to imagine that the human constitution was so badly contrived, that a
state of general health could be overset by every trifle; for
instance, by a little cold; or that the recovery of it lay concealed
in a few drops, or a pill. Did they better understand the nature of
chronic diseases, and the causes which produce them, they could not
be so unreasonable as to think, that they might live as they chose
with impunity; or did they know any thing of medicine, they would
soon be convinced, that though fits of pain have been relieved, and
sickness cured, for a time, the reestablishment of health depends on
very different powers and principles. Those who are acquainted with
the nature and functions of the living body, well know, that health
is not to be established by drugs; but that if it can be restored, it
must be by nicely adjusting the action of the exciting powers to the
state of the constitution, and the excitability; and thus gently and
gradually calling forth the powers of the body to act for themselves.
And though I believe that most general diseases will admit of a cure,
yet I am confident, that no invalid was ever made a healthy man by
the mere power of drugs. If this is a truth, should it not be
universally known? If it were, there would undoubtedly be an end of
quackery, for all quack medicines, from the balm of Gilead, to the
botanical syrup, are supposed to cure diseases, or at least asserted
to do so, in this mysterious manner.
Dr. Cullen, in his Nosology, gives us the following definition of the
gout.
"Morbus haereditarius, oriens sine causa externa evidente; sed
praeeunte plerumque ventriculi affectione insolita; pyrexia; dolor ad
articulum, et plerumque pedis pollici, certe pedum et manuum
juncturis, potissimum infestus; per intervalla revertens, et saepe
cum ventriculi et internarum partium affectionibus alternans."
Now, though this definition comprises a tolerably good general
character of the disease, it contains some notions, depending on the
prejudice of hypothesis, which, on a careful examination, ought not,
I think, to be admitted.
In the first place, I would deny, that the gout, considered as a
diseased state of the system, is hereditary. This may perhaps excite
some degree of surprise; and, "I had it from my father," is in the
mouth of a great majority of gouty patients.
If the diseased state of the system, which occurs in gout, were
hereditary, it would necessarily be transmitted from father to son;
and no man, whose father had it, could possibly be free from it.
There are, however, many instances to the contrary. Our parents
undoubtedly give us constitutions similar to their own, and there is
no doubt, that if we live in the same manner in which they did, we
shall have the same diseases. This, however, by no means proves the
disease to be hereditary.
We shall hereafter see, that the gout is a disease of indirect
debility, brought on by a long continued use of high seasoned food
and fermented liquors. There is no doubt that particular
constitutions are more liable to be affected by this mode of living
than others; and if my father's constitution be such, I, who probably
resemble him in constitution, shall in all probability be like him,
subject to the gout, provided I live in the same way; this however by
no means proves the disease to be hereditary. The sons of the rich,
indeed, who succeed to their fathers estate, generally succeed also
to his gout, while those who are excluded from the former, are also
exempted from the latter, and for very obvious reasons, unless they
acquire it by their own merit.
So that though the son of a gouty parent may have a constitution
predisposing to the gout; that is, more liable to be affected by
causes, which produce this disease, still, if he regulate the stimuli
to the state of his excitability, he will remain exempt from it.
This distinction is of much greater importance than is generally
imagined; for if a person firmly believes that the gout, as a
disease, is hereditary, what will be his conduct? My father had the
gout, says he, therefore I must have it; well, what cannot be
avoided, must be endured; let me then enjoy a short life, but a merry
one: he therefore abandons himself to a luxurious mode of life, and,
if the gout be the consequence, which most probably it will, he
accuses his stars, and his ancestors, instead of his own misconduct.
On the contrary, if a person be convinced that he has received from
his ancestors a constitution liable to be overpowered by the use of
high seasoned food, and fermented liquors, and excited into gouty
action, what will be his conduct? Surely, if he reason at all, it
must be in this way: my father was dreadfully afflicted with the
gout; I have frequently witnessed his sufferings with the deepest
concern. But is not my constitution, which resembles his, liable to
be affected in the same manner, by similar causes? To avoid his
sufferings, therefore, I must be very temperate; more so than those
who have not the hereditary propensity; for the exciting powers,
which would only keep them in health, would, if applied to me,
infallibly bring on the gout. In consequence of this reasoning, he
adopts a temperate mode of living, and avoids the disease.
