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OBSERVATIONS

THE NATURE AND CURE

GOUT;

NODES OF THE JOINTS ;

ANl> ON THB

INFLUENCE OP CERTAIN ARTICLES OP DIEZ

GOUT, RHEUMATISM, AND GRAVEL.

JAMES PARKINSON,

HOXrON.

LONDONt

' TBIMTBD BY C WHlTTUrGBAlf, DBA* ITRUT f

FOR H. O. SYMONDS, 1>AT£IiN0STER ROW ; MURRAY, FLEKt
STRtSTS ARCH, CORNHIU; AND COX, iT. THOaCAS

9TRIBT, BOROUGH*

' .i^rr^^ .

>> «

.•.' -I- ■ '

/ - • 1 »

i .• .

\:o3i

'\-

PREFACE. '»"

. . .... ■ - ... ,.!:....(

IT is upwar4s pf thirty year?jpia^J=witti
nessed, with great satisfaction, in the case
of a much respected rplative, the EtppareDt
cure of the Gout, by the use of the caustic
fixed alkali. iVppiearances, for a time, pro-
mised an entire restoration to health ; but
subsequent events made it appear that
there existed but little cause for exultation,
and shewed, that the cure of Gout should
not be attempted, without a careful regard
to many circumstances which, in this case,
had not obtained suiEcient attention. .

jjNearly fifteen years ago, I experienced
the mortification of fipding, that I was also
under the influence of this tormenting ma-
lady. Obliged to submit to the perform-

ance of the most laborious part of a ha-
rassing profession, /arid therefore dreading
the serious inconveniences arising from
confinement, T repeatedly risqued, in op-
position to the harsh remonstrances of my
judgment, the free application of cold
iVater to the parts suffering under gouty
inflammation. But this, as may be readily
conceived, was not done, by one who had'
often anxiously reflected on the nature of
this malady, without a vigilant atteiitioa
to its effects; nor without obtaining some
additiotial information on a subject, which
pain and inconvenience had rendered par-
ticularly interesting.

Attention to the discoveries of the illus-
trious Scheele, and to the very ingenious
application of those discoveries to the il-
lustration of the nature of gout and gravel,
by Mr. Murray Forbes; with thfe suspicion
that the immersion, ia cold waterj had

which would prove so highly repugnant to
general opinion.

But the perusal of Dr. Kinglake's Dis-
sertation on Gout detennined my iatea-
tions. Strongly suspecting that the adricc
delivered in that work, with so much bfr-
nevolence and zeal, must in many instances
prove highly injurious; and believing ti^lt
tl?e, observations which I had made might
lerve to prevent too general an adoption
of that advice, I resolved on their publi-
catixm, I Itoped, that the observations of
a fellow sufferer would not be unaccept-
able to the victims of this highly afflictive
m^dy, especially when it should appear,
that whilst I had witnessed in others the
effects of the more generally approved re-
medies, I had fteriy^ einpToyed^oh myself,
those which had been considered as most
likely to produce evils of a serious nature.

dependence on a similar state of the sys»-
tem, with that on which Gout depends.
was hardly suspected.

I was frequently urged, by the hope of
benefiting my fellow sufferers, to lay be-
fore the public tlie obsertations which I
had made on this disease, and its several
modes of treatment. But, fearing that the
work might not prove of that utility which
I.expected ; and knoivihg that every trifle
from niy pen must bisiray the nnfavour-
ableness of the moments in which they had
been written, I was induced to hesitate.
Besides, when I reflected on the strong
Opposition to a humoral pathology of this
disease, which had been made by the justly
celebrated Cu!!en, and when I considered,
that t^ie notion of this disease depending
on a materies morbi was aUnost universally
PBJected, I hesitated at advancing a theorVj

which would prove so highly repugnapt tx>
general opinion.

But the perusal of Dr. Kinglake's Dis-
sertation on Gout determined my inten-
tions. Strongly suspecting that the advice
delivered in that work, with so much be-
nevolence and zeal, must in many instances
prove highly injurious; and believing that
the, observations which I had made might
serve to prevent too genera! an adoption
of that advice, I resolved on their publi-
catitJU. I lioped, that the observations of
a fellow sufferer would not be unaccept-
able to the victims of this highly afflictive
malady, especially when it should appear,
that whilst I had witnessed in others the
effects of the more generally approved re-
medies, I had freely erapfeyed~6n myself,
those which had been considered as most
likely to produce evils of a serious nature.

• • •

The hope also of rendering an essential
benefit to the labouring part of the peo*
pie, by making known the particular cir-
cumstances I had remarked, respecting
-the nature and cure of a disease, ^hitherto
but little known, except to the sufferers*,
was also a powerful incentive to this pub-
lication. That it may prove useful, is my
first wish ; this accomplished, my anxiety
for its fate, in other respects, will not be
excessive.

JAMES PARKINSON.

Hoxtan Square.

* Nodi digitorum, Galielmi Heberden Cbnunentarii da
Morborum Historia & Curatione, p. 130.

ERRATUM.
P. 28, 1. 6. for Currie read Curry.

TABLE OF CONTENTS.

CHAPTER L I

Characteristics of Gout — Proximate Cause proposed
— ^Discoveries of Dr^ WollafitoD> Dr. Q: Pearson, and
Fourcroy — Dissection by Mr. Watson — Inquiry re-
specting the Existence of a peculiar Acrimony in this
Disease 1

CHAPTER II.

Remote CaUse5-<-Hereditary Disposition — IndigestioBrr^
Errors in Non-naturals — Intemperance — Differen.tEf-

. fects from difierent fermented Liquors — Of Wii^er^
Cyder — Beer — Acids and Acescents — tCircjumst^nices
preventi ng the Escape of morbid Acid *2^

CHAPTER III.

Examination of the Symptoms — ^Their Agreenaent \vith
the supposed proximate Cause 52

CHAPTER IV.

Diagnosis— Difference between Gout and Rheumatisms-
Anomalous Complaints apparently dependent on
Gout 59

CHAPTER V.

Particular Affection of the Joints, apparently depen-
dent on the same State of the System, as that which
produces Gout. History, Diagnosis, &c 69

CHAPTER VI.

Indications of Cure in the Gout — To prevent the Forma* ■ r »

tion of the morbid Acrimony — To remove and cor-
rect that which already exists — ^To repair the dimi- •• . A
nished Strength of the System — Indications during
the Fit. 8* i

CHAPTER VII.

Treatment during the Fit — Different Indications no-
ticed — Opinion of CuUeu — Opiates — ^Topical Appli-^
cations % 117

CHAPTER ym.

Remarks on Dr. Kinglake's Practice — Retrocedent
Goat— -Application of cold Water dangerous... 190 ,

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CHAPTER I. :

' ' . - I . . * ■ . ^1 . ■'.••'

' '. . . • I • ' .

(CHARACTERISTICS O? GOUT— PROXIMATE CAUSE PRO*
POSED-— l5lSC0V£Rl)SS OF DR. WOLLASTON, DR. G.
PEARSON AND FOURCROY — DISSECTION BY MI^.
WATSON— INQUIRY RESPECTING THE EXISTENCE OF
A PECULIAR ACRIMONY IN THIS DISEASE. '

OouT is a ' hereditary disease, chiefly affecting,
with pain and inflammation, parts possessing a
Jigamehtbtis or tendinous stmctune. It most fre-
quently attiacks the joints, and particularly thos^
%)f the hands and feet. It sometimes also mani-
fests itself, by painful affections of internal parts^,
which often alternate with the affections of tha
limbs. It deposits, on the parts which it affects,
a concrete saline substance, which is sometimes

< 4

accumulated in considerable quantities, particu-
jariy on the joints of the fingers and hands.

V /

The different forms in which this disease ap-
pears, have rendered it necessary to divide it
into reg^sM:^^ ki^u^r gout. Ip tlf^e' former,
the attacks of which are known by the denomina-
tion of regular fits of the gout, one or more joints
of the extremities become inflamed, painful, and
tender, and frequently in an exquisite degree. A
symptomatic fever, proportioned to the degree of
pain and inflamm^tipH;^ vyjth evening exacerba-
tions, accompany the other complaints, which dis-
tress the patient for uncertain peripdsjj sonnet imes
for several weeks. When theiit goes off, the Joints,
which have been the seat of t^ie disease,. aje always
found tP have begoin^ rigid and inflexible, in pro-
portion to the degr^g in which the disease has
existed in them ; frequently remaining enlarged,
^Xid 4Ac^a,We ©( fi;e^ ipjqtioA^ , for a cpn^ideraljtp

itiip?^ Qa the other b^^nd^ tl^ P?t*^^?: ^^ !^^ ^*^^
time, exp^rienfi^^.so perfwjt w e2;ea>ptioi?. ft pjga
^pq^e,! ^^^jejjei;aHjf,to. l^ tp tUerppj^^ion,, thi^
the ftt hft$ pqc^i,9^^ t^e iftc»t : ^utfy:y cl
iftthe^tem. . .,...'v,y:,: ;..-;. ; :■:] >.,;

«j-

In the irregular gput^^tljie affectioa of thejf^yjt?
U much less confined tlian» j^ the fopxi^» . ^§9lp^
times it leaves the jointer £^t firs^ attacki^fli, ^pd
fixes on some distant, pfa;(j)| an^t ^oxnetii^es^ ^tier
harassing the patient, hy making a circuit, in-

dtidin^ dtafi6st ^vefy Joint of the eMremities, the
jfit is terttiili^ed b^^ a>^f^eiiewed attack oh the
part first dfTedted. in 9ome cafi^/the^ disease
<}i!l!tiitli*^it«idtfoii ifi the ektri^mities fbr a tiinei
and ocdisieiis symptoms i^ a very ^armtrtg n^
ttire, by It^ irttacfc oft iSk>me internal ^irll; thi8
also abating oil the retialm of the disease to the
part which had been first attacked: this ii
termckl, retrocedent gout. In other cases, in
WWcft? there exist the most evident inarks of a
g^t^ dRathesis, no affeetion of the extremitiesi
takeii place, bfit (Complaints of a very anomalous
kind <i^w that some internal part is under the
ijh^fluerlicfe of this disease : these i^iay be regarded
fiis cAses ef misplaced gout. A want of powei^ an<t
tene^in the systcwi appears to accompany both!
thete'state^ of gont.

The JrtX)ximate cattle of gout appears to be^-^
sfr peculiar salirte acrrrtioriy existing in the blood,
in such a proportiottr, aS to irritate and excite tor
ihorbid action, the minute terminations of the ar-
teries, ift certain parts of the body.

The humoral pathology of diseases, in general,
hating yielded to the numerous and powerful argu-
ments, with which it has been opposed, it is not
with the expectation of a prompt and implicit

B 2

adoption, that the above coqjectui^r&ojQ^ecI,
respecting the proximi|.tQ cruise of this disease^
Strong apgun]tent3. in U« support^ jt, ; how^i^r^ is
hoped^.will offer tbenuielvcfs, lyheaitto natur?.oC
the morbid matter, w^ich is sef^rated, m fthi^^ dis-v
ease, 9fid. which has beetn ascertiiia^d byjiie io^
dispu^ablg ^e^idence ; of, diemical ; analysis^ is* con-t

. .'.'—.{• : , • . .'■ ' ' ■ ,-

Dr. WoUaston, in a pap<er read before the Royat
Society, June 22, 1797> detpQnstrated tjhat tht
concretions, which form on the joints of gc^j^ty^
persons, are composedof the lithic (uric)^acid and
soda; forming a compound ss^tj the lithis^pr
iirate of soda,* Dr. G. Pearson, in a paper,j?ead
before the Royal Society, December. 1 4, ; 1 797, ifi^
which he relates the result of the analysis ,of npH
wards of three hundred urinary calculi, particu*
lariy jnentions the existence of this.acid in arthntic
concretions. The word lithic, borrowed froin the
term lithiafis, he recommended to be changed to
that of ouric or uricf Fourcroy also, about the.
same time, discovered the uric acid ^n tl^e^e con*
cretions. J

' . t 1 <

• *

* Philosophical Transactions^ for th^ year 1797, Part.L
f Philosophical Transactions,; for the year 1797, PartlL'
f Annales de Chhnie, XXVIL i: >:,i. .

When we View in ia person who has been long
iwrtyect to this djgease, the prodigious quantity of
this tnatter which hSis been separated from the
syj^era,* forming almost ijl the smaller joints of
the bands into white, and apparently cretaceous
nbduleS, Wis are Naturally l6d to the opinion, that
the tkliciotf ihUfet have been pretematurally charged
with this matter, or with the principles of which
it is formerf. '

No case which has been recorded affords, per-
haip^,' m remarkable an Instance of the extent to
which St ihorbid matter has beeh separated, in this
iTisease, ^ thsit of which the dissection is given in
the first volume of Medical Communications, by
Mr" riteiii^ Watson, suf^^oti to the Wp3tminster

(

The. subject of this case had been a free liver in
his ybtiih, and became si martyr to this di3ease so
ekrly, that he might have been called anoldfmian
at forty. He died of gout at the age of fifty
yearti; ciiid hacl iiot been able, for a long tiirie, to
lie strait in hrsbed. His legs were drawn up to
his thighs, and his thighs to his belly, his knees
resting on his breast.

r I'f f

Onfe of the great toes was found ib t)e icnuch

enlarged, and upon dissection the first joi^jt ef it
was found to be in9losed in a bed of cb^jk-lj]^
matter, fike a fossil shell : but tfce bpaeits^|f w^^
neither inpreased iji si^, nor alter^ ji;i it^ t^jctiir?.

>r.

The joints pCthe fingers were fdso swelled ^\id
knotty; every knot resembling a luipp of pjiajk ;
Mid Mr. Watson was told, that when he playecl
at cards, he used frequently to score up the gapip
with his knuckles.

On the middle of the right tibia there appea^e4
an pblopg tumour^ resembling a node, oyef yfhkih
the integuments were very thin, ^d regj^y tft
Bu^'st : it was a mere Reposition of ch^l)^-4i^e m^-t
ter, betwei^ the ?ki^ a;nd p?rio^teum j ^(J i^ugli
thick and large, had not as yet done anj^Jmi^
to the bone.

,'■;«.. ■> I

He had at di|Fer^nt tiqiQS, but more. Mrtic^»>
larly a little before he died, complaippd gr^qatly of
tiQlent excruciating pains in his head ^ often ima^
' gining that he was fallipg, or tljlnvbK^g 4owa
headlong. This of course led tp aa e^^^ipation
of Wd, brain. . ^

w ;

After sawing through the cranium all. round, it
was found ij|ipp§ipibJe to reiijpvj^.ljhi? tjone^wi^l^t

Also diTiding the dum -fiibtei- i which befa^' dotl^i
the adhesion appeandd nek to be owiilg4o the (O^
tr^Umlmory dbpth of tttiy of the fiirrovs on theio^
aide bf thd jikuJI^ but te^oUi iit^bnundcidn^ 'thidlp
CTingy and Bbdntdtion^Jdf the ^AoffU, rMt^t^ and ttila
Mr; Wmiibn fld^f I tHiiikv w)lt>iicliffik»efftly ft^dMfi£
fer tfateeJatoinaiin^ pimit k the be&d^ iM^ giri«tu

The fasciculated texture, bordering on the si*
nnsea^ was rdlnarkabfy s^rMg. Mere ihe gladds^
isrtfaejr ate ^caUed, ,wei*6 large dud very distihct i
the bra jn; itasif being a^'ilrm «k Wtic.

