or a sudden application of its remote and predisposing causes. They
act upon the accumulated excitability of the system, and by destroying
its equilibrium of excitement, and regular order of actions, produce
convulsion, or irregular morbid and local excitement. These exciting
causes are either of a stimulating, or of a sedative nature. The former
are violent exercise, of body or mind, night-watching, and even sitting
up late at night, a hearty meal, a fit of drunkenness, a few glasses
of claret or a draught of cyder, where those liquors have not been
habitual to the patient, a sudden paroxysm of joy, anger, or terror,
a dislocation of a bone, straining of a joint, particularly of the
ankle, undue pressure upon the foot, or leg, from a tight shoe or boot,
an irritated corn, and the usual remote causes of fever. The latter
exciting causes are sudden inanition from bleeding, purging, vomiting,
fasting, cold, a sudden stoppage of moisture on the feet, fear, grief,
excess in venery, and the debility left upon the system by the crisis
of a fever. All these causes act more certainly when they are aided by
the additional debility induced upon the system in sleep. It is for this
reason that the gout generally makes its first attack in the night,
and in a part of the system most remote from the energy of the brain,
and most debilitated by exercise, viz. in the great toe, or in some
part of the foot. In ascribing a fit of the gout to a cause which is
of a sedative nature, the reader will not suppose that I have departed
from the simplicity and uniformity of a proposition I have elsewhere
delivered, that disease is the effect of stimulus. The abstraction
of a natural and habitual impression of any kind, by increasing the
force of those which remain, renders the production of morbid and
excessive actions in the system as much the effect of preternatural or
disproportioned stimulus, as if they were induced by causes that are
externally and evidently stimulating. It is thus in many other of the
operations of nature, opposite causes produce the same effects.
8. The gout consists simply in morbid excitement, accompanied with
irregular action, or the absence of all action from the force of
stimulus. There is nothing specific in the morbid excitement and actions
which take place in the gout different from what occur in fevers. It is
to be lamented that a kind of metastasis of error has taken place in
pathology. The rejection of a specific acrimony as the cause of each
disease, has unfortunately been followed by a belief in as many specific
actions as there are different forms and grades of disease, and thus
perpetuated the evils of our ancient systems of medicine. However varied
morbid actions may be by their causes, seats, and effects, they are
all of the same nature, and the time will probably come when the whole
nomenclature of morbid actions will be absorbed in the single name of
disease.
I shall now briefly enumerate the symptoms of the gout, as they appear
in the ligaments, the blood-vessels, the viscera, the nervous system,
the alimentary canal, the lymphatics, the skin, and the bones of the
human body, and here we shall find that it is an epitome of all disease.
I. The ligaments which connect the bones are the seats, of what is
called a legitimate or true gout. They are affected with pain, swelling,
and inflammation. The pain is sometimes so acute as to be compared
to the gnawing of a dog. We perceive here the sameness of the gout
with the rheumatism. Many pages, and indeed whole essays, have been
composed by writers to distinguish them, but they are exactly the same
disease while the morbid actions are confined to this part of the body.
They are, it is true, produced by different remote causes, but this
constitutes no more difference in their nature, than is produced in
a coal of fire, whether it be inflamed by a candle, or by a spark of
electricity. The morbid actions which are induced by the usual causes
of rheumatism affect, though less frequently, the lungs, the trachea,
the head, the bowels, and even the heart, as well as the gout. Those
actions, moreover, are the means of a fluid being effused, which is
changed into calcareous matter in the joints and other parts of the
body, exactly like that which is produced by the gout. They likewise
twist and dislocate the bones in common with the gout, in a manner to be
described hereafter. The only difference between what are called gouty,
and rheumatic actions, consists in their seats, and in the degrees of
their force. The debility which predisposes to the gout, being greater,
and more extensively diffused through the body than the debility which
precedes rheumatism, the morbid actions, in the former case, pass more
readily from external to internal parts, and produce in both more acute
and more dangerous effects. A simile derived from the difference in the
degrees of action produced in the system by marsh miasmata, made use of
upon a former occasion, will serve me again to illustrate this part of
our subject. A mild remittent, and a yellow fever, are different grades
of the same disease. The former, like the rheumatism, affects the bones
chiefly with pain, while the latter, like the gout, affects not only the
bones, but the stomach, bowels, brain, nerves, lymphatics, and all the
internal parts of the body.