From this you must be convinced, that it is not a matter of small
moment to determine, whether the gout is hereditary, and consequently
unavoidable, or not. The next part of Dr. Cullen's definition is
"oriens sine causa evidente". This too, I can have little hesitation
to pronounce erroneous. The cause of gout, namely, the use of highly
seasoned food, and the use of fermented liquors, with, in general, a
luxurious, and indolent mode of living, are quite evident enough in
most gouty cases, and are amply sufficient to produce the disease.
There is another part of the definition, likewise, to which I would
object, as it gives a false idea of the nature of the disease, and
therefore causes the preventative plan to be pursued with less
confidence. I mean that part where he says "per intervalla
revertens."
That the gout, when once cured, is apt to return, if the mode of life
which brought it on be not abandoned, no one will deny; nay, the fits
will increase in violence, because the constitution gets more and
more debilitated. This, however, is not peculiar to the gout, but
common to most diseases.
In describing a broken leg, it would surely be wrong to say, that it
is a disease which returns at intervals, after being cured; yet, it
will return as infallibly as the gout, if a person take the same kind
of leap, or expose himself to the same accidents as those which
brought it on. Let those, therefore, who wish to avoid a return of
the gout, totally change their mode of living: otherwise, if the
attacks return, let them blame themselves, and not the nature of the
complaint.
These observations were thought necessary, with a view to do away
some prejudices, which very much retarded our inquiries into the
nature and cure of this disease. I shall now proceed to give an
account of the symptoms by which it is usually attended.
The gout generally attacks the male sex; but it sometimes, though
more rarely, attacks also the female, particularly those of robust
and full habits. It does not generally make its appearance, till the
period of greatest strength and vigour is past; for instance, about
the fortieth year; but, in some cases, where the exciting causes have
been powerfully applied, or where the hereditary predisposition is
very strong, it attacks much earlier; such cases are, however,
comparatively rare, and can, in general, be easily accounted for.
This disease is seldom known to attack persons employed in constant
bodily labour, and who live temperately; and is totally unknown to
those who use no wine or other fermented liquors.
If then a person of a full strong habit have for several years
accustomed himself to full diet of animal food, and a regular use of
wine, and malt liquor, though he may for a long time find that he can
perform all the functions with vigour, his strength will at last
fail: the mind and body become affected with a degree of torpor and
languor for which he cannot account, and the functions of the stomach
become more or less disturbed. The appetite becomes diminished, and
flatulency, and other symptoms of indigestion are felt. These
symptoms take place for several days, and sometimes for several weeks
before the fit comes on; but often, on the day immediately preceding
it, the appetite becomes greater than usual.
In this state, if the person have fatigued himself by violent
exercise, or if he have exposed the extremities to cold, or if his
mind have been particularly affected by any anxiety, or distressing
event; or in short, if any directly debilitating cause have been
applied, the fit will often follow. It sometimes comes on in the
evening, but more commonly, about two or three o'clock in the
morning; the pain is felt in one foot, most commonly in the ball or
first joint of the great toe; but sometimes in the instep, or other
parts of the foot. With the coming on of this pain there is generally
more or less of a cold shivering, which as the pain increases,
gradually ceases, and is succeeded by heat, which often continues as
long as the pain; from the first attack the pain becomes by degrees
more violent, and continues in this state, with great restlessness of
the whole body, till next midnight, after which it gradually remits,
and after the disease has continued for twenty four hours from the
commencement of the first attack, it often ceases, and with the
coming on of a gentle perspiration allows the patient to fall asleep.
The patient on coming out of this sleep in the morning finds the part
affected with some degree of redness and swelling, which, after
having continued for some days, gradually abate.