.-.J.. ./... .••-* •» <•»

The outer surface of the pia mater was smeared
with ii/smooih kucas^ of th^ isohwc dnd t!§niiist*
eiice oFcteaMU i The ^ftedutia ofolongMft tifid ilbiii
doHa ijfuiiatiq \mre iQ«obi>^ Wtiy <^bh^

part of the brain ; the tunica simMdiS^ WiA
thickened, harsh, and gritty ; and the glandula
piiieaUii qdte diesirofed i ootbiiyg f eififtillkr^^ iiut
it!J meiii^btranoua ^at Med Witty ddiidreiidnir ^
setlibiin^<verY miadU pearls; '

The bod^^ thotigh tMth matfiMed, isihtdUd
an appearance of fat under the skin, at least, two
iihches m thickiiess^ The mesediei^''#tt9 loaded
wkh ht^ The stomacli tod inteMkies, tbotighf

pale, thin, and greatly distended by accumulated
air, afforded no mark of particular disease. The
spleen and pancreas were sound; the liver indu-
rated and of a paJe yellow colour ; and with the
gall bladder, buried in fat. The kidnies were
small m si^e and filled with hydatids. The vesica
urinaiia was thick aiid contracted ; but neither in
it nor in the kidnies was the smallest-particle of
concreted matter.

When the abdominal portion of the aorta was
brought to view by dissection, it was discovered
to be ossiAed the whole way, from the diaphragm
to the very termination of the iliac arteries.

1 . ; The yalves of the heart, with all the great ves-
sels emerging from its basis, and the whole tho-
racic, portion of the aorta, were perfectly free

I fiipm ossification.

, The lungs, though in a soft and pretty healthy
I itate, were not without some flight marks of the
I disease; as a small stone was found in one of the
I lobes; but the bronchial glands, accompanying
E 4fce trachea, were filled with gouty matter.

I , Thejoints of the lower limbs were so very rigid,
that it was not without labour they were gotten

astoniiidi a sitfi&tioiv^ woikld aUbir txf ihe getting
td tlie abdomen. .OniesBminatioii, the cause of
this conduction appealed^ to be erHently owing
to ihe state of the' ligam^tut^, which wer^ hare-
de&ed, much iAiekeoei^ and had lost theit* po^
lisbed hue y while the ^ynovia^ like a mixture of
dialk, oil, and watery was become as thick and
as smooth as*cream.

•

The cartilages were not much altered ; nor were
they marked with any grooves or ridges, such as
<M^ some4:imes seen in gouty joints that havb beed

exercised ' ■

•' ■ . • '

From this examination, Mr. Watson concluded^
-jthat the gouty matter -has the strongest tendency
towards the extreme parts^ of the foody, and gene*
luHy^ fixes in the greater quantity;' whete th6
weakest impetus of the circulating fluklff is m\)st

.Jikely to leave it.

•)::.-.. . • ^ • i • .■■■■' '■ r ' ' '■ ' .

^Tiie foregomg case, in which so prodtgious ai
quantity i of 4norbid matter was secreted, eith€ir
manifeirts that the urate of soda, described by
Mr. Watson as chalk, was present in the sys^
tem:. jor rather, that a peculiar sdine acri«
mony existed, fitvourable to the formation of the
.uiacacid..

^ No Nevidegtice ihd^ei is likely to be iiddaoiii,
to ^bevv^m w|;iat. states or in ("^hat stages dfoebibik*
pittioJEi/ the princ}{^68;of this peculiar acidexistrdii
the; blood. ./Xfa ?h?frw tibe; teast chance of success
m /sQch.ait iniiilirj!, iii«ei;ies of experiments. Would
be Tequined on 'the btood of . the healthy^ . 'aa wd!
hd ooi that lof tltte^'gQUty ;' and weiie th^e estperi'-
ments even to be performed, withaU-diiQaBccuracy^
yet positive information would hardly be obtained.

It is mort^ probable 'that the .uric acid would ii6t
be found ;toi.dxist, fontiaUy^ in the blood; .Asu^
perabundance of the acid principle, only, might
be detected in the blood of the arthritic and ne*-
phritiC; TiswU; cotobiTOtion^^froM the trie

^i^.r-esult«(y mu9t be tbeiwork of aoiEie part of
the-anioi/^l^iiJ^rteiKty skiee it is^ AOt JuioiVii to.eidst
k^ aay^of/ the. sliilptstanicer 'vvhicb are emplot^red as
fop4» . ]E^€ in wi)iat part <^ ther system tbi^^^nir
tion is performed, it is, perhaps, impossible at
present to determine. It appears to be most pro-
b£4)tte^ tbak a sup^ii^o^n^^e of its^ princlpidfilkre
introdyl^ into tibe slomach; a(nd ihsncr ipasses
into: thfe blood, fi>nAing there t< salite aoriiiroi^
cfra peculiar kind« ^Bwtjbat pecuiiatiiaitang^
vbeukt afid; modiiicatioa o£ its prinpsplesi^ from whioh
|t^ eadstence. m the actual form, of tiric add pro-
ceeds, is most probably the result of the action

imd, deposit ;ia 4j|^;)?i»t pftrts,,r^. tl^ kidmeU

^mopg. the gi^cwiisliui^ {K)w^^ ppii$e«3^d by
ofg^i4se4 matter^.i^^hat f>f din^'tiog wd aifeotr
ins ^^<¥^ ebemk?aJl.«oinbin»^ian9 and d^oompotfftr
tiocmi, ^ which the wisteiw^i^f beiog^ antnud
cur yegetal^^e^i depend&i * Heofi^ do the different
iadividu^ls, of the animal and vegetaUe kingdom^
possess the power* of reciprocally interchangiiig^
aiul of reducing to their own naturp, th^r severat
constituent parts: and thus may th^ veg^tahji^
acids be converted^ by some part of the animal
9y^tem$ mto tba lactiQ^ D^ic^ or pboi^boric acids.

It xn^y^ however, alway/s remain as difficult td
determiwe^ oa wlwit preeii^e stat^ of tho Wood'the
form^iouaftfaeurieaqiddep^s; 4i9 to ascertain
that pi9cu}iar state which is most favQiirable to the
produ^ticm of bile, or of any other secretion. JJn^
der this mio^^nty, respecting the real devtaticltt
m the stato of th6>btoiod, firom that of healthy it
has hjeoa thought preferable to denonainate the
pr(^iQi04;O: vaitae of tliia disease, a peculiar saline
acrimpnys^thau todesignaAeit by axiy: term which
might convey the idea of the actual existence of

the nftift acid k^elf ia the btoed.

• . *

.} Whether tte aric acidnf&ttitrally hdoAgs M
kQinan ^jBtefn,- when anldi^ired bj the 'hidiA-
gence of injurious habits; or wheth^ it entfrely
owes its origin to mdrbid changes, the consequence
0f* some errtfr with nespedt ^ t^ the ii^esla^ must
at presatit remain tindetehnined. - At' jn^^saat;
alsoi experiment does* ndt'fiAn^h lis with 2Sq^
tiring positive';* resp^^etitig 4he source of this acid]
tor of' the itfetter IWi^rf Whi^* its origin -hats ifeetf
derived. ' Untilr W ^ -thus aided,c we must
4dopt Wteh coAJect^NiJ'^s the vainous circum*
kances '^ Mt^ndaifit oil'lhegcnitj diathesis sean
to AXAhtitxMV^ . ! ' 1. . >

' It-^equk^ but little atiquaintitnce With the sic&
to know, that impaired digestion is the most pro-
lific -sourcb of litiidity it^ th^ htiihan ^stem: In
almbst €n^€^>ca6e of weakened stomach, orofde-*
ficient tlig^$bk>n^ acid eructations point OM' the

• « *

faulty chatty* which feas been' inducfedf ib this con-
tents of ibe n^tomachi . A considerable' fia^t of the
aliti^t' ui^ ! b;^ Iman is of la^n. a^^ent
in 4b6m ickses, in whifch- th^ • gastrie jriice is not
ini a ^piroper< state, or in; which the stoiibach n not>
endued ^ith a proper toae^'ai^rmentatioti'ipn^
ductiveof to acid' b|)pear6tatidce place/ ''-^^^^^ ' ' *'

The fermentation which' thus takes ^laceita the

MOQiiehc^as been <Kithei^o regarded 'as the ado-
tmis^ and the aeetousocid has of course been supu
futeed to be its product. But when it is consi^
dered that the food, whilst under the action of the
masticatory organs, beounes thoroughly ijfnbued
with an animal fluid,* the saliva, which has been
secreted, from the circulating, blood, and which
contains, with phosphate of soda, of lime and of
ammonia, nearly a fourth part of albuminous maU
ter ; that upon reaching the stomach it becomes
blended also with the gastric juice^ another highly
animalized* fluids and t^at itis also acted upoq
by the stomach itself, a doubt cannot fisdl to arise
respecting th^ propriety of considering the fermen*
tationwiiich takes place in the stomach, as the
acetous fermentation.

Farther reasons for this doubt will' be found ia
the diflbrence of time requisite for effecting the
changes of the two fermentations. In the gastrio
lermentafion^itlie changesi are effected with tnudi
greater rapidily than in the acetous. - Some dsy^
are necessary for the duration of the ^detous fer*
mentation* before vinegar is produced ; but, very
frequently, within a few 'minutes after taldrig'ii
glass full of weak wine, sour belchings will denote
the formation of the morbid acid. The difference
of the >aokib, proceeding from the two fermenfa*

tiot^y AfTard^ another t>l9ectioii. The* add {pro-
duced by the gastric fermentation yields a last^
treiy different from Hiat of rii^egar: those wh^
are sabject to the unpleasant occurrence of acid
eructations, often say, that its taste is very drfierent
from that, of Tinegar, and that it also affecfS
the organs of taste,, in other respectL*, in a pecu-
liar roanndr.. These eircam^ancesf^ with those
whid) have been ah*eady mentioned respecting
the food being impregnated with animai fluids^
mm! surrounded by, and acted on, by parts pos-
sessing the living pmncipd^ lead directly to the
oprnion, that any acid thiis fptmed^ must be rathef
of ao amima}, than of a vegetable, nattre^ ^kistead
of the ax^etous acid, antacid obay b^^x^eited to b^
formed, v^hich having been itebjected to the
powers of animalization with which the stomach is
eiiduedy woftld possess properties df^S^rent from the
acetous, and such aswouhi evinee it tO(bea pecii**
liar animal acid. This acid it appears proper to
^is^iingnish by the term, gastric adid^ shK^e as ^
fittid feonted in the stomach is oniif hereby de^
sigBa4;ed, the term is. equally proper, which ever
way observation and experitsvent may deckle^^ as
to the mode of its fbrmationi. ::
• • ■ ■ ■ . . .■

The distinction here proposed does not at pre^
seisiit ma^tfest its^f'to be of much consequence^- but

tn the search of tratb; k id necessary to prevent
tbe ccmtinued adoption of the leaat error; since
that which ncfw is regarded as trivial, may lead
to .conjectures and hypotheses fraught with the
ni)(St ii^urious consequences. It is on this account
oikty that these suggestions are o£Eered with re*
9p^t to the nature of this acid ; for in the present
ytate of our knowledge, little difference can result
ti[^refrom, either in the pathology or the cure of
gout. ,

' The repr^ensible deviations from the plainest
und strongest dictates, of reaspn, by. substituting
Tarious heterogaieous artificial mixtitreS;^ for the
fimple natural food destined for the earliesi pe^
riods of childhood, are always siBcceeded by the
formation of this morbid acid in 'the. stomadl
Such also are the imnatural and injurious articles
^Qspioyed for the purposes of nourishment and im
dulgence, in the subtequeht periods of existence^
as cannot fail to pfoaiote the formatioa of aei#
dity, and of course such diseases as are dependent
onrt,

»*' »•

. In in&ncy, TonBtingSi severe gripings^ somr tod
green stools, proceed irdm the iiijmriotis nature of
thisaeid. . It is also ht^ly probable^ that the

rickets is a disease depending on a morbid state
of. the fluids, proceeding from a snperaban-*
dance of acidity. It may be presumed to be a
law of the animal oeconomy, that neither the
acids nor alkalis shall exist in the circulating fluid
in a free unneutralrzed state, except in certain rare
instances. Agreeable to this principle, it appears
that in gout the uric acid enters into combination
with the fixed alkali, soda, furnished perhaps by
the ^ledium of the bile, )and originally derived
from the animal and alkaline parts of the food.
But in the aliment of young diildren, no alkaliiie
matters are present ; it is indeed almost entirely
composed of acescent matters, the acid derived
from which can only become neutralized at the
expence of the earthy particles, which nature had
destined for the supply of. solid matter to the
bones. Hence it appears, that ai one period of
human life, mollities ossium may be produced by
the same morbid superabimddnce of acid, which,
yrhen life is more advanced^ occasions gout.

' ■ ■ * • .