II. In the arterial system the gout produces fever. This fever appears
not only in the increased force or frequency of the pulse, but in morbid
affections of all the viscera. It puts on all the different grades of
fever, from the malignity of the plague, to the mildness of a common
intermittent. It has moreover its regular exacerbations and remissions
once in every four and twenty hours, and its crisis usually on the
fourteenth day, in violent cases. In moderate attacks, it runs on from
twenty to forty days in common with the typhus or slow chronic state
of fever. It is common for those persons who consider the gout as a
specific disease, when it appears in the above forms, to say, that it is
complicated with fever; but this is an error, for there can exist but
one morbid action in the blood-vessels at once, and the same laws are
imposed upon the morbid actions excited in those parts of the body by
the remote causes of the gout, as by the common causes of fever. I have
seen two instances of this disease appearing in the form of a genuine
hectic, and one in which it appeared to yield to lunar influence, in
the manner described by Dr. Balfour. In the highly inflammatory state
of the gout, the sensibility of the blood-vessels far exceeds what is
seen in the same state of fever from more common causes. I have known an
instance in which a translation of the gouty action to the eye produced
such an exquisite degree of sensibility, that the patient was unable
to bear the feeble light which was emitted from a few coals of fire in
his room, at a time too when the coldness of the weather would have
made a large fire agreeable to him. It is from the extreme sensibility
which the gout imparts to the stomach, that the bark is so generally
rejected by it. I knew a British officer who had nearly died from taking
a spoonful of the infusion of that medicine, while his arterial system
was in this state of morbid excitability, from a fit of the gout. It
is remarkable that the gout is most disposed to assume a malignant
character, during the prevalence of an inflammatory constitution of
the atmosphere. This has been long ago remarked by Dr. Huxham. Several
instances of it have occurred in this city since the year 1793.
III. The gout affects most of the viscera. In the brain it produces
head-ach, vertigo, coma, apoplexy, and palsy. In the lungs it produces
pneumonia vera, notha, asthma, hæmoptysis, pulmonary consumption, and
a short hecking cough, first described by Dr. Sydenham. In the throat
it produces inflammatory angina. In the uterus it produces hæmorrhagia
uterina. It affects the kidneys with inflammation, strangury, diabetes,
and calculi. The position of the body for weeks or months on the
back, by favouring the compression of the kidneys by the bowels, is
the principal reason why those parts suffer so much in gouty people.
The strangury appears to be produced by the same kind of engorgement
or choking of the vessels of the kidneys, which takes place in the
small-pox and yellow fever. Four cases of it are described in the 3d
volume of the Physical and Literary Essays of Edinburgh, by Dr. David
Clerk. I have seen one instance of death in an old man from this cause.
The catheter brought no water from his bladder. The late Mr. John Penn,
formerly governor of Pennsylvania, I have been informed by one of his
physicians, died from a similar affection in his kidneys from gout. The
catheter was as ineffectual in giving him relief, as it was in the case
of my patient. The neck of the bladder sometimes becomes the seat of
the gout. It discovers itself by spasm, and a suppression of urine in
some cases, and occasionally by a habitual discharge of mucus through
the urethra. This disease has been called, by Lieutaud, "a catarrh of
the bladder." Dr. Stoll describes it, and calls it "hæmorrhoids of
the bladder." But of all the viscera, the liver suffers most from the
gout. It produces in it inflammation, suppuration, melena, schirrus,
gall-stones, jaundice, and a habitual increased secretion and excretion
of bile. These affections of the liver appear most frequently in
southern countries, and in female habits. They are substitutes for a
gout in the ligaments, and in the extremities of the body. They appear
likewise in drunkards from ardent spirits. It would seem that certain
stimuli act specifically upon the liver, probably for the wise purpose
of discharging such parts of the blood from the body, as are vitiated
by the rapidity of its circulation. I shall, in another place[58],
take notice of the action of marsh miasmata upon the livers of men and
beasts. It has been observed that hogs that live near brewhouses, and
feed upon the fermented grains of barley, always discover enlarged or
diseased livers. But a determination of the blood to the liver, and
an increased action of its vessels, are produced by other causes than
marsh miasmata, and fermented and distilled liquors. They appear in the
fever which accompanies madness and the malignant sore-throat, also in
contusions of the brain, and in the excited state of the blood-vessels
which is produced by anger and exercise. I have found an attention to
these facts useful in prescribing for diseases of the liver, inasmuch as
they have led me from considering them as idiopathic affections, but as
the effects only of morbid actions excited in other parts of the body.
[58] Volume IV.