Still however, after a fit has come on in this manner, although the
violence of the pain after twenty four hours, by the excitement that
it produces, cures itself, and is considerably abated, the patient is
seldom entirely relieved from it. For several days he has every
evening a return of considerable pain and fever, which continue with
more or less violence till morning. This return is owing to the
exhaustion of the excitability by the stimuli of the day, and its
remission is caused by the accumulation of the excitability, by
sleep.
After having continued in this manner for several days, the disease
often goes off, and generally leaves the person in much better
health, and enjoying greater alacrity in the functions of both body
and mind, than he had for some time experienced. This is owing to the
general excitement produced by the pain, which removes the great
torpor and debility which preceded the fit; and from the inability to
take exercise or food, the excitability accumulates again. This is
the true explanation: it does not depend on any morbid matter, which
the gout hunts from its lurking places, drives to a joint, and thence
out of the body, as has been imagined by many.
At first the attacks of the disease are confined to one foot only:
afterwards both feet become affected, though seldom at the same time;
but when the inflammation appears in one, it generally disappears in
the other, and as the disease continues to recur, it not only affects
both feet at once, but is felt in the other joints, especially those
in the upper and lower extremities, so that there is scarcely a joint
in the body that is not on one occasion or other affected. After
frequent attacks, the pains are commonly less violent than they were
at first, the joints lose their strength and flexibility, and often
become so stiff as to be deprived of all motion.
Concretions of a chalky or calcarious nature are likewise formed upon
the outside of the joints. This arises from an inability of the
capillary vessels, which ought to secrete the calcarious matter, and
deposite it in the bones, to perform their office, from debility:
hence by sympathy other vessels ta ke up the matter and deposite it
in the wrong place. These concretions, though at first fluid, become
at last dry, and firm: they effervesce with acids, and are totally,
or in a great measure, soluble in them.
After this short description of the gout, when it occurs in its
regular form, as it is called, I shall now proceed to inquire how the
exciting causes produce this disease, and what is the state of the
body under which it occurs.
The gout seldom occurs but in those who have for several years lived
upon a full diet of animal food, often highly seasoned, and at the
same time been in the habit of taking daily, or at least very
constantly, a greater or less quantity of fermented liquors, either
in the form of wine, or malt liquor, or both. The affection of the
limb has all the appearance of an active inflammation: the part
becomes swelled, hot, red, and intolerably painful. It is this
circumstance which has misled practitioners, who have supposed it a
case of sthenic, or active inflammation: not only the appearance, but
the causes which produced it, induced them to think so; hence they
were naturally led to employ the debilitating plan: a little time and
observation would, however, be sufficient to convince them of its
inefficacy. They would find that the application of leeches to the
part, and of the lancet to the arm, instead of subduing the
inflammation, would increase it: or if it did not, that the pain
often attacked some internal part, which was ascribed to a
translation of the morbific matter from one part to another, but
which is merely owing to an increased debility: a little attentive
observation would convince practitioners, however mysterious it might
seem to them, that this violent inflammation was not to be cured by
debilitating: on the contrary, they would see cases, in which the
patient, though contrarily to the strict orders of his physicians,
could not forego his old habits; but would take his wine as usual, or
in greater quantity, after a few days abstinence; and this abstinence
having in some degree accumulated the excitability, he would find
himself much relieved by wine, and would exultingly tell them, that
they were mistaken. Circumstances of this kind seem to have staggered
their faith a little, but still the idea of active inflammation which
they believed was visible, and almost palpable, dwelt so upon their
minds, that they were but half convinced. The favourite idea of
increased action of the vessels of the part had so interwoven itself
with every other, that we find it never lost sight of, in the
indications of cure. Hence, though bleeding is not now generally
practised with the lancet, yet leeches are often applied; but the
most usual plan is to consign the patient to patience and flannel;
strictly forbidding wine, or fermented liquors. As an exception to
this general mode, it is however observed, by some practitioners,
that when the stomach is weak, and when the patient has been much
accustomed to the use of strong liquors, a little animal food, and
even wine, may be allowable, and even necessary.