Youth does not indeed appear to be liable to
any particular morbid effects, decidedly proceed-
ing from this cause. JU* indeed conjecture might
be' allowed to suggest subjects for future examht
nation^ i di^enses migbt b& mentioned; . as. depend*

iog,.. perhaps, on. this pitttm^lAT ^aMe;^n\ich''ia*
vatii^tts qutoneous eruptions and Mdiscbtd^eif) >c^ti€fy
ilxti:en)^ Ibanness of tJi^ bodjr^ &e; -«' '^s»i " • '■

ff As life^ adv:ances, ^he»mbrbid e0fecihi^f>the'gtt«H
trie acid ibeoocne mciie indent/ Digestion ikino^
impaired; ' and the patient is fre^aentty ^dis^reist'
withi.painfiCjf 'the>'. stomach, -heartbumy ^ or emCr
katioastii theihcidity ttf; the Jitter being often said
to eoocee^ ttjat: b€ viiiegai^; and to excite the sen*
sat ion ' wh ich*. is g^erally described by the expresM
sion^i (Setting. the teetHrwi edge.' • Whettthe^ cir4
ciuDstan£^s<^re cohsid^Fed,' there can ^^xi^^llttl^
reason^ito doabt th^lp^oprietyof regairding ^hi
itomteHj wihen in a. debilitated slate/ as^ an inex-i
haiistible>*cib«rce of acidity. > Tiie acid ityidds,^
passing! intO' the intestines^ and being thenco ahM
sorbcid/.and conveyed j>y the medium of the blooct
into. emy. part • of <he body^ neoBssatily undergooci
certain changes- add mod^cations^ dependent on
the v^ri«|;y .bf< strdcturs andidifiertoce of |)owerl
inibd sBiierab orgiainsy tbih¥Ji6se acti9n.it becomes

■eKpo^edi.'i' •.-.' •:.;.'»>•:' i^ .•• t. , .t ; • 1! -^ii; ./
.... i .' ^iiirr .'':■ l - ;?} ' -'^ ' •-" • .' ;»' r,:: .-.1I

It may be ; here objected; that • not- only • ajcid
fruits, but vinegar and rvegetable acids in general,
are frequently taken, and particularly iti youth,
with entire impunity. But not to enlarge on the

1«

difference . of idiMyncx^^^ many mesvir expe-
riencing ^#py iifiedEiyenieiice from acids^' ^^riiilsfe
others are susceptible^ id die highest, dbgreey of
the injuries which have been here particularly no-
ticed^ considerable difierenbe must result fit>m
the diiaebmittKpenods'drf life. In infimicy ahd youths
when nature is buried in: giring the nece^ry Ae^
gree of fir^;Qiiesb to thci more solid parts oftbe
bodyi the prevailing {^rinbipde t>f iwridity, if e«ii*^
ing in the bloody ntoy then havi^ itfei ^to^ offied
to aeeom^isH in ' assisting m forming iihe phte^
pboric f(eid( Whicb> ib combinatioik with Imie^ is
to give the due de^efe of:«didity to the lkmes4
But wliiim that peiiod'Kif: life arrived^ when the
bones may, t^e 6upt)osed.t6.hav6 attalined admoilt
their utmcTsI degt^ of firhinesi^ and solidify; and
whic^^ perhaps^ it way laet be too inuch to
f)rei$Um^^ )nay l>$ about that time (from the Uiiity^
fifth M the fbrtieth year)y iA whibh goi|t generaily
appearbi the pj^osphoi^ cund has then iniKii }«ss
to perform. It hito ilow meitely to keep- up the
necessai^y supply nof . feolid naatter to the bcli^ea»
which may be rendered necessary by that absoi^
tion, and removal from the system, which is per-
tiaps tottstantfy goii^g tm, in a ^eater or less
^degree. A considerable piart therefore of/thosfe
principles, tvhlch were before employed, : in con-
stitnting the phQq)horfc add> may^ from tiipder-

goiiig: the «|»propriated action <rf n diff^^ni series
of vessels, become fhe>itric acid. I«'«elTe» to<»oi
firttt this o^ioto, that " the Wltie :<rf infeirts and
tiorses <3ont£ims t^e^ tittli^ phospb^e of Hme and
i>h<MplH^ teid J it itr tiot ^til ' aft«i< dssificatknk
is ^isl/6Si, ' that thes^ el^ntints aft 'Ibund ii^ ab«ati>
dandfr 'to the Urinary flttidi Tte tfrine of o*d
taed', -eta the <»ntraryi contains them in a grel*
quantity ; the bony system, already overdiarged
with phosphate of lime, refuses to admit more
of it»^.'»

Indeed as the diflference between the varioibk
uniihsU acid^ depends, probably, wi the po^^^^d*
y idded by the hervcms influence to the Veissels b^
whicft they are formed, and by which tSiose tes^
isels 'a^e enabled to idect and combine the several
prmcipJdr, which constitnte the diflFerent acidisr^
there canbis litde reason to doobt, that, at one
period, ^Aid nnder the influence of a particular
diiktheijis, the uric acid may be formed from thA
same jprinctpfes, which under other circumstances;
by ^ dtfiiefence of mod}fi(!:ation, might have been
rendered some other particular acid, for instance,
the phot^iphoric.

* Ekment* of Physiology, by A. Richeraud. P. 97.

C 2

AlthpugbhW^bJe to trap^jtJlHs a^o?«gularly
from, thje rtgpi^h, ; through ni^s^ variows ^ j|H>ciiQc;gk
* J;iO0Sr 9J:id comtimatioAS, to,{tM. actiji^ forwa^.iou
0f gouty Gon«retiQns, or oif ^tfee c^lq^UAR, pf.^he
W^d^er^it m^j not, ,1?^ ji^ipjrppjBr. tp .^n^fjaspwr. to
.^sqertgini, wjietber it jf> .discoverable lin j^jj^jntejr-
fnedj^te states, .and whet]befj,i)ature has prqyid^
wiy other means pfpropqriijg it^,discb^rgft, yf}^^
pxisting in too Is^rge a qusmtity^ , ,

Frequently, after trifling febrile affectionsj^ich
as are generally combined with a slight degree of
iC^airh, and ,wl>iph conjpaon pjbsefvatipn b^fifat-
tribut^d. tp iaterr]4pJi^4, . p(srspirat^pij> a :'Rr^ciH jr
^te.pf.^a. pip}^ .polofir,..;Qal(?d t^y.jpl^pip^ps,,^
.^eritio^3 , ppdiffient, is d^pp^^ed . by , t|]e f^i^Q,
This kipfj pf , : spdioj^nt ^ ,alaipst| always,, t^o^be
found in tJn^, qrine which ^s.J3iade= after ^he^J^
fit of intermitteiits has gpne,off| and^|is?jalsp.dfSr
<¥>ve^i:able, ..at jSome period, or other^ rjpf almp^t
eyery fever. The appearance of this^indipfj«§4iT
ment,- in the , urine of gputy person?,., iS|^j;o fyi^

quent, as to haye occa^on<eiJ, urine which <?J?posit$
it, to be distinguished Ify the term, gpufy, urjine^
A copious sediment of this kind frequ€;9tlyu imiir
cates the termination of a paroxysm ; and on its
sudden disappearanqe^ a fresh attack or relapse
may oftentimes be expected. This sediment.

t ,

which had been considered by Soheele, and other
chemjisfts sinccf his time^ as uric (lithfc) acid mixed
with some phosphate of Ume, Proust beheves to
consist chiefly of ai peculiar animal acid, to which
he gives the name oiF the RosacicAtid; and which
he observes possesses a greiater degrfee ' of solubn
lity, and much less disposition to crystallization i
than the uric acid. That this acid may differ so
much from the uric, as to allow it to be considered
as a diflperent and a peculiar acid, is very likely i^
at the same time, it is highly probable that it ap-
proximates, in ife tiature and Cbitiposition, very
li^r'to the uric acid, with which it ha!s been
hitherto coiifbtirided. The uric acid is,however;-well
knbwn to be almost a constant ingredient in urine/
and the quantity in which it exists, in that fluid J
makes it evident that its rem6V&r,' in in' excre**
tnentitious ; state, is intended to be acicomplishect
by such excretion, ' ,

When it i:s considered also that an acid, the na-
ture of which has not been yet ascertained, but
which, has been regarded by sonie as the phos-
phoric, and by others as the uri^ acid, is found to
exist in 'the matter emitted by perspiration, there
need be Kttle liesitution in concluding that in this
way al^ an outlet is secured for this acid when it
estists in superabundance. Th^ probability of

this is increased, by this aGi4ity being consider*
abJy augmented during the criticaJ periods of
9ome diseajsesj find particularly i^ the gout itself,
Serthojlet ai5Qertaii:ied, thi^ paper^ coloured blue
(qt litmus^ b^oaine red on being as^posed to the
perspiration pf <^ part p#BC|e4 with the inflamm^

lion of goiit.

• Th^ digcbAr^ge of the uric acid with tise urinei
m^y h^ regarded as th$ nKist constant mode by
which it^ superabundance is . iqtenddd to be , pre**
vented, But when,r froro the profusQ ia^tr<>duot
tion of those siibstance$ into the stomachy on wlm^h
tthe formation of this acid depends^ a sudden wod
^onsiijierable augmentation of it takes place, it is
prrobahl^ the skin unites with the ktdnies in per-«
forming the depuratory office; andtli^ supers
abundant acid, sontewhat changed;, perhaps^, in
its nature, is exhaled, ih combination with the
sweat. Thus may be explained the general sour
sweatSj to which tho$e who possess a gouty dia-
tJ^esis are -so frequently liable ; as well as tine acid
>vhicfe, in maiiy persons;, is separatfed by the
emunctories in the »roin, and which is so ex^
tremely pungent, as to resemble tli^e acetic acid
in ks smell, and to -occasion, oftentimes, a Very
considerable degree pf ex<coriati(^n in the parts on
w4iich[ it h.as remaned ^ter its ^x^udatioif , l]he

kidnies and skin therefore appear to be intended
to act, as the natural regulators of the quantity
of this acid, in the human system.

t ■ » ■ '

But in those cases, where the excessive indul-
gence in such articles of food, as yield mych of
the acetic and carbonic acid, has generated a
larger quantity of this acid than can be removed
by £he joint operation of the kidnies and skin^
d^ase most probably will succeed.

It appears by Dr. Wdlaston's experiments that
the tiric acid, as JweH as that compound of it with
Goda, which forms the gouty concretions, requires
a very large quantity of fluid to hold it in solu-
tion. Whenever, therefore, it exists in a morbid
proportion in the himian system, a strong dispo-
Mtion to its crystallization must prevail ; and its
separation in a solid form js reasonably to be ex-
pected. The part where this separation will take
place, will necessarily depend on certain particu-
larities in the general diathesis, not, perhaps, to
be explained. In some habits, the kidnies will
prove to be the organs destined to effect this mor-
bid separation ; in which cases, the saline concre-
tion will be found either in the urine, bearing the
appearance of a red-^and, or forming ojie species
of urinary calculus. In other habits, the liga-

mei^ts and tendons will .be.ij^e pafts oip^.wJ^ich.t^he

morbid excess pf this acid \iriU,. be deppsiied. In

this case, gouty inflammatio^jwijl bp in^uqed^j and

after every attack a thickening, with a considerable

degree of stifl^ess, of t^e jigaropjljits, aijd^hipdr^ce

of mptioi], will be q<;icfisfpned.ju,c9i:v^ of

jthe deppptipuof the gou^y n;i£^t^er,^ At ttbecom?

pef^cemex^ of this dispose,, yi^h^i^ tbe .p^pxysois

^rjer sljigfht and. sddojiip^ ^ sij^icjept, ppp^^nnity ii^

yielded bet ween, .the, ^|« for tl^e a^^rptiop pfr the

deposited matter, which is in general soon removed,

and the motion of the jpint^; in ^ littl^.j^^ime? quite

^^^^^^•> . ?^^ when;,tJie,p^rpxy^ms;,ar^.of,^oiig

duration, the intervals, fcom. disease pre w)t sqffi*

cient to, allow of the femoy^^ of .t:he deposited

matter, before a fresh sepai;£^t,ion anji (digpositipii

takes place ^ hence accumv^atjon prQC^4?» •"^^^'^
.considerable cpllectionj? are, formed, in di%i;ei:^t
joints. The injurious p^oc^ss/i3 n^ost pbseiyable
in the joints of the fingers and Ijands,] where . frcr
quei^tly the whole ligaipen/;ary,apparatus becomes
involved in the concrete mass, wUicbsometim^Si in
consequi^nce o/ the absorption of the superincum-
bent teguments, becomes so exposed, a^ to admit
of its removal from the part, in a state pf purity.

Hilherto we have only caught a few glances at
6rie of the corpponent parts of the arthritic coi^- :

Cretiori. The peculiar acid which it contains hasi
been examined, and some : conjectures have been
offered with respect to its origin : the other com-*
podent part, the soda, now demands attention. It
iS'Uni»e0efisary here to trace back the soda to its
first admiasibn into the system, by the tnedium of
mjHiy pfithe various articles of food ; nor does it
ai|>pek)r.to^be riece^ssary to enter upon the difficult
qjaestibri j where the soda first enters; into> Corabir
nation with the uric acid; in whiqb inquiry,. the
pr^ence pf vsoda in the. bile, and ' itsr. adtnixture
M^«tji the gastric acid, might howe v^ fiirhish somb
assistfince/ It is suffidcQt for* the prqiBent purpose
th^ H is found 'to es^ist, in combiriat ion (with the
urio.ac^/ in the arthritic concrietionsL ^^ v v; ^

Biit since the arthritic condretions comtain
sodaiastwell as .the. uric acid, the former substance
may $^in* io deserve to be regarded, eqiially widh
thejliatter^aft of morbid origin, arid as equally tJele*
terious, by contributing tb the 'fornwJt ion of these
mprbidi ^cumulations^ ^ : But it } is ; tp be cousin
dered, that the formation of these depends: bn* the
insolubility of the matter of which they are com-
ppsed'j and. that tbifli insolubility proceeds entirely
fron^ J the nature of tb6 ^ uric acid, : the soda not
cont9'ibutji\gv thereto in the least, ;p: butt con Ih^
^ntr^r;^ po&ses^ing a* t^eney iter (increase itsi'so^

26 ,

lability. Its combiaation with tfa^ uric acid may
iiuleed be regarded as a salutary measure^^as one
(of the processes performed by the preservative
powers of the system, agveqable to aj^ e6tpblishe4
Laiv of the animal oeconomy, aad conformable
u^ith the laws of chemical ai&iity. For in ev^ry
case, exc^t where iim seeretion an<i consprva-
tioa of a peculiar acid is proposed, the acids, f^
have .been idready remarked, are found in th^
aniinal systenoi, in combination with an alkali, -or
an earth,: in • the fbrsa of neutral salts; in whidi
less acrid state they are -npt so likely to icri-
tate, and injurp the san^i£erous, and ^ther ves*
ads tbriAugh whidi* they pass, as the acids th^m^
pelves would in a free and pure «tate, Agroes^ly
to this idea, the uric acid is concluded to be the
noxious principle in those d^ad&i diseases, the
gonat, gravej, and stone; but tlie propriety of
tJhis conclusion will be better judged of,^ wfeen it
16 iCon^eT'Od alosug vritfa those circutnstances,
^fbidi may be regarded as tbe remote causes of
ihis disease, and with; those symptoms w4iich cha*
faeterize the /disease.

v: it is hoped, t^at ou' ai review of what has
been here fitated, the conjecture tfeat gout de-
fiendsod. a s^iioe^aorimony of ^'pfeOuli^fcr kind;
:W]|1 not biitiMmaKli^red as ill Itmiided, • Iji those

p^*son8 who possess a gouty diathesis, the sto^
tnach is almost always disposed to the formatioq
of an acid; — ^their perspiration, even in health,
but more particularly itntnediately previous to,
and during the attacks of gout, generally mani*
fests a high degcee of acidity ; — Ihe parts salTering
under gout ' fi^uently exude a strong acid mat^
ter ;i — and the separation of a'peculiar saline mat^
ter by the vessels of the psLrts affected, appears to
be the regular termination of the disease. The
l^onsideratibn of theses /^smstances can bareHy
fait toTupnifeAt' reasdnsfof agreeing, in this suppo^
mtion: but reasons perhaps still more cogent
will be' found in 4b0 ejoileilent puWicaticm of
Mf . Forbfes, which, though wfkten pi*eviously to
the important discovery of Dr. Wollaston, con*
tains arguments highly confirmatory of the opi*
nion here delivered respectitig the nature of gout
and gravel. It must also be remarked, that the
learned professor, who so beautifully simplified
the knowledge of diseases by clearing away the
erroneous notions of, the humoral pathology, did
not refuse to admit the existence of a pretematu-
rally saline state of the blood as the cause of a dis-
ease. Speaking of the scurvy, which he believed
to originate in the production and evolution of a
saline matter, he says, " That this saline state is
constantly, in some measure, produced and evolved

by . the t ammal process, appearsfrom this^ that
certaitt-.exeretioas of saliue matter are constantly
made, from the human body, and are therefore pre-
sumed necessary to-its .health*."

