school-boy, careless of his safety, ventures to enter this subterraneous cavern, when! to his great delight, he finds nothing in it but the same kind of stones and water he left behind him upon the surface of the earth. In like manner, I have found no other principles necessary to explain the cause of the gout, and no other remedies necessary to cure it, than such as are admitted in explaining the causes, and in prescribing for the most simple and common diseases.