Thus has an erroneous view of the disease been the cause of an inert
practice, which wavers between the suggestions of a favourite
hypothesis, and the conviction of facts.
On inquiry, however, we shall find none of the increased vigour in
the system, which has been suspected, nor increased action in the
part more particularly affected; on the contrary, the whole body is
in a state of indirect debility, or exhausted excitability, and the
part more particularly affected, in a state of asthenic inflammation.
If the gout were of a sthenic or inflammatory nature, might we not
ask, why the causes which produce it, do not produce it in the
meridian of life, when they produce their greatest effect, and when
real sthenic diseases are most apt to occur? or, why the symptoms of
the inflammation, like all other real sthenic inflammations, are not
relieved by the debilitating plan? The contrary, however, points out
to us clearly the nature of the disease: the gout is not a sthenic
disease, or a disease of strength: it does not depend upon increased
vigour of the constitution, and plethora, but is manifestly asthenic,
like all the rest of the asthenic diseases. The mode of living is
such as brings on indirect debility, or exhaustion of the
excitability, such as the use of rich and highly seasoned food, and a
daily use of fermented liquors. These at first certainly produce
vigour, or strength, and will be the cause of sthenic diseases; but
they are generally taken in such a manner, that, though they produce
a degree of excitement above the point of health, still they only
approach the line of sthenic disease, without in general falling into
it. They continue, however, to exhaust the excitability, and by the
time that the vigour of the body begins naturally to decline, the
system of a person who has lived in this manner is unusually torpid;
all the blood vessels, which have hitherto been distended with rich
blood, begin to lose their tone, from their excitability having been
exhausted by the use of these powerful stimulants; but this torpor is
particularly and first experienced in those parts which have been
more immediately subject to the action of the exciting causes; viz.
the stomach and bowels: symptoms of indigestion occur, and the
excitability of these organs having been almost entirely exhausted by
the violent action of the stimulants applied, cannot now be roused to
any healthy action; the food is not properly digested, but runs into
a kind of fermentation, which causes an extrication of gas: this
distends the stomach and bowels, and produces pains, uneasy
eructations, and all the distressing symptoms of indigestion. Nor is
this in the least surprising, when we consider that many people who
have brought on complaints of this kind, have been in the habit of
eating heartily of rich and highly seasoned animal food, and of
drinking from a pint to a bottle of wine, and perhaps a quantity of
malt liquor, almost every day of their lives for years. This mode is
sufficient to wear out the powers of the stomach, were it three times
as capacious as it is, and of the constitution, were it ten times as
strong.
When a torpor, or state of exhausted excitability, of the whole
system, has been induced in this manner, and symptoms of indigestion
produced, any directly debilitating cause applied to the extremities,
adding to the indirect debility, causes a total torpor, or inactivity
of the minute vessels of the part, and thus totally destroys the
balance between the propelling and resisting force; hence the vessels
will be morbidly distended with blood, a swelling and redness will
take place, and an asthenic inflammation, produced in the way which I
fully pointed out in the last lecture, will be established. Hence the
pain, and other symptoms, which accompany a fit of the gout. Hence
likewise we see, why debilitating powers applied to the part will not
reduce the inflammation; and why a warmth, which aggravates every
really sthenic inflammatory affection, is so comfortable in this.
Almost any debilitating cause, when the system has been brought by
intemperance to the torpid state, which I have described, will bring
on a fit of the gout, but nothing more certainly than cold or
moisture: hence if a person have his feet chilled or wet, he will be
almost certain to have an attack.
Hence we see that the asthenic inflammation is not the disease, but
merely a symptom of it; and like other symptoms, fallacious in its
appearance; the disease is a state of indirect debility, to which our
attention ought to be directed.