• < ;•

; By ifche Syllabus of the Course of Lectures of
Dr.. Curriejjj, m whiehrbn analogy between gouty
inflamm^km. aad iphosphoric combustion ' is sug-
gested, ai)d by th^ reports received respecting the
lectures themselves, ^here appears .to be little
doubti but that the ^M p^hlio^iiQii of th^ Doctor's
op^ions> 91^ tbis:^uli^^c^/iwpuld ;s|Uj)ply u^.with
the most ringenipus dqducM^ions: frpm: tjiie vaJi]^abIe
^iscqvQrj^.pf Dr.-.Wplla^ton^l^nd might, pr-Qte \^^
^CQtially b^Qfici^ jbq: thps^ afflicted- yr^h' this
n^alady. • , .. , .^/ •. -,;. v-; ; • • .\ ^■■' :. . ■■•)

. * CuijeoVFir^^ipes. §

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' : 1

REMOTi: CAUSES — HEEEDITARY DISPOSITION — INDI-

GEST10N-— ERRORS IN NON-NATURALS INTKMPEr

RANGE — ^^DIFFERENT EFFECTS FROM DIFFERENT FER-
MENTED LIQUORS OF WINE — CYDER — ^HEER—

ACIDS AND ACESCENTS— CIRCUMSTA^XES.PREVE;NT-
JNG THE ESCAPE OF MORBID ACID,

§ ' ^

)

^ROM.^the uiicertain,ty,,. which, exi^ijs respecting
the real pature. and inorei immediate c^uset of 8:out • '
the necessary k:nowljedge, respecting its rexi^C|te <
q^uses must be difficult to be obtained. This di^
fifukj, is particular|jr . e:5i:periencedi whilst ende?-^
youring to determiAe vy^hat circumstances may be
considered as pred^sponent causes of this diseased
These l^^ye.been supposed, tp be much more nu-
i:nerou5 thap the opiniop bjere entertained, respect?
ing the nature of the disease, appears ta warrant ;
original constitution, for the most part heredi-
tary, middle or advanced age, and a weakened
state of the stomach, appearing to bevthe chief cir-
cumstances which require to bethus^ considered.

The examination of the occasional causes of
this disease, on which we shall now proceed, will
assist, as has been already remarked, in determin-
ing the degree of confidence which may be placed
on the proximate caiise which has been proposed.
To render this examination more effectual, in this
respect, the mode in which these excite their mor-
bid influence will be made the chief object of
inquiry.

Excessive indulgence in pleasures, the sudden
change from a full to a spare diet, and profuse
evacuations, enumerated by CuUen amongst the
occasional causes, may be considered as producing
theil* injurious effects, by occasioning dfebrlity,
and thereby disposing the smaller vessels to tak^
on that kind of increased action, which is not only
compatible with, but even dependent on dimi-
nished power. The occasional causes which re-
main to be considered, may be divided into two
dasses; such as promotfe the generation of the
morbid maitter, and sudi as prevent its expulsion
from the system.

)

hidigestion produced^ either by the quantity y of
quality of alime?itSy may^ without the least hesi-
tation, be pllaced among the more active of the

occasional csiises of thiB' disealsei Ohser^ttxotk hBs
related! J ^msliiged tfaef connexion between gbut^
an|d animfistifed ^tite of the stOknach rj an<}» in the
hiking of this disease, this cbnnextoh isknown to
bed prominent cii^umstance. The g^net^ation of
the gastric accd^ it has been already observed^ al^
tnost cofistant]/ lu[XH[>mpani<ss indigestiito ; atid^
kereit mnst b^ addi^,<diat this; acid^i may exisf
inrthA stDiitiadb>» to a considerable degree^ witbout
manifeiSting itself, by anj sensible e£febt onthe
fluoes and t>rgans of taste. That a iifiorbid exee»l
of additjr in tbe tiyiterhj on Wliich il> is sii)p^]|ofiied
tkat ^OQt rdependsy may be tteriited- itom thiil
fionriJDd^ appeats to be ap obvious as not toilemaml
any additiiind anrgij^tnent. ; - • f . ^)

Intemperance in the use of spirits, cannot but

be ire^tdBd^as one of tfane occasional cans^s x)f this

diisea^. IMl; )[iemiaioci9 practice, las far as re«-

^€^ts ^mit^ ia|)p^arB to act in atwo^fold tnannen

In the first plaoe, by diiorttering the (fn actions^

tiie id(^ott¥auch^ a«id xlioctoioniBg tndigeetioi^^ it giv^es
»

tist to an incTease in the quantity of the gagftric
«oid ; and secondly, by io^airing the «iiiergy of
the rm\(Sfm system, it raiders those Iparts, which
have before suffered from the attacks <rfgout, more
susceptible of morbid impression, and more likely
^ takejoadkeased action.

S3.

^ That ^ the gdiA is, hwvfever, less attributaUe to^
the i&toxieatihg pidnciptey thfain to otber piiiQci^fi
existing in win^ &c. i£i)etident.fi*om thks.cireum-:
stance, that those, who^ ane .so tmhapj^y las to> 'be
under the danrinion of an attaohment to spiritoui^
Ikpiorsi^-wpeseidom subject to (attacks of thergouft,
unless^ Tfhidnthey take> wineralso, or wbeH they,
join the^fuisie of acids to^lihiatof spirits, . asi: isb
fmn^h.'' Numerous dnstanoes occur ndoere those
who at>e devoted' to tiie drinkii^g of ^irits have
been perfectly free from -tfie attaokii of goiit^
iintil after a debauch, in which wine; ohpuikbhaa
been^ taken ' freely. In such .cases, itjis>'byt,nd
tnean^an' Mfrequent /occurrence, forv gouty f da-*
flammation to manifest, itself, eveh'.0J3ki the. suot

•

ceeding day, or evening of such indulgence.

► ,

TJie free use of xviney or of other ferment€d li-
^norSy may be regarded as one of tibe> most obvi*
ous, and one of the most powerful, of the occasional
causes of gout. General observation has marked
the drinker of vjrine as peculiarly obnoxious to this
malady : and it may also be observed, that iJie
disposition to gout generally exists in «/ /degree,
proportioned to the cdnfinement to wine, in con-
vivial indulgences.

Every medical man must be informed of the

• 3S

frequency) vith» whicb t)atients ^^^implam of ei-^
traoEiely sour cerac^atioM diirectly>; after the tskifig
of a glas3 of wine, or the use of vinegar or pickles.
This. £pequently indeed occurs to such^ a degree . of
ioooUYeniene^ as to seidm to authorize tbe opinion^
thatif^tjie jwhok contenitsioDf/the stomach pat^
take^ in a}greatmeasuce,fibC this sudden morbid
change* .iw i ' ^

•». »

• t i

4i''A

With a rapidity equally difficult to explain, is.
the taking of vinous or acescent substances into
the ) stomach succeeded ^y arthritic pains, and by
the formation of sabulous concretions. ^Often-n
times^ within « few hours after the indulgence in
even a few^ glasses of wine, have sharp ardiritiq-
pains testified :th^ morbific power of that cordial^,
which, in every other respect almost, may be con-
sidered to be as salutary, as it is pleasant. Equally
fr^ueni^ arie tb^ cases, in which sudden and severe
fit§^of the gravdi arq referred, by the sufferers, toi
the^bavingtoo fiieely dr^ukf only a few hours be*>
fwe^ of .win^i or of becsc, whidi,^ by too long*
kee|>ing, had^ ^cquir^ that,, degree of acidity
which gains it the d^stinption of stale; beer, a i

^ *

4 ) . ■ ^ ...

A considerable difference is discoverable, in the*
morbid effects which follow the too liberal \u^' of
different fermented liquprs. Thus wine^ in generaly

appears rto dispose most to the gout ; cyder and
the low jiew wines seeitt to occasion tlie gravel ;
whilst beeo-^ except in a certain state^ does not
appear to be particularly productive of ^tfaen
To ascertain the reason of this difference appears
to be highly worthy* df being attempted ; since
the investigation may not onlj lead :to a mote
perfect knowledge of the nature of the disease,
but also may sierve to establish some impcHtant
points in the method of core.

The liquors obtained by femmfation, finr tfae^
purpose of beverage^ may be divided, aoeordnig'
to their effects on the human body, into strong
winef^ in which the fennentative process has conw
ploted its course, cyder, perry, the low wines,;
and beer.

To obtain the vinous fenmentatiim, in- which is
included that by which beer is formed, it is ne*
cesiary that sugar, extractive matter, and a vege>
table acid, should be diffused in water, and plated
in a certain temperature. Ab the acidity of the
liquor, resulting from the vmous fermentaticm,
will depend on the quantity of vegetable acid, in
tbt original matter subjected to this operation ; so
will' tha quantity of alcohol, separable by distilla--
ti01#'4fP^ OA the <)uantity of saccharine mat-

3S ,

ter : so also will the strerfgth or weakftessf 1if the
fermented liquor depend on the fjuantity 6f Wjiter,
through which the other matters are diflfesedi '

The grape, which ranks foremost amotig tliS
fruits from which this dfi'd-hning bevera^ is oB-
tained, when folly ripe, contains a juicer of a
slightly acidi' atid luscioflsly ^et il^onr. This
liquor cbnststi^ bf a vegetable '(the tartaric) acid, a
gelatinous glutinous m^tey, 'and sugar, all cbiti-
bined with a certain portion of water. TheS-sugkr
is in so considerable a proportion, that some of
the more luxuriant anwJfi^feiitjeWes'of this fruit are
said to yidd VhJrty piarfcd in the hundrl^ of ^ pecu-
liar kind of iSiigar. Herfce it is, that iii* thd wiiie -
of the grape a greater proportion of spirit ^iis*y6n-
tained, than in the Wine' foitaed from other fruits t
and henc6*it is, that it poss^sfes such a body, as
to allow so long a' duratibn of the fermentative'
process, ati'dthbse various chainges and new com-
binatl6'riisi;y{^ilst in cdixipletely closed Vessels, as
render it so delicibusly flavoured^ arid so pleasingly
intoxicating. By ihti irftiihate tiombination, it^
constituent' pnrtciples are alm6st entirely con-
cealed from the detection of the taste. , Although
containing a considerable proportion of alcohol,
this exists in so peculiar a kind of combination, .
that it only maiiifests itself by diistillation, or by
' ' 1)2

■^•-

»•

«.

. »..^

the ^u^ll)r certaii:^ evidence of its presence in the
wifle.^it«elf, its powers of intoxication. Thus also^
hardly disqoyerable by thQ tsji^tej a considerable^
quantity of acid exists in all wines, from which,
yvhen t^ken into the stomis^chv may progeecj that
superabundance o^ aci(Jity in the syst^, whence^
it i? probable, t|iQuric,acidl, derives itsja^qst abun->
dant principle. ., Thus, bylbp u$e.o£ wijie-it is
ooru^qture^lr that gou^j.nuty. Jb^ ,pCGasioned,f , asj
well as jSonxe specif Q^jgri*yel,,.and of the Jarger
urinary calculi. . ,

,%: i. ■•"••;

,^r: »

I.t ^^y^ppaj:,tQ,b^^,^9il)Ie pl^ctioA to this,
opinion, that,, many. ^rp in ,tji^,.l^^it of taking,
profipiely of wij;kQ, wathouJt.^xperieqcjng^ny of ther
injurious effects which baye been here atti:ibuted
to it. But it should be, coni^idered, that frorau
the influence of habit, and of a.princiiple ,pf ac-.
commodation in the animal ec^ouomy, even strong
poisons are sometimes taken with impunity. Thus
opium may be chewed almps^;. as an article of
food, aud^lqohol be drank ^Jmost^s freiely asj \yater..
But .this, particular .apparent indemnigcation will
perhaps be. still better accounted for, by reference.
to a. circumstance. which has been already men-
tioned. The matter of perspiration 2^pd the urine
haye been mentioned above, as the appropriate
vehicles^ for thci removal of superfluous saline

matter^ ^r6ni the *y stetoy With tile vitioiri acM;
We have .already seen/ a consideriabfe' portion of
alcohol is blended; the diuret?c quaHties of whicK
are well known. From this union a two- fold effed;
is insured upon a free potation of wine ; a stipeir-
abundant (jfuatitity of acid is introduced into the
system; but at the same time a greater quantity
of urine is formed, by which the uf ic acid, or iii
neutral cmribination With soda, each requiring a
large quaiitity of water for' its solution,, will be
suspended, and carried off: and thiis, perhaps,
the equilibrium may be preserved for a consi-
derable time. But should this disfchaTgte of super-
abundant acid be suspended, from any cause n6t
here to be ascertaiiled, then may such a morbid
ptevatetice of iacidity take place, as may, accorcl-
ing to certain existihg circunistances, and the
peculiarities of diathesis, occasioh either gravel

or gout.

'. i ••• .• ■-■■ ■■ :

The low new wines, such as possess not a sut
ficient quantity of alcohol to prevent them from
soon acquiring a considerabte degree of acidity,
in addition to that which has been left unchanged
from defect of the continuance of fermentation,
possess^ in a high degree, the injurious powers
here attribnted to the stronger wines The low
thin wines of the northern provinces of France,

and of Germany, the wines made in England
from currants, gooseberries, &c. with cyder and
perry, are liquors of this description. An appa-
rent objection may be here noticed; liquors of
this kind are chiefly drank by the poorer class
of people, whilst gout is almost proverbially
marked as the inheritance of the rich, But the

# •

poor labourer purchases, by the sweat of his body,
those exemptions from disease, which the rich and
slothful, unwilling to mak;e the necessary sacri«
fices, fail to obtain.

From certain circuihstances, perhaps dependent,
on a difference 4n the other articles of diet, as weU
as in the exercise, the humbler classes, it has
been observed, seem to be more liable to concre*
/ tions in the urinary passages, than to complaints
of a gouty , nature.

The mass of the people, however, in those
countries where liquors of this description consti-
tute their general beverage, by no means escape
the attacks of other diseases, which, in their nature^
manifestly approximate to the gout. Such is the
gradual enlargement of the joints, hereafter treated
of more particularly ; and such is thj^^t prototype,
of the gout, the acute rheumatism. The resemr
blance between this latter disease and gout is, in-

deed, so great as to lead much towards a suspicion
of an ideutity of nature in many respects.

The evidence of Dn Haxbam>^ whose residence
in so celebrated a cyder county as Devonshire,
and whose particular attention to the diseases of
the inhabitants of that county, must render his
evidence incontrovertible, proves the connect i(m
between the use of cyder, and the existence of
arthritic and rheumatic complaints*. The Doctor,
attributing the same noxious powers to the new

^ Nee cert^ longe differ! Tinum Rhenannm iip&matto ge->
neroso^ nm qu6d hoc multo plus mudlagims habeat.^-
Utravis horum mustea si bibis afiatim^ doloribus colicis et
rheumaticis certo certius yexabere; nee arthritidi obnoxii
hsecce hauriunt impune^quippequosprotinus corripitparoxys-
mus. Nee gravibres peenas luunt bibaces Germanic ad ripas
Rheni & JVIosse incolse, se vino tartareo ingurgitantes^ quam
nostratespamaret^avide perpotantes; ibi enim, & hic^ ar«
thritis morbqs est endemicus^ & ihaxime communis; neque
tot uspiam^ etiam inter plebeculam, podagra l^borant, quot
in Damnonia provincia, ob pomaceum notissima. Ac credere
fas est, iporbi hujus frequentiae cansam fuisse multum et con-
tinuum vinonim usum^ tartaro maxim^ abundantium, quah'a
sunt yina Mosellanica, GalUca^ & pomacea nostra : ex quo
enim honim invaluit usus, long^ jnagis quam ant^ inc^rebuit
arthritis. Vinum Burdegalense, praesentis aevi delicias ! baud
magni fecit aetas elapsa; & decuplo plus poinacei nunc
factum & epotum est, quam annis abhinc triginta.