IV. The gout sometimes affects the arterial and nervous systems
_jointly_, producing in the brain, coma, vertigo, apoplexy, palsy, loss
of memory, and madness, and in the _nerves_, hysteria, hypochondriasis,
and syncope. It is common to say the gout counterfeits all these
diseases. But this is an inaccurate mode of speaking. All those diseases
have but one cause, and they are exactly the same, however different the
stimulus may be, from which they are derived. Sometimes the gout affects
the brain and nerves exclusively, without producing the least morbid
action in the blood-vessels. I once attended a gentleman from Barbadoes
who suffered, from this affection of his brain and nerves, the most
intolerable depression of spirits. It yielded to large doses of wine,
but his relief was perfect, and more durable, when a pain was excited by
nature or art, in his hands or feet.
The muscles are sometimes affected by the gout with spasm, with general
and partial convulsions, and lastly with great pain. Dr. Stoll describes
a case of opisthotonos from it. The angina pectoris, or a sudden
inability to breathe after climbing a hill, or a pair of stairs, and
after a long walk, is sometimes a symptom of the gout. There is a pain
which suddenly pervades the head, breast, and limbs, which resembles an
electric shock. I have known two instances of it in gouty patients, and
have taken the liberty of calling it the "aura arthritica." But the pain
which affects the muscles is often of a more permanent nature. It is
felt with most severity in the calves of the legs. Sometimes it affects
the muscles of the head, breast, and limbs, exciting in them large and
distressing swellings. But further; the gout in some cases seizes upon
the tendons, and twists them in such a manner as to dislocate bones in
the hands and feet. It even affects the cartilages. Of this I once saw
an instance in colonel Adams, of the state of Maryland. The external
parts of both his ears were so much inflamed in a fit of the gout, that
he was unable to lie on either of his sides.
V. The gout affects the alimentary canal, from the stomach to its
termination in the rectum. Flatulency, sickness, acidity, indigestion,
pain, or vomiting, usually usher in a fit of the disease. The sick
head-ach, also dyspepsia, with all its train of distressing evils, are
frequently the effects of gout concentrated in the stomach. I have seen
a case in which the gout, by retreating to this viscus, produced the
same burning sensation which is felt in the yellow fever. The patient
who was the subject of this symptom died two days afterwards with a
black vomiting. It was Mr. Patterson, formerly collector of the port
of Philadelphia, under the British government. I was not surprised at
these two uncommon symptoms in the gout, for I had long been familiar
with its disposition to affect the biliary secretion, and the actions
of the stomach. The colic and dysentery are often produced by the gout
in the bowels. In the southern states of America, it sometimes produces
a chronic diarrh[oe]a, which is known in some places by the name of the
"downward consumption." The piles are a common symptom of gout, and
where they pour forth blood occasionally, render it a harmless disease.
I have known an instance in which a gouty pain in the rectum produced
involuntary stools in a gentleman in this city, and I have heard from
a southern gentleman, who had been afflicted with gouty symptoms, that
a similar pain was excited in the same part to such a degree, whenever
he went into a crowded room lighted by candles, as to oblige him to
leave it. In considering the effects of the gout upon this part, I
am led to take notice of a troublesome itching in the anus which has
been described by Dr. Lettsom, and justly attributed by him to this
disease[59]. I have known several cases of it. They always occurred
in gouty habits. A distressing collection of air in the rectum, which
renders frequent retirement from company necessary to discharge it, is
likewise a symptom of gout. It is accompanied with frequent, and small,
but hard stools.
[59] Medical Memoirs, vol. III.
Of the above morbid affections of the nerves, stomach, and bowels, the
hysteria, the sick head-ach, and the colic, appear much oftener in women
than in men. I have said that dyspepsia is a symptom of gout. Out of
more than 500 persons who were the patients of the Liverpool infirmary
and dispensary, in one year, Dr. Currie informs us, "a great majority
were females[60]."
[60] Medical Reports on the Effects of Hot and Cold Water, p. 215.
VI. The gout affects the glands and lymphatics. It produced a
salivation of a profuse nature in major Pearce Butler, which continued
for two days. It produced a bubo in the groin in a citizen of
Philadelphia. He had never been infected with the venereal disease, of
course no suspicion was entertained by me of its being derived from that
cause. I knew a lady who had periodical swellings in her breasts, at the
same season of the year in which she had before been accustomed to have
a regular fit of the gout. The scrophula and all the forms of dropsy
are the effects in many cases of the disposition of the gout to attack
the lymphatic system. There is a large hard swelling without pain, of
one, or both the legs and thighs, which has been called a dropsy, but
is very different from the common disease of that name. It comes on,
and goes off suddenly. It has lately been called in England the _dumb_
gout. In the spring of 1798 I attended colonel Innes, of Virginia, in
consultation with my Edinburgh friend and fellow-student, Dr. Walter
Jones, of the same state. The colonel had large anasarcous swellings in
his thighs and legs, which we had reason to believe were the effects of
an indolent gout. We made several punctures in his feet and ancles, and
thereby discharged a large quantity of water from his legs and thighs.