When this inflammation is violent, and accompanied with great pain,
after several hours continuance, it excites the action of the minute
vessels, enables them to propel the blood, by which they are morbidly
distended, and restores the balance between the resisting and the
propelling force; and thus the inflammatory appearances will for a
time subside, but the torpor of the whole system remaining, and the
debility of the vessels returning, when their excitement, which was
the consequence of their action, has ceased, another asthenic
inflammation will take place, which will again cure itself as before;
so that during a paroxysm, several remissions will take place, as was
mentioned in the description of the disease. As, during the paroxysm,
the pain causes a considerable degree of excitement over the whole
system, the action of the stomach and other parts is roused by it;
during the fit likewise, little nutriment is taken, so that by the
action of the stomach and bowels, they get rid of their load; rest
likewise assists to accumulate the excitability, so that from all
these causes together, the body becomes restored to a state of
vigour, which, compared with its former torpidity, makes the patient
imagine that this friendly disease has restored him to a state of
unusual health, and even renovated the powers of his constitution.
Under this mistaken idea, he does not, when the fit leaves him,
abandon the mode of life, which brought on the disease; highly
seasoned food, and the usual quantity of wine, are again resorted to:
after a time the torpor of the system, and symptoms of indigestion
return, and he again hopes that his friend the gout will come and
cure him.
By a continuance of this plan, the inflammation again appears; but
the system having become more torpid, the inflammatory action is by
no means so great as it was before: if it has power to restore the
equilibrium between the resistance and propelling force, and thus
cure itself, this effect is entirely confined to the inflamed part.
The other foot labouring under similar torpor, or debility, now feels
the effects of the propelling force, and an inflammation takes place
in it, which having cured itself in the same manner, and the torpor
of the foot first affected being returned, or even greater than it
was before, on account of the previous excitement; the inflammation
again attacks this foot, and thus the gout is supposed to emigrate
from one limb to another. The gout, as a disease of general debility,
however, remains the same; and it is only these symptoms, which form
but a small part of the disease, that vary according to
circumstances.
If, during an asthenic inflammation of the lower, or upper
extremities, the torpor and debility of the whole system increase,
then the force of the circulation, or propelling force, being
diminished, the symptoms of inflammation will suddenly disappear; but
as great debility now prevails, the stomach will be apt to be
affected with cramps or convulsions, or an asthenic inflammation of
some internal part will take place: for, though the propelling force
is not sufficient to overdistend the debilitated vessels of the
extremities, it will distend those of the internal parts nearer the
heart, which are now debilitated.
In this case, it has been generally, but absurdly imagined, that the
gout is translated, or recedes from the extremities to some internal
part: the term of retrocedent gout has therefore been applied to
occurrences of this nature. From the explanation which has been
given, it is evident, that this term is improper. The general
debility being increased, the propelling force becomes unable to
produce an inflammation of the extremities, and this is the reason
why it disappears. The disease, however, is not at all altered in its
nature by this variation of symptoms. It is still the same, by
whatever name it may be called.
It sometimes happens, that after full living, the stomach becomes
particularly affected, and the patient is troubled with flatulency,
indigestion, loss of appetite, eructations, nausea, and vomiting,
with great dejection of spirits, pain and giddiness of the head,
disturbed recollection, or muddiness of intellect, as it is termed,
with all the symptoms, which usually precede a regular fit of the
gout, yet no inflammatory affection of the joints is produced. This
state has been absurdly enough called the atonic gout, as if there
were a gout accompanied with vigour and sthenic diathesis: but the
absence of inflammation in the extremities may depend on two causes.
First, the powers producing the disease, may have debilitated the
stomach and first passages, while the vessels of the extremities are
not particularly debilitated, and the resisting force is able to
counterbalance the propelling force: in this case, no morbid degree
of distention or inflammation of the extreme vessels can take place.
Secondly, the general debility may be such, and the power of the
circulation so much diminished, that, though the extreme vessels may
be debilitated, no inflammation, or preternatural distention will
take place.
Hence, we see, that this is still the same disease; but that
physicians have erred in their explanation of the symptoms, by
regarding that as the principal part of the disease, which is only a
symptom.