De Morbo Colico Damnonioi*um, page 1 3.

wine3 made from the grape as to cyderj observes,
that the. drinking freely of either, in its new slate,
will most certainly occasion the pains of the colic
and rheumatism : nor will those'who are liable to
the gout drink them with impunity, since they
will be speedily attacked with a fit of this malady.
The people of Germany, he observes, who drink
large quantities of wines impregnated with tartar,
suffer not more than those of Devonshire, who
drink so freely of cyder; for there, as well as
here, the gout is endeihic, and exceedingly
common ; nor do so many, among the common
people in any part of the world, suffer from the
gout, he observes, as in the county of Devon,
so famed for its cyder,'

It now remains to examine the properties of
beevy a beverage so general in this country, that
the examination of the effects it is likely to ^pro-
duce on the human system can hardly fail to
prove interesting. It is not necessary to dwell
longer here on the methods by which this liquor
is produced, than to remark, that it is obtained,
by a species of the vinous fermentation, from
J^arley, which is composed chiefly of saccharine
and gelatinous matter, and contains little or no
vegetable acid : hence the product of thii? fer-
mentation differ? frpm the liquors already treated

I
I

of, in its containing, eren when the "fentffenta-
tion has continued sufficiently long to rend^f ^ it
fit for: drinking, a considerable portion of saccha^
rine and gelatinous matter with alcohol, and but
a very trifling degree of acidity. Such a liquoi^,
fi*om the small quantity of add it- contains,
must, when compared with the liquors already
treated of, appear to be entirdy innocent in its
nature, as far as respects the disposing to tbie for-
mation of goujt. Churlish indeed would he be,
who, without the strongest evidence, would im-
pute noxious properties to that bland and rich
beverage, home brewed ale; a liquor which, at
the same time that it possesses the most pleasingly
exhilarating powers, contains a larger- portion of
nutritiohs matter thari any other known fermented
liquor. The properties of this liquor must be ad-
mitted to be particularly salubrious iikdeed ;• for
whilst^on the oiie hand, it is free from tbci;t pro-
portion of acidity, which it has been endeavoured
to. demonstrate disposes to diseases of a Certain
description, so, on the other hand, it holds the
alcohol, on which its pleasing stimulating powers
depend, in such combinations, and under such
peculiar modifications, as seem to lessen those in-
jurious properties, which alcohol obviously pos-
sesses, when separated by distillation trom the
other products of the fermentative process. Thus

no particolsir wsceptihility of disease chara(v
^rizjBf^ the drinker of strong beer, whilst the vota--
Ties to Avine may be regarded as the devoted
ifjcititp^ to gout and gravel, and the slaves to the
abuse of spirits to jaundice or dropsy. .,In a
word, beer, of which protracted fermentation
b0s not so far changed all its saccharii^e and Mu-
tinous parts, as to prevent' it from hanging about
the glass with some degree of viscidity, and to
which age has not given acidity^ appears to be
a liquor well ^calculated : to support the spirits
ftJuring laborious exertions, and to be least likely,
to produce injurious consequences.

This being admitted,, it becomes necessary to
6ts|te the reason, why this liquor is placed among
th^ substances likely to become an exciting cause
of this and of other diseases* It must however have
already appeared, that the hurtful powers tending
to the production of gout and gravel exist only in
this' liquor, when, from mismanagement or age, it
has acquired a degree of acidity ; and much is it
to be Jamented, that the laborious poor in gene-
ral, at least, in and about the metropolis, obtain
this liquor, generally, in this its most noxious state.

The nearer any fermenting liquor approaches
to the completion of its fermentative process, the

greater is the quantity of alcohol it contains. Ex*
perience has taught this to the drinkers of strong
beer, and particularly to those who indulge in
porter. . Not finding their cordial too powerfoUy
fraught with malt and hops, they have sought
to obtain it in that state, in which its ^ exhi^
rating powers manifest -most influence^ Hence
they have discovered, that beer possesses the
most stren^h, not whilst the; more silent and
efficacious part of the vinous fermentation is yet
going on, during which peri6d it is termed mild
beer ; but when a slight degree of acidity mani-
fests the vinous fermentation to be completed,
in which state it is called stale beer. Thus have
the drinkers of strong beer been led to seek-
donstantly for this test of the strength of thfeir
beer; and thus gradually have been induced, by
habit, to consider a slight degree of acidity as a
necessary part of the flavour of good beer. But
as every depravity of taste necessarily> demands a
regular inci'ease in its gratification,, so most por-
ter drinkers, unless they have been able to ascer-
tain the injurious effects it sometimes produces,
are clisposed to drink their beer in that state in
which acidity is very predominant.

It is much to be feared that this taste cannot
be indulged, unless the virtues of this most useful

and salubrious liquor is impaired, in a considerable
degree.. Patter which is brewed of a sufficient
strength would not, preserved, as it always is, in
properly closed vessels, acquire that acidity, which
characterizes stale beer, for a considerable time.
Bte it certainly cannot be expected of the pwter
:brewer, with whom the quickness of the retura of
hi$ immense capital must be aii important coasi-
d^ratiQn, to hoard up hii^ beej to its deterioration,
^M^ tOfbis.Qwn serious injury. . A more expedi-
'j^ioj^s ;, method, it is said, is sometimes adopted,
by whicli sourness is substituted for strength.
But should the brewer consider it to be his duty
7iot to mix new b^er with old; yet this is not the
Case with the tapster, who, impelled to please the
palate <rf his customers, may often find himsdf
und^r thfe necessity of mixing beer; actually acid,
with that which is in itself sound and good. i
1 . > • . - •

Here, however, is not, indeed, the place to deter*
mine, whether it proceeds entirely from a'depraved
taste in the drinkers of malt Kquors, or from the
tricks of the brewer or of the tapster, or from the
lack of the genuine juice of barley in its composi-
tion, that the malt liquor, in general, drank in and
about the metropolis, partakes more of the nature
of vinegar than of humming brown beer. It is suffi-
cient to remark, that in proportion as beer pos-

45.

jesses ; acidity, it may be coQjsidered a^, ppQperjto be
placed among the of^c^a^onal causes^ pf tjiis^dti^easdi

The connection be^tweea the ass^med>pj5D;^^
cause of tiiis disease, aqd fhe effects. :^)fh(i'larg(t
use of acids a^z^^e^Cfw/^onthe syst^ini;mii$t:be
sufficiently obvious ^t^.,eyqry^, one/ r No. Q|ie who
has had. frequetit opportunities of Qbperviing Jiie
several changes Xo which . arthritics a^ j^subject;^
can. have failed to notice the frequency with which
the paroxy^n}? of t^fje. gout , have succeeded^ ; iii a^
v^ry short space of time indeed, after the t^d^in^
. freely of ^substances of this, kind« . , , >

« • >

But no. one has treated this , ^iibjept^ M(ith fio
much propriety and force as Dr. Cadog§4i hfM
done in that work, wliich, for it S:^ benevolent \^i(eal
and high degree of utihty, has the strongest clp^in^^.
on the gratitude, not only of the arthritic^ bu.t ^f
almost every invalid sufferer under diseases . of ^,
chronic kind. The observations of the Pocjior qn.
this point are in such strict accord^ce with tho»^: ,
principles, to the establishment of which the jai*-;
guments in this work are directed, that the incli-
nation to adduce them here as corroborative evi-.
dence could not be resisted. — " The nature of
most' chronic diseases, and their first symptojn,,
heartburn, as it is. commonly called, plainly shew

the original cause to be acid crudity prevailing iii
the juices ; producing cibagulations, concretions,
and obstructions pf various kinds ; all which are
Y6iy matkiieBt in the gout, rheumatism, stone, and
most nekVoQs cases : the rem^ies also, that some-
times r^liev^e' and palliate, confirm this ; ^ctv as
the volatile alkalies,' hartshorn, sal ammoniac,
testaqeotis pbwders, sope, &c. Many -may be

they have^ these diseases, ;th^y take little or no
acids : but there are many thihgs they take that-
are acescent, that is, that are liable to become acid,
especially T^y the beat of the stomach. This they
are not aware of; but they are in their nature
iHuch m(H*e prejudicial tfian things already sour;
fop; besides that people take not these in jany
q^iai^tity,^ the acescent never become soui but by
the act of fermentation, which, being raised in
the stomach, where it ought never to happen, pro-
duces strange tumults, wind, vapour, gas, that
is, that Fume arising from fermenting liquors of
any kind, which has been known sometimes to kill
at a stroke. It may here be necessary to enume-
rate some of those things called acescent. These
are sweets of every kind, puddings, cakes, pastry,
creams, confections, &c. and every thing made
of iBour, especially fermented ; bread, in particu-
lar, so far from being the wholesome thing many

\mt' hy the; strong fernQent it contaiisEt, jit ftrbet^
into fenoentatton ewry thing ^psdble^ttf 'it iifeoEt/it)
in^S'WritJxin thest<»nacb; ^Inthisl^Miipemaifc)
^so <?ofisider most sorts c^ seaAmings^v^sttiffihgc^t

fi^rcemeats^ and . ooilnpotrtiided^ sauces** > > > Bat the»
^atest aceSoent^ xM^ rather bane <tf all; h^ apd
lavir^inch and otherwise^' whoever •jthef> are thafc'
t^ke ii coDstandy^-^fis wine: wine '^fone pi-odoces^
more i diseases, than idl the* other causes -put togii^
ther; AH men' alk)^ that wine- takeii t6iexcess Ui
biirtib} ^:tbey see theiidinediate e\dls that^foObw ;>
but distant effects, that require inm^ilittentvrel
and deducive observation, very few see or be-
lifiv^; ikikl, jndgio^ from presefrt and agreeable
fadings,; they say that a little wmQii0.:wtthoIesome
andg^od fpr every one, :and aococdi'tiglr^ t^e it
evexyd^y^ give it theirxchildten, abdjbeacbthenii
to^like i|;y by debauching their natural %aste in the
eariiest infancy*/* t Vj >

Muck applimtion to study or humieis is very
justly placed by I>r. Culien among the occasional
cauaes, of gout. It is not by medical men alcme
that the fact must have been repeatedly observed^

* ATliissertation oir the Gout, &c. by WilKam Cadogan,
?elt!>w of the Co] l^ge of Physicians, p. 49. *

tHsrf amocNis emjdojnnent of the mind has a strong
wad direct tendency to impair the functions of the
digestive organs. The observation must have been
oiten macte by others^ that vomiting, disorder of
the bowels, heartburn, and sour eructations^ are
llie frequent consequences of the occurreneie of
Auv circumstance, which suddenly calls the mind
into tuixious and distressing exertion* No hesi-
iMlioa therefore can be necessary in resolvmg,
UmiI this cause is one of those which contribute^
ill n considerable degree, to the generation of an
^Htl in the -Stomach, and to its subsequent preva-
lence in the system.

• Having now enumerated and examined those
iuH3wional causes of the ^gout which promote the
Ibrmation of acidity in the prima vice, it is neces*
Wiry to attend to those exciting causes, whose
noxious influence is exerted, in checking, the
ilmlmrgc of the superabundant acid from the
nyntittu.

That the urine is intended to carry off a large
profKirtioQ of the superfluous saline particles from
llir iiO<ly, and that it naturally manifests a pre-
ilmriiriant acidity is well known ; but of the cir-
rurfi^tarires which direct the proportion of acid
y^UUtU thus enters into the compositiou of urine
iuitbiog has beea yet discovered : no success.

therefore is likely to result^ from an attempt to
discover what circumstances act as eXQiting causes^
by preventing the discharge of the morbid excess
of acidity by this channel. But the strong acid
perspiration which is, generally, separated by the
inguinal glands, the proihse acid sweats to which
arthritics are iiubject, and which is particularly
found to exude from any part, suffering under
gouty inflammation^ plainly shew that the cuticu*
lar pores are channels, by which the superfluous
acid may be ejected. The presence of acid mat-
ters, in the discharge by perspiration, is much more
obvious than in the urine ; from which much use-
iiil information may be derived, respecting the
proper time for promoting this discharge j since
happily the circumstances, on which the ^diminu-
tion, or increase of the discharge pf perspiration
depends, are much under our power. An inquiry
respecting the influence c^ these circumstsmces,
as exciting causes of this disease, is, therefore,
particularly requisite.

The ceasing of usual labour^ cold applied to
the lower extremities^ and night watching^ are
mentioned ^by the illustrious Cullen^ among the
occasional causes of this disease; but without
pointing out the mode, in which they produce
th^ir effecis on the system.

The efifi^ of exercise ia promotkig perspifatioa
hi sufficiently ki^own^ and onlj a very slight de^
gree of ooasideration is necessary to determine
that the cessation df dccustamed labour most be
^succeeded, by the retention of much excvemfm^^
itious matter^' which had been used to be dift*
charged by the emiuaictorie$ of the skin. During
the regi^r exercise of Khe labourer^ the ebciida*
iion of a saline matter takes place from the gcn^
tsi sur&oe of the body^ whilst the inguvna and
ortV/^y with the feet, pour out a matter, frequently
so affensive to the smell, as to leave little doubt
of the salutary consequences of its removal. In
proportion to the degree of laborious exertions
will be, in general, the quantity of matter thu9
disdmi^ed, and the votatility of its effluvia ; not
bat thc|t it frequently happens, that a consideraUe
difference, in both these rei^ects, wiH arise from
'Origin^ difference of constitution. It would
be difficult to specify aH the infurious conse-
quences of the suppression of such perspiration,
by the cessation of usual labour ; bqt that the re-
tention of a morbid^xcess of acid, is likely to be
one X)f the misdiiiefii thereby produced, cannot, it
M ^resumed^ be difllGidt to conceive*

Sf ihe application ^fcoM^ io the i&tver exire-
mitiesy the ' perspiration must h<e considerably

^ V

41 \

checked^ at leasts in the limbs to which the cold is
applied. The discharge of perspirable matter
from the feet and from the groins, so essential,
doubtless, to the welfare of the system, must be,
in a great measure, thereby prevented; and in
proportion as this takes place, the morbid ac-
cumulation of acid may be formed.

During the hours of sleep in bed, the rest of
the body, and the texture of the bed clothes, al-
low of the accuntmlation of heat and of vapoar.
Which must very much ^omote ihe flow of the
matter of perspiration. Night watckingy on the
contrmy, must diminish the perspiration, and thus
be productive of similar injurious consequences, i --
with those exciting causes which have been just
enumerated. Wheii it is accompanied^ at the
same time, by sludy^ the exertion of the mind
may iiiduce such a derangement in the frinctions
of the stotkiad), as may occasion ^indigestion, &c.
In this mamier then may this cause be considered
as disposing to this malady in two ways: by
promoting the formation of acid in the stomach,
and by preventing its discharge from the system,
by the coticidar anunct<me8.

JE «

*?(

CHAPTER III.

EXAMINATION OF THE SYMPTOMS— THEIR AGKEEMEMT
WITH THE SUPPOSED PROXIMATE CAUSE.

A TASK of some difficiilty presents itself in the
fidlowing chapter. — ^The examination of the se-
veral phenomena preceding^ accompanying, and
succeeding this disease, with a view of ascertain-r
ing their agreement with its assumed immediate
cause.

Among the circumstances most remarkable,
previous to the coming on of the paroxysm, are
the diminution of appetite^ flatulency y sour firucta-^
tionsy and other symptoms of indigestion^, shewing
that the functions of the stomach are more or less

• • •

disturbed. After what has been already said,
respecting the probable origin of the acid, ou
which gout appears, to .depeQd, it oguiot be ne-
cessary to make any remarks here^^on the obviom
connection between these circumstances, which
acccHnpany the formation of that acid, and the
subsequent disease.

The frequeiit nutnhness, which alte^nat^s with a
sense xif prickUkg along i the zvhel^i^Jhe lower
e^tremitiei ; the frequent crumps-of the muscles qf
the legs; 'the unusualitirgescence oftke veinsydnd
the eji^treme. coldness of the legs and of thefeet^
are symptoms so equivocal ,in their naijure^ as tp
allow no more to be. said, respiting tbepi^ than
that they probably result from ^ peculiarity of
structure, perhaps hereditary, in consequence of
which the blood is not propelled through the
lower ej^tremities, with that powier .and efficiency
.which is, accordant with health. ^ ^

f ■ • . ■ ,

'The ceasing of a stoeating zohich the feet had
jcqnvrnonly been affected ivith [before^ is placed^ by
Cullen, among those symptoms whiqh generally
prece4e the paroxysm. The matter whiqh is se-
paratqd from the feet by sweating is well known
to possess frequently a very pungent odour. The
acrid exudation from the feet has been particu-
larly taken notice of by I>r. Hulme ; and " if,"
Cullen remarks, "this happens, especially in scor-
butic persons, it will be a remarkable proof, that
. jp scurvy the fluid js suffer a coni^iderableK:hange^.'^
With at least an equal degree, of reason it may be

* First Jineis. I»I.i)CCC.XI.

6a9d> tfadt in gouty habits^ iti iirfiidi acidity is
l^^valent^ end in whioh the pef^ration is xiftftk
l>bviouidy su^id, the fiuidi? haye suiSered a peculiar
chBSkge. The ceasing of a Sweating which the
&et had commonly been afiS^ed with before^
takitfig jdace a little thne previouis; to the coiiiifi^>
Wi of the pdiroxysm/ also shews that 6<mietbiiig
Was therd>y retained, which proved in scmie way
^efiScient in prod^tcing the disejM^e.

Tlfte gout seldom 'iHtacks pets&ns emplbyed in
constant bodily labour: This wdl known feet is
by no means difficult of explanation, on principles
agreeable to the theory of this disease, which has
l>een here advanced. Perspiration, as hss heesh,
already observed, aj^ears to be one of the destkied
latieahs ^f discharging, tiot only any excess <rf sa-
iine matter, which naturally belongs to the 9f^
tern, but also any inbrbid saline acrimony, which
the kidmes have failed to separate and remove.
That conistant bodily laboHr will consideraMy
"promote tt»is salutary process cannot be deiibted,
wtten it is <!?onsidcred, that not only the quantrty
of the matter of perspiration is considerably in-
creased thereby, but that rtie proportion of acrid
and offensively odorous particles, which are thus
discharged, appear to be also increased*

\ s

liis l^ifaequent am&i^ theife'pe^pte who make
no nse of mine oir other fermented liquors.^ This
is a &cty strongly CcHToboratoiy of tbs arguments
whfcb have been adduced in &your of theprodd*
mate cause ftf gout^ which has been here assjumed.
It Jias, however, been already so fully consi-
jdered as not to render it necessary to dw^ on it
in. this place. Arguments of some weight might
aisQ' loe^duced from other points in the history^
€^ gout. The leai &eiquency with which females
are affected with ti^ disease than males, may
fiiirly be attributed to the mifch smaller quan^
thy 6£. wine which they drink thanmen. It^most
frequent appearance in the spring may be attri-
buted to the detention and accumulation of those
(ddetieciou matters, by the action of the cold of
the pieeeding winter^ whidi in warmer weather
obtain ;theii! escape with the matter of pei^i-
rntiop.

The deposits of urate of soda on the joints^ pe-
culiar to this disease, afford almost demonstrative
evidence of the propriety of the opinion proposed^
respecting the proximate cause of this disease.
This opinion also derives considerable support,
from the identity of Constitutions, in which gout
and urinary calculi occur ; manifested by the fre-
quent occurrence of the two diseases in the same

person/ at different periods of life, and by the ex-
traordinary facts of some of the children of a
gouty parent being hereditarily disposed to gra-
vel, and of some of the children of those subject
to urinary calculi becoming the victims of gout^

Many other points, in the history of this disease^
are purposely omitted to be noticed here, in aon^
sequence of their being of sa equivocal a kind^ as
not to be at all decidedly favourable to any par^
ticular theory. No circumstance, however, is
here passed over from which any argument cdiild
be expected to^ be derived, which would militate
against the assumed origin of gout.

The phenomena accompanying this complaint^
during its regular progress, are. chiefly ref^aUe
to tbq inflammation which chafacterizes ithe pa^
roxysm, and do not therefore allow of any. partis
cular explanation, derived from the peculiar nature
pf the real pi;oxiraate cause of Ithis disea^. It is
not, how^^ver, meant to admit, that none of thes^
phenomena bear evidei^ce favourable to the opi-;
nion here endeavour^cJ to be supported. On the
contrary, the peculiar appearapice, — the particular
shining aspect of parts, under gouty inflamma7
tion, points out a difference between the inflam-r
^nation of ^ut and common inflammation ^ whilst

«7

tiie different termination of the two inflanimationi
also points out a difference,^ which admita of an
easy explanation, if the prpposed theory ^sspecting
the proximate cause of thii^ disease be admitted.
The natural termination of common inflammation
is the secretion of pus ; but in gouty inflammation
pus is hardly ever formed ; but, perhaps, in every
case of gouty inflammation, more or less of a pei-
culiar saline substance (urate of soda) is deposit^
ed ; being the morbid secretion, proper to this
species of inflammation. In the dase already de^
scribed this morbid deposition had taken place in
various internal partsi and, consequently, it is
concluded, that each of those parts had been the
subject of gouty inflammation.

• M

Nor does the suddep shifting of the disease from
one part to another, appear in the least to militate
against the idea, of the existence of a morbific
matter in this disease. It indeed appears to re-
sult from the actual presence of a morbific matter
in the blood, and which is therefore present, where-
ever the circulation reaches, and only requires a
susceptibility of arthritic action in certain parts,
to produce its elimination, and its rejection from
the system. This susceptibility of morbid action
existing in certain parts, renders them liable to
run into^ at the same time or in succession, that

fiMliJiar BieiHbid oction^^ which is induced by the k^>
teence of that peculiar saline acrimony^ which im
^saential to the existence <^ this disease. Hence
Ibe sudden appearance of the disease, in one part^
may take place totally independent of its cessa-
tion or suspension in another. It is not howerer
meant to foe denied, that general observation has
ertablished the fact, that arthritic action will <^t€o
ht suddenly raq>ended in one part> and be as siid*»
denly produced in aome distant and oftentimes in
^cftne knportant part, whose natural actions caa^
not be impeded but with actual danger to life.
But, even under these circumstances, nothing ccm>-
trsidictory to the proposed proximate cause 9p*
pears. The phenomena,^ on the contrary, appear
to be most easy of explanation, on the supposi-
lioQ: of the presence of a peculiar morbid "saline
acrimony in the system.

r ^

i . r.

■< •■<'

CHAPTER IV.

DiAGNOSISH-DIFFESJSNCS BETWEEN GOUT ANP BBBfr-

• < . ....

MATtSM — ANOMALOUS COMPLAINTS AFPAIUSfiTI^itY
DEPENDENT ON GOUT.

W^HEN the circumstances attendant upon tibe
gouty paroxysm, and the particular parts whicft
the gouty inflammation seizes, are well consider-
ed, but little difficulty can arise in distinguishitig
regular gout from any other disease, with the ex-
ception of acute rheumatism. Between these two
diseases, indeed, a similitude often appears suf-
ficient to authorise the opinion, that they both
depend upon certain states of the system, not very
widely differing from each other. Acute rheumar
tism may, however, in general be easily distin-
guished from gout by an attention to th^ cir-
cumstances. It is generally accompanied by a
greater degree of fever than gout : it commonly
attacks those who have not yet attained that pe-
riod of life at which gout commonly appears : and
it generally, even at its commencement, attacks
several joints at the same time, a circumstance
which very seldom happens in gout.

Much benefit might perhaps result, were the
powers of discrimination to be carefully exercised
by the physician, in determining which, among
the numerous strange; lani^ anomalous diseases of
the human body, arise from the same morbid state
bf the System with that op which gout itself de-
Jifehd^; Morbid affections, referable to this class^
are probably much more numerous than at pre-
sent is supposed. In habits in which the gouty
>4j^tt)esis prevadls> but in which, the gouty inflam*
pDfif^tion does. not attack the feet and hands in the
i^su^ manner, different parts evidently become
J^blq to, painful affeqt ions, bearing a peculiar and
4istijnctjve character from tl^ose disea3es of these
p^rts vvhich are already known^

» i:

,;; The celebrated GuUeip has particularized ipost
of the symptoms which take place in the atonic
j$tate of goiit ; in which, although the gouty dia-
thesis is prevalent, no inflammatpry affection of
the joints takes place. ' In this state the i^toipach
often . becomes affected, and loss of appetite, in-
digestion, flatulency, nausea, vomiting, with se-
vere pains in the stomach, are produced. In the
bowels also pains resembling those of the colic,
with great irregularity in passing the fseces, aqd
various affections, difficult to explain, are found to
occur. AVith these affections of the aJimontary

canal^ the various symptoms of hypochpn^lusis s"^
are often distressingly, combined. When the vif^ ,
pera of the thorax become the seat of the dis^ase^
the patient puffers from palpitations, fainting^*
s(sthma» &c. When the head i$ affected^ giddiness^
head-ach> a^p)exy> and palsy t^ke place.

. : . ' -w •.. :.. .: ■;:. ■ . • .. •

The differ^it forms of 'this Proteus-lik^ disease
are by no nieans thoroughly known : so varioim
and so deceptive are its appearances, that in everjr
case, in which the gouty diathesis is known to be
prevalent, and in which the inflammatory affec-
tion of the joints does not take place, every mor-^

' • J '

bid affection must be considered with the most '
careful exertion of the judgment. The circum-f
stance .which most particularly renders this attei)-r
tion necessary is, that those affections, which pcpjr
ceed from this cause, bear a most close resem?
blance, in their symptom9, to the genuine acute
inflammation of the same parts, whilst they differ
from it as much as the chropic does froip thci
acute rheumatism. In making the necesS9.ry di^i
tiinction, it. may be useful to bear in mfnd, that, i^
these complaints^ th^ fever is very inqonsiderabl?^ ^
and that the symptoms are much less violesntiancl
the progress of the disease. much more $low, thw
in active inflamniation. . / '

The inflammation which takes place in these
cases^ appears to depaid on increated action, ao
ccmipanied with dkninii^ed power, and^ perhaps^
maj with propriety be termed el»xmic inflam*^
mation. To this class of diseases may bereferredj
perhaps, that affeetion of the diest^ dimominated
angina pectoris. To this kind of inflammation,
it is very probable also, that hjrdrops pecjAoris
frequently succeeds. An instance (^ this appears
to have occurred in the following case.

A gentleman o( the temperament to which gout
is supposed most particularly to belotig, and
whose father had suiflfered from gout, but in the
latter part of his life had been asthmatic, was at*
tacked at thirty-eight years of age with gout*
His indulgence in wine had been moderate and
uniform^ a few glasses daily, but rarely to excess.
He had experiencefd, for the last two oir three
years, < a considerable portion of distress and
anxiety, from which he had nbw obtained re-
lief. Hie attack of goiif, which was in the foot.
Was but slight, not confining hiiq more than a
week. In about four monthi^ after thi^ attack of
gout, he had a severe return of deep-seated pain, .
ill the middle <rf the thigh, when^ he had once or
twice experienced it, previous to his attack of gout.
This by rest, warm fomentations, and sudorifics, was

lemoved in less than a wed^u la three weeks tinio
after this mi acute pain sei^^ him in the loiaifiy nf
the same side> aecempaaied b}r a slight degree <if
the pain m the thigh. Hie pain in the loins being
sttpposed to proceed from graveU the meam
thoagfat most i^^tpopriate iisere em^^ypix ia
about a week this complaiat subsided, the udae
depositing a very considerable sedimoout of a pbok
colour. In about six months from this time he
found his breath become short at night, and his
strengdi itmdi impamd : and at the end of aibrt-
iftight the breathing became so difficult at going
tO' bed, as to require his being propped up in a
sitting posture every night. He now applied for
medical aid; when his pulse being fimnd to be
very low, mid he exceedin^y weak, and no shortr
ness of breathing taking place in the day^tin>e^ a
blister was applied between the shoulders, and vi^
rioos antispasmodics and expectorants Were tried^
for a few days, without success. He was then ble^
and lost ab6ut five ounces of bloody fronat which be
experiaiced veiy great relief to his breathings
but^ at tlie B^xsiQ time, suffered a conisiderable
farther prostration of stnength. Iii ab<m|t four
4Mr five days, the shortness of breathing retummg
to as great a degree as before, it wa^ proposed U»
take away three or four ounces of blood by cupr
ping from the chest . But although the shortness

/ .

of breathing was exceedingly distressing, yc*
he begged to avoid the loss of more blood, cott*
fident that, although it might afford ^im tempo-
rary relief, the exhaustion of his strength would
be irreparable. All that was prescribed by the
eminent ph3rsician who had first seen him, as well
as by two others, proved ineffectual, and within
six weeks he sunk, overcome by the accumulation
of water in the chest.

• *

> >

Much difficulty occurred in determining the
nature of the foregoing case ; particularly at its
commencement, when, although slight or low in*
flammation was feared, the regular occurrence of
shortness of breathing at night seemed to point
out some other d^ange in the organs of respira-
tion. With respect also to the connection of this
disease with the gouty diathesis, much room ifor
conjecture remains. On the one hand, his father
having laboured under asthma, was a circumstance
which induced the patient himself, and . others, ta
consider the affection of the lungs to be purely
spasmodic, and originating in a peculiar heredi-
tary disposition. On the other hand, subsequent
reflection excites the suspicion, that the affectiw
of the lungs, as well as the uncommon affection
pf the thigh, the pain of the side, and the profuse
•lateritidus i^ediment of the urine, proceeded from

til^t iame prevalent disposition Jn the solids, of
peculiar acrihiony itl the fluids, bn Which gout
depends, of which too he hdd experifenced a sh'ght
attack.

If thii cbiijefctures advanced in the preceding
pkges fefe ^dihitted, thfen may it be offered for coh-
feideratibn, Whether the tedundant iacrimoiiy, from
Which the litic acid is derived, was liot imperfectly
elitnihated, by the slight attabk of gout, which so
spebdiiy ceased : atid, whether the succeeding ano-
ihalous attacks of the thigh, side, and Iiihgs, Were
, hot ftkrlheir tffbrtii of the system to procure the
chahge t)t sfeparatioh of that remaining morbific
ttiatter. Whether gout depends oh a peculiar
state of the sblids, or bf the fluids, will not, il
is pi-esutned, d.t all affect this question ; since it
is' hot difficult tb suppose, that the imperfect com-
plelioh bf gbhty action, or the iihperfect separa-
Itioh of a tnbrbific matter, might either be suc-
icfeeded^ by the pecutiat and anomalous symptoms^
manifested in the fbte^oihg cas^e.

Many xAher cases, ^^Viticihg; that both gout,
and its kftidred tttalady the actite rheumatism, fre-
qiletitTy ciccasion serious atf(?ctions of the internal
jiarts, requiring the uthfxost ^^xertions of diagnostic
skill, might be here adduced. Some of these will

appear in that part of this essay, which is appro*
priated to the consideration of the different modes
recommended for the cure of gout.

Repeated observatioas have shewn, that most
of those who are attacked by disease of the liga-
ments of the hip joint, after five and thirty or
forty years of age, are such as have experienced
actual podagral attacks^ or who have manifested
decided marks of a gouty diathesis. From the
observation of this apparent connection, perhaps,
originated the term of hip-gout, which is so ge-
nerally applied to this complaint ; and which from
the sciatic nerves becoming affected, and marking
. the course of the pain, is known among medical
men, by the term Sciatica. Sometimes this affec-
tion is found to amount to only slight and tran-
sient attacks of pain ; but firequently also the
attack is more severe and permanent, and is suc-
ceeded by mischiefs of a serious kind. Such an
alteration takes place in the articular ligaments
of the hip, as is productive of a considerable degree
of lameness, and a great degree of pain upon exer-
tion during the remainder of life. May not this
affection depend on the same morbid acrimony,
and on the same deposition on the ligaments,
which take place in acknowledged cases of
gout?

•

To this cause there appears to be reason to at*
tribute that painful affection of the loins^ which is
distinguished by the indefinite term of Lumbago.
The circumstance of no symptom of any disease
of the kidnies^ or of any other viscus being here
discoverable^ would be altnost alone sufficient to
direct the attention to the ligaments of the verte-
bral column, or to the vast tendinous apeneurosis
spread on this part, as the seat of this distressing
complaint. The increase of pain on sudden anid
particular motion, as well as the part in which
the pain is fixed, also serves to confirm this con-
jecture^ with respect to the parts thus affected.

»»

V . 'i !

j)kpkkbkKT ON Ttf E siME State of the SYSTfiiar
AS Tfl^T WHICH PiibbubEs oSxjt. — flisTokt;

iHAGl^oSlS, &C.

*Bfesit)ES tHosfe ah(imail6ti§ iffefctiwi^, already enti:
liietated, as df)pitfeiitly aepehdmgj oii thfe i^e
stdtS df Ite fluids; as that wKich produces tegular
gout; iK^ is brie cothfa^iiit, pWbably depetiditig
on the same cause, which merits particular atten-
tion, from the frequency of its occurrence, and
the distressful inconveniences it occasions*

This complaint is — an enlargement of the
joints^ which takes place slozvlyy and zvhich differs,
in several respects y from those which proceed from
diseases hitherto described.

* Whilst this work was at press, a few days only previous
to this sheet being worked off, the author saw the advertise-
ment of Dr. Haygarth's Clinical History of Diseases. On
obtaining the work, he was surprised to find the Doctor had
there fully treated of the disease, which is the subject of thit
Chapter, and which had hitherto so much escaped the notice
of medical writers. On perusing Dr. Haygarth's excellent
work, some differences appeared between the doctor's ac-
count, and that which had D^n prepared for this work. Tq

Jf gen£x^y ^rj5t ijiaiiife&ts itsejyf ia .one of the
1^ Joints of ^he fingers* : jfche eiids of tlie bojne^
fonpipg the jo^pt bec9me sli^hf ly p^/^if J an^ P^^T
<^er, l^d a small jtjegree of enlargjepent is at )firs|:
perceiYe<J. The swelling, Yj^i^th tl;ie tenderness
an4 pain, gradually increase ; so that, at diflfereni;
periods, ipi .djifferent persons, but generally ii>
^bo\fp three q^onths, the pain and ejolargep^tent
oqqasion considerable ipcpiivenience. ]V^yriad3
of minjute h<j>jb points sometifljiies seejppL^ to be
jp^iercing the bone, whilst at other t^naes a sting-
ing seivsation pervades the .tume^ed parjt ; the
pain being considerably increased by ,the least
p^-essure. The motion of the joint becomes so
impeded by the enlargement, that the merely
closing of the hand, in its ordinary employments,
prpduces a very considerable degree of pain.

have corrected these in thfe present work, and thereby to have
produced a nearer agreement of the two accounts, might, at
£rfi{t thought, appear to be no more than was actually due to
the high professional abilities, and superior opportunities of
information, possessed by Dr. Hay garth. But a regard for
trhth requiring that the facts should be related exaptly as
they occurred, it was thought fit to present them to the
reader, with the observations they produced, as they had
been originally noted ; and to point out the more important
variations, in the two reports, in marginal notes. Theadvan-
tage of two separate evidences is thus secured.
, * In two cases lately observed, this was not the case. In
one the inner condyle of the os httmcri was first affected, and
in the other, the inten^l tmdlcolUi.

As the swelling continues to enlarge, a very
slight degree of redness comes on, and some^
times threatens suppuration, which, however,
very seldom ensues. Sometimes this inflam-
matory state, after continuing a certain time,
varying much in this respect in different per*
sons, at length subsides, when the mobiHty of the
joint is found to be much diminished, and the
swelling increased in size and hardness, but
much less painftil and tender. In this state it
sometimes continues, with the exception of
a very gradual increase of the size and hard-
ness of the tumour, and consequent injury to
the motion of the joint, during the remainder of
life.

Within a little time, perhaps two or three
months, of the appearance of this first swelling,
some of the first joints of the other fingers become
afiected in a similar manner, and pass through a
similar course : and thus most of the other fingey
joints become the seit of this malady, and undergo
%he morbid phang^s just described,

As the mischief advances in the hand, proofs
of the general influence of a peculiar morbid state
j^re evinced, in some of the larger joints, particu-
larly in ^he wrists, the elbow, the ankle, and knee
joints. But even when the larger joipts are atr:

tacked, it is not to be ascertained, in the living
subject, whether the seat of this malady is in the
more prominent parts of the ends of the bones,
which form the joint, or of the peritoneum, just
before it separates to give a covering to the capsulatr
ligament, or.in the ligamentous parts alone. Some-
times extreme tenderness, on pressure being ap-
plied, shews that the os calcis, or its immediate in-
vestiture, partakes of the mischief. This tender-
ness, which, in the first of the morning, will hardly
allow the foot to rest on the ground, diminishes
after the pressure has been repeated, during walk-
ing, for about half an hour. Sometimes the tender-
ness, accompanied by a slight degree of enlarge^
ment, exists at the back part of the os calcis ; and
in one case a knotty seam-like hardness was disco-
verable in the tendo achillis, which very much im-
peded the walking. A hardness somewhat similar,
with an indentation and contraction affecting even
the integuments, is also sometimes obsei'ved in some
of the flexor tendons of the fingers, in those who
possess the diathesis here described. When this is
the case, the conesponding finger will always be
found firmly contracted, in proportion to the irir
jury which the flexor tendon has experienced.

Frequently the bones of the feet become so af-y
fected, as to occasion great difficulty and pain in'

72 .

walkings which is only performed^ in a mann6F|
which renders the crippled state of the parts very
evident; giving the idea to the patient of thQ
metatarsal bones, which form the arch of the fopt^
being crushed together by the pressure of the
body.

After some time most of the joints, and, wit]>
the rest, those of the spine, partake of the pre^
vailing disposition to rigidity ; so that at last the
flexibility necessary for performing the most sim-r
pie offices in life is lost. Thus crippled, the
unhappy sufferer sinks under liis calamity; his
various incapacities, proceeding from his inability
for motion, giving the idea of his being premar
turdy afflicted with the decrepitude of old age.

The persons who appear to be most liable tq
this complaint, are those to whom its injurious
effects must prove most particularly afflictive.
iThe Jabouring poor, whose hands are their only
meansof support, appear to be the most frequent
sufferers by this malady. A slight and transient
injury to the hand is, indeed, a serious injury to
the poor; but a disease which thus entirely
destroys its powers, renders the situation of its
victims truly deplorable. They toil on, depressed
|>y observing the daily diminution of their ability

••>

^ L^rious exer|;ipfi^ aud are at lasjk mourf^ftdly
pbliged to si^bmit to repeive frpn^ ph^rity^ t|i^
^j^pport, wl>ich t:heir haoids can nip longer procure
l^h^. '^he ex^min^ipn of tha inn^tfs^ of thq^e
Jioui^^s which fecieive tjje parochial popj*, will ge*
ijerally shew sufjT^jent proofe of thp prevalence of
fhis ixwiady. Mar?y will bp Ip^nd driven thither
^ho still possess a considerjahle portion pf con^i-'
tutional strength, but who, jtl^i^s piaiipeid,a re eur
tirely deprived of th^t ])Iessing to an independent
spirit, the power pf suppprting tfjenjselves by
their own exertions^.

The misery which this complaint sopo^imesJ
inflicts, is thus enlarged upon with the hope of
exciting the attention of medical men towards it,
and of inducing them to make Jciiown, in their
respective circles, those observations which paay
^p likely to prove beneficial in mitigating evils,
which must be so severely afflictive to the poor*«

* Dr. Haygarth gt^serves^ that '* these noijes more coxor,
inonly attack persons in tugher and middle^ than in thi^
lowest class of life. However^ it is not exclusively a disease
of any rank : I have seen it^ though seldom^ among the pa^
tients of the Chester Infirmary/' Having first particularly
attended tf> this disease, in consequence of finding myself
the subject of it, I made pretty diligent inquiry respecting
it, and found it exceedingly frequent ftmong the parish 9g«idi

The partictdar .enlargements of the ends of the
bones here described, differ sufficiently from those
which take place in scrophula, to allow the dis-
tinction to be very easily made : they occur much
later in life than the latter ; the tumours never
acquire that magnitude, nor that soft and pulpy
feel ; nor does the skin possess that glossiness and
redness which are observable in scrophulous tu-
mours ; neither do they, except very rarely, ter-
minate in suppuration. They differ from those
tumours of the joints which proceed from external
injury, and which generally accompany a carious
state of the bones, in the pain and tenderness, as
well as the inflammation and tumefaction, exist-

poor ; which led me very early to make the conclusion^ that
it existed most frequently among the lower class of the peo-
ple. Subsequent observation has undoubtedly shewn^ that it
is not so much confined to the poor as I at first imagined.

Dr. Haygarth also remarks^ that *' out of the number of
cas^s which he had witnessed (thirty-four)^ there was but
one man.'' It happened^ as has been already remarked^ that
I was first led to particularly attend to this malady, by be-
coming subject to it myself: since which I have certainly
seen it in several males ; and have lately seen a node* of this
kind on the third joint of the finger of a gentleman, which
had began to assume somewhat of a pellucid appearance.
Recollection, however, confirms the fact, that these nodes
more frequently happen to women, and, agreeable to the
Doctor's observation, seldom before the period when the
menses naturally cease.

.■i-.

Ingin amuch less degree than in those. Whethei'
they differ essentially, or only in degree, from
those tumours which are formed by the gouty
concretions, does;iot appear to be certain. The
iirst appearance of the chalk-stone, as it is termed,
is not unlike that of these tumours ; but in gene-
ral the gouty concretion becomes much sooner
pointedly prominent, the morbid matter is more
rapidly deposited ; the integuments also become
pointed and shining, and soon become extremely
thin and then ulcerated, allowing the gradual escape
of the deposited matter. But in the tumours, to
which our attention is here particularly directed,
the tumefaction, instead of soon becoming promi-
nent, preserves the general form of the end of the
bone, thus enlarged, the integuments undergo but
very little change, and, as has been already ob-
iserved, suppuration seems rarely to take place.

The only instance, at present known to the au-
thor, in which this species of tumour had proceeded
to suppuration, was in a female about fifty years
of age, a maniac, and in a very infirm state.
Suppuration had taken place on five of the finger
joints, and in one knee, in every one of which
the ends of the bones were so carious, as would
have rendered amputation necessary, had she not
^e^i^ in that reduced state which forbad it. The

]J|^aAgeme|)t of hef piind w^ ^npl\ as pr^v^^
ijejr fumi{sdiing ^ny account .of the prigin of-t^i?se
Rumours, tb^ ijnflawnatioi^ ^d suppuration f^
lijrijich was ajttribjutefj to her haying l^een ,copt-
^$tantly exposed to considerable cold, during t^
preceding winter.

Pr. AVilliam Heberden made the following bri^
j^paarks on these tumourjs, to which he Jias ^
pigff!^ a chapter in his most excellent work.

*' £)e Nodi's Digitoriun. — Nunquam rite in-
t^Ilexi n^uram tumorum, qui interdum nascuntm:,
1^ pisi magnitudinem, prope tertium di^itorum
artiqulum. Nihil certe illis commune est cum
^hritide ; quoniam in multis reperiuntur, quibus
morbus ille est incognitus. Per hominis aetatem
manent ; vacant omni dolore, neque spectant ad
exulcerationem. Proinde deformitas major est,
quam iacommodum : quanquam motus digitoruip
impeditur*."

The observfiti^o^is 9f Dr. Heberden diiFer in
so](ne i:espects from those which have been oflfered
jin the preceding pages. On this difference it

♦Gulielmi fleberden Commentarii de MarborumHistoria
J^ Curatione, . .p. ipo.

#ill fte ilScessary to ma&e d fe^ rettiafkS. Hie
Doctor speaks of these tumors, as existing only on
the third joints of the fingers^ which -may be ,
accounted ibr from the circumstance of their al-
most always making their first appearanpe oa
tliose joiritjl; some months, and even sometimes
yearn, elapsing before they appear on the second
series of the finger joints. Although it is un-
dbiibtedly a fact, that they are often to he found
bit those persons to whom gout is unknown ; yet
they often exist where gout has manifested itself,
in some slight attack, at some former period.
This has appeared to be the case, on inquiry of
several h&i-ia working people, who had no idea oif
having been honoured by a visitation of gout ;
biit who could remembier, iat 6ome former period,
having a slight redness, with pain, on the instep or
^nkle, which they had considered merely as a
sprain or rheumatism. The Doctor speaks oif
these tumbui's as being entirely free from pain ;
t)ut that they are sometimes painful, giving the
sensation which excites the idea of stinging
and burning, the author's own personal expe-
rience has proved; biit this is not constant,
arid, pferhaps, does not exist until after the tu-
tnours have attained a certain stage. These
differences being thus explained, no doubt can
J*(^inaih that the disease, noticed by Dr. Hebejr-

den, is the same with that to which this chapter li
devoted.