A day or two afterwards his ancles exhibited in pain and inflammation,
the usual form of gout in those parts. In the year 1794 I attended Mrs.
Lloyd Jones, who had a swelling of the same kind in her foot and leg.
Her constitution, habits, and the sober manners of her ancestors, gave
me no reason to suspect it to arise from the usual remote causes of
gout. She was feverish, and her pulse was tense. I drew ten ounces of
blood from her, and gave her a purge. The swelling subsided, but it was
succeeded by an acute rheumatic pain in the part, which was cured in a
few days. I mention these facts as an additional proof of the sameness
of the gout and rheumatism, and to show that the vessels in a simple
disease, as well as in malignant fevers, are often oppressed beyond that
point in which they emit the sensation of pain.
Under this head I shall include an account of the mucous discharge
from the urethra, which sometimes takes place in an attack of the gout,
and which has ignorantly been ascribed to a venereal gonorrhæa. There
is a description of this symptom of the gout in the 3d volume of the
Physical and Literary Essays of Edinburgh, by Dr. Clark. It was first
taken notice of by Sauvages by the name of "gonorrhæa podagrica," in
a work entitled Pathologia Methodica. I have known three instances of
it in this city. In the visits which the gout pays to the genitals,
it sometimes excites great pain in the testicles. Dr. Whytt mentions
three cases of this kind. One of them was attended with a troublesome
itching of the scrotum. I have seen one case in which the testicles were
affected with great pain, and the penis with an obstinate priapism. They
succeeded a sudden translation of the gout from the bowels.
From the occasional disposition of the gout to produce a mucous
discharge from the urethra in men, it is easy to conceive that it is the
frequent cause of the fluor albus in women, for in them, the gout which
is restrained from the feet, by a cause formerly mentioned, is driven to
other parts, and particularly to that part which, from its offices, is
more disposed to invite disease to it, than any other. The fluor albus
sometimes occurs in females, apparently of the most robust habits. In
such persons, more especially if they have been descended from gouty
ancestors, and have led indolent and luxurious lives, there can be no
doubt but the disease is derived from the gout, and should be treated
with remedies which act not only upon the affected part, but the whole
system. An itching similar to that I formerly mentioned in the anus,
sometimes occurs in the vagina of women. Dr. Lettsom has described it.
In all the cases I have known of it, I believe it was derived from the
usual causes of the gout.
VII. There are many records in the annals of medicine of the gout
affecting the skin. The erysipelas, gangrene, and petechiæ are its
acute, and tetters, and running sores are its usual chronic forms when
it appears in this part of the body. I attended a patient with the late
Dr. Hutchinson, in whom the whole calf of one leg was destroyed by a
mortification which succeeded the gout. Dr. Alexander, of Baltimore,
informed me that petechiæ were among the last symptoms of this disease
in the Rev. Mr. Oliver, who died in the town of Baltimore, about two
years ago. In the disposition of the gout to attack external parts, it
sometimes affects the eyes and ears with the most acute and distressing
inflammation and pain. I hesitate the less in ascribing them both to the
gout, because they not only occur in gouty habits, but because they now
and then effuse a calcareous matter of the same nature with that which
is found in the ligaments of the joints.
VIII. Even the bones are not exempted from the ravages of this
disease. I have before mentioned that the bones of the hands and feet
are sometimes dislocated by it. I have heard of an instance in which
it dislocated the thigh bone. It probably produced this effect by the
effusion of that part of the blood which constitutes chalk-stones, or
by an excrescence of flesh in the cavity of the joint. Two instances
have occurred in this city of its dislodging the teeth, after having
produced the most distressing pains in the jaws. The long protracted,
and acute pain in the face, which has been so accurately described by
Dr. Fothergill, probably arises wholly from the gout acting upon the
bones of the part affected.
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 the _whole_
system. 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 which
terminate 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 of _misplaced_ or _retrocedent_ gout. 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 yielded of 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 the METHOD 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 relief which
has contributed so much to its duration, and mortality.