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 in _violent_ morbid action in the blood-vessels
and viscera.
III. Such as are proper in a _feeble_ morbid 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 cold and 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, is _blood-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 in favour 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
makes its 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.
[61] Defence of Blood-letting, vol. IV.
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 action in 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 business and 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, is
_purging_. 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. _Vomits_ may 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 vomit indicated 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. _Nitre_ may be given with advantage in cases of inflammatory action,
where the stomach is not affected.
5. A fifth remedy is _cool_ or _cold air_. This is as safe and useful
in the gout as in any other inflammatory state of fever. The affected
limbs should 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.
[62] Medical Observations and Inquiries, vol VI. p. 201.
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 nourishment or 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. _Blisters_ are 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.
[63] Physical and Literary Essays, vol. III. p. 469.
9. _Fear_ and _terror_ have 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 in his 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.
_Sweating_ has 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 inflammatory state
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.
[64] Defence of Blood-letting.
Many different preparations of _opium_ have 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
not only 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 often suffered 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 day the pain left me, the
swelling might have left me too in a much less time[66]."
[65] Medical Observations and Inquiries, vol. vi. p. 220.
[66] Essay upon the Cure of the Gout by Moxa, vol. i. folio edition,
p. 143 and 141.
III. I come now to mention the remedies which are proper in that state
of the gout in which a _feeble_ morbid 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. _Madeira_ or _Sherry wine_ alone, 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. _Porter_ should 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 spirits_ should be given, either alone, or in the form
of grog, or toddy. Cases have occurred in 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 of _æther_ should 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.