In a disease, the observations respecting which
have been made by so few persons, sufficient facts
do not aippear to be yet collected, to allow the
forming of a well-founded opinion, respecting the
causes on which its existence depends. Consider-
ing, therefore, that, in this state of our knowledge
respecting this disease, conjecture is excusable^
the following suggestion is oflfered.

It has been already endeavoured to shew, that^
from certain errors in the modes of living, a pecu-
liar saline acrimony is engendered in the system j
from which, during the paroxysms of gout, a de-
position of a peculiar saline combination is formed,
on those parts which become the seat of gouty
inflammation. It also appears that Nature has
appointed other outlets for this morbific mat-
ter, such as the kidnies, and certain emunctories
on the surface of the bod v. Besides these, it is
conjectured, that when the morbific matter exists
in less abundance, than in -those habits in which it
excites gouty inflammation, the periosteum, or the
ligaments, or the ends of the bones themselves,
may assume the office of slowly secreting from
the system, and of depositing that matter which.

if allowed to accQinulate> would, perhaps, deman4
for its removal the more violent and more €s;ten<^
sive action, which constitutes a fit of the gout<
It appears to be rather confirmatory of thj^ con-?
jecture, that this affection of the finger joints has,
as in the author's case, been found to take place
aflber the ^tacks of gout in the feet have been
suspended. Another circumstajjice, which also
tend$ to confirm the conjecture here offered, is,
that the persons whom this disease generally at-
tacks, are those whose chief drink is malt liquor,
or those who drink sparingly of wine, and whose
fluids, therefore, may be expected not to abound
so much with the uric acid as those whose indul-
gencies are less limited. All this is, indeed, but
conjectural. The suggestion is, however, admitted
here, since the arguments which may be employ^
in lis subversion may serve to erect a. better
founded and more useful fabric.

The plan of treatment which has been adopted
for this malady, it is agreeable to observe, has, in
the few instances in which it has been employed^
been generally successful. The assumed indica-
tions on which the removal of these tumours were
attempted are, — 1st. To diminish the increased
action of the vessels, in the part, by which the se^
icretion of the morbid matter is performed : 2d|y,

l*tt promote a free perspip^ibh bf the jpaH; alferta
. efl : aridSAly.To correbt tHfe prevailing dis^sritibtt
toaddity in the primae vlSs, ihd iti th^ s^rsteih
in gifeheml'.

t «

Thb lii^ahs ivhifeft it Has ttefeii thought pii^per
hithi^rtb td enij^lojr, fbr thie iccbiiipli^hmerit of the
fiif^t bf theSJe objects j has befeii the iipplication of bn6
6t more l^chfei to the tnihefieci part ; the riuttiber
erf leeches BSiAg deterinihed by the extent of the
tuihour dhft degfeb of the disbase. To obtain the
object bf the isecoild ihdicdtion; the part has beeil
fttHTdtifidW by d pllalster of eqiial parts of simple
diachylbn aiid bf ^hile soap, the adhesion of which

to thb Sklii bbcortiiss in a few dijs isb slight, as to
adinii theffeb exit of the perspirable matter through
the ^nt^hibh, hindered from escaping farther, con-
denses bn the surface of the plaister. By this
application the part is kept continually moist',
frequently so strictly so, as to appear on the re-
moval of the plaisteh, after two or three days, as
if it had been to lon^ ^bddened in hot water; To
fulfil thelhirdiAdicAtion, adhe attentfoh h^isbeeh
advised lo thb ilibde bf living, by avbidin^ acid and
Acescent matters^ aM partictllarly ifeuch fermented
liquors as have begAh to manifest hlarks of aces-
Ciefricy : in a word, the regimen here particula-
rized, as appearing lb be best calculated for the

gotity, hsjA been enjoined. To neutralize that
Acidity which, being present in the stomadi, would
secure its increase, by acting as a ferment, the
soda, has been given in doses from five grains to
ten or fifteen in the day.

From the combined influence of these measures,
the utmost success that hope could look for has
been obtained. The gradual diminution, and,
finally, the complete removal of such tumours as
have existed for several months, have been thus
procured; whilst those which have existed for
some years have been so much reduced, as to
allow of considerable motion in joints which had
become nearly immoveable.

Ih the author's case, a node of this kind was
removed from tlie last joint of the third finger of
the right hand, which had continued upwards of
twelve months; as well as one fromjthe last joint
of the first finger, and one from the last joint of
the second finger of the same hand, one of which
had existed about six, and the other about three
months. One was also thus removed from the
last joint of the thumb of the same hand, which,
although it had not been more than a month
forming, had acquired considerable size, and ap-
peared to be making a rapid progress.

Soon after the appliication of the leeches^ the
sensation of lieat and stinging in the parts ceased^
and the tumours , became nearly free from pain.
In some of |Jie tomours a slight diminution soon
became perceptible, as if the deposition of the
morbid matter having ceased, with the increased
action of the vessels of the part, the continued
ordinary action of the absorbents, was suffieiextt
to carry away that portion of matter, which had
been already deposited. In other tumours of
this kind, although the pain was thus removed, as
well as the inflammation of the integuments, stiH
their size remained unchanged until the soda had
exerted its influence on the system, when their
diminution evidently took place.

In a female, about fifty years of age, the bene-
fit of this plan was very evident : the joints of the
fingers were almost all considerably enlarged : the
insteps suffered considerable pain, on the feet
being pressdd to the ground, proceeding from the
enlargement of the lower ends of the metataFsal
bones : considerable pain was also occasioned by
every attempt to walk, owing to a tumefaction of
the lower ends of the tibiae. • Frpm these causes,
.which had existed eight or ten years, but which
had considerably increased in the last three years,
she was able to.walk but little more than.a quarter

of a mile at a time, and that with a great degree
of pain. Leeches were applied to the tumefied
parts, and repeated about every ten days, and
twelve grains of soda were taken every day for
about a month. At the end of that period the
amendment, which had commenced after the first
week, had become so considerable, that she was
able to walk two miles, and return, after three
or four hours resting, with but very little incon-
venience. After this, she repeated the leeches at
more distant periods, and took the soda in smaller
quantities, under" which plan she continued to im-
prove so much, that, to use her own words, she
seemed to be made young again. In fact, the
change she experienced was so great, being re-
leased from pain, and rescued from what had been
deemed the decrepitude of age, that a total
change took place in her habits ; her long hoarded
dresses and ornaments were resumed, and her old
acquaintances were again vii^ited. Her spirits,
naturally good, but which had been depressed by
pain and confinement, were now rallied ; and a
considerable degree of hilarity manifested such de-
Kght, as might be expected to be felt by one who
had, as it were, shaken off those infirmities which
she had expected to continue during the remain-
der of her life.

N •

CHAPTER VI.

INDICATIONS OF CURE IN THE GOUT — ^TO PREVENT
THE FORMATION OF THE MORBID ACRIMONY — TO
REMOVE AKD correct THAT W«ICH ALREADY EXIST8

TO REPAID THE DIMINISHED STRENGTH OF THE

SYSTEM INDICATIONS DURING THE FIT.

Agreeable to the various opinions which have
been entertained^ respecting the nature of this
disease, have been the different conjectures re-
specting its cure. Those who have believed gout
to be an aflFection of the nervous system, depend-
ing upon a certain general conformation and state
of the body, have consistently believed that it was
not very probable that it was curable by medi-
cine. Those also who have believed it to depend
on a certain unknowa morbific matter, have also,
with equal propriety, conceived.it to be incurable,
until the real nature of that morbific matter was
ascertained.

The experiments, however, of Dr. WoUaston,
have, as it has been shewn, determined the nature

of the peculiar morbid matter which is formed^
and secreted^ in gouty habits 3 and hence the nar
ture also of the peculiar acrimony from which that
matter is derived, and on which gout itself de-
pends, may be conjectured, and, perhaps, with a
tolerable near approximation to certainty. On these
grounds, it is presumed, that the cure of gout is
to be attempted on new principles, and with a
much greater chance of success, than heretofore
there could have been reason to expect.

The various phenomena which constitute gout,
and the several circumstances which have been
enumerated as its remote causes, lead to the
adoption of the following indications of cure dur-
ing the intervals of the paroxysms. First, Tq '
prevent as much as possible the formation of that
peculiar saline acrimony, on which the disease has
been supposed to depend. Secondly, To p^po-
cure the removal and correction of so much of
this acrimonyas may be already formed. Thirdly,
To repair the diminished powers of the system.

Whilst endeavouring to comply with *the first
indication, by preventing the formation of that
peculiar saline acrimony, from which this disease
is supposed to proceed, it must be considered
that this acrimony appears to be connected with

the formation of a peculiar acid^ the uric, which
most probably derives its constituent principles
from that acidity which is formed in the stomach,
and iBi •afterwards admitted into the circulating
mass.; Great caution, therefore, appears to be
necessary in the selection of such articles of didt
as will best agree with this indication.

Having already pointed out the injurious ten-
dency of loine in promoting the formation of the
gastric acid, little more need here be said than to
remark, that in several instances, where its em-
ployment had been suspended, benefit, proportion-
able to the length and rigour of the penance, has
almost always been expei'ienCed. A gentleman
of considerable respectability in the city, about
forty years of age, whose father was much tor-
mented with gout, had enjoyed a good state of
health until about five years before, when he first
experienced an attack of gout in the foot ; which
was repeated within the twelvemonth. After
this the fits became so frequent and long, that
no sufficient time occurred between them to
admit of the recovery of strength. Hence he ap-
peared to be hastening, from the continual short-
ening of the intervals, between the paroxysms, and
the perpetual increase of his debility, to a state
pf permanent lameness and disease. His indul-

getnte al.the table was withm the bounds of mo-
deration ; and half a pint of wine aft^r his <iinner,
with a pint of porter, or a glass of brandy and
water in the evening, constituted his g«ieral in-
dulgences of that kind. With a curative intai-^
tion he had been in the habit, for about three
months, of drinking a solution of soda> highly
supersaturated with carbonic acid.

Being a person possessing a fnll share of reason
arid fortitude, the opinion which had been formed
respecting^ the disease,' and the necessity pf exact
compliance with the prescribed rules, were ex-
plained to him. He was ordered to abstam from
wiiieiarid all fermented liquors ; to drink with, tod
aft^his n^eals, in as small a quantity as'he couU
be satisfied with, spirits, very much tiiluted with
wate^; to take about f^een grains of soda (car-
bonated) in the course of the day ; to use a^ much
exercisfe, ad his strength would permit; and to eat
freely of such vegetables as should not appear to
occasion acidity in the stomach.

Anxious for relief, and aware of the necessit v
of exact attentions to the prescribed rules, he
complied With the greatest fidelity. After taking
the soda for a month, as directed, the qtiantity
was reduced to a half, which was persisted in about

a month longer. The regulations as to regimea
were, however, strictly attended tO' for upwards
of two years, during whiqh tiqie no appearance
of gout offered itself. But during the succeeding
six months, circumstances occurring which ren-
dered his presence in convivial parties more fre-
quent^ he then experienced a few menacing sen^
sat ions, which he directly opposed with the soda^
and necessary abstemiousness, and with success.

A gentleman, about fifty years of age, who had
indulged freely in the pleasures of the table, had
been the victim of gout about fifteen years, and^
du^'ing the last three years, had been cQO^ed
^y^ry three or four months, with extreme p^n,
from one hip to the other, over the os sacrum^
which left him in a crippled state in the intervals.
About twice, in this period, the disease mani*
fested itself in the feet and knees, during which
attack, and for some time afterwards, the back
^nd loins were essentially relieved,

The plan adopted in the foregoing case was
recommended in this, and was pursued for up^
wards of six months with tolerable exactness, tha
transgressions being but seldom : in consequence,
he remained free from disease, for nearly twelve
months^ when the deviations frpm the prei^rib,^

8»

rides, wh|ch at first had been bnt trifling, became
now so considerable, as nearly to approach to an
equal indulgence in injurious habits, with what
had formerly been admitted. Hence ensued a
return of disease, but under circumstances more
easy of endursmce, the pains being confined
chiefly to the feet. The relief obtained in this
case, appearing evidently, to the patient himself,
to be the result of the changes which had been
recommended, the soda was occasionally taken,
and regimen attended to, when the urgent influ-
eiice of example, and the unwillingness to act
different from those ^ound him, did not oppose
the sujg;gestions of prudence. Hence, as might be
expected, but a partial benefit was obtained j the
relief, however, evidently agreed with the degree
of strictness, with which the rules were attended

to. i • ^ ' ' f : . . ■ '

* ... • ....

In proportion to the strictness of the abstinence
fromvthe use oi wine will, in general, be found
the degree of benefit experienced. Considerable
difference also will be. found, in this respect,
from the kind of wine^ which are employed. The
low English wines, either surcharged with car-
bonic acid, or approaching to the state of vine-
gar, low cliaret, thin port, and foreign white
winea, Ibwered by English wines, appear to be

most injuridtts. Old Port, aotund, and with tbe
least possible acescency, and Madeira, possessing
similar charters, appear to be the most prefer-*
able of these ensnaring poisons.

The injnrioils efiFects o( fermented liquors in
general have already been fully noticed whilst
considering the causes of this, disease : it only,
therefore, remains to particularize again the dif-
ferent states in which these may be found, and to
point out whidi of these are to be considered as
injurious, and therefore necessary to be avoided ;
and which may safely be admitted, whilst aiming
to attain tbe cure of this disease.

As has beea already observed, fermented liquors
may be found in the state of evident fermenta--
tion ; in a state, in which sensible fermentation
has ceased, and a spirituous principle prevents its
progressicm tbwards acescency ; and in a state of
acescency, or even of actual acidity. From what
has been already said, it must be evident, that
the middle state is that in which these liquors au*e
most admissible. In the first mentioned state,
there is reason to fear injury, not merely from the
quantity of carbonic acid thus introduced, but also
from the rapidity with which fluids in this state
pass on,, in some states of the stomach, to acidity*

Tbe mischiefs likely to result from the empiojr^
ment of these liquors, in the last ifientioned
state, must be sufficiently obvious, if the nature
of the disease has not been here entirely misrepre-
sented,

Whilst endeavouring to prevent this disease, by
the adoption (rf a proper regimen, it is necessary
that the attention should be particularly directed
to one circumstance, which would not otherwise,
perhaps^ obtain that consideration which it really
demands. The general beverage at dinner, smtdl
or table beer, and which is often taken with a
considerable degree of freedom, is seldom thought
to be of consequence sufficient, to be consi-
dered as to its injurious effects 3 whilst, undoubt-*
edly, great part of that which is drank, is in a
state very ill fitted iot' tbe stomach of the vale-
tudinarian,. Unless this kind of malt liquor pos-
sess more, strength, than that which is generally
possessed by the liquor, designated by the name
of small beer, it will, very soon after the air is al-
lowed access to it, run into the acetous fermen-
tation. Frequently also, it is to be feared, that
some particular management takes place here, as
well as in the stronger beers, and that, perhaps,
sour beers are broken in and mixed with the new,
to render it fit for almost immediate use^ or to

get rid of that which, alone, would be found too
sour for drinking.

It is necessary, therefore, that those who are
disposed to gout or gravel should be extremely
particular in this article of their diet, and to re-
solve never to drink of this liquor when it manifests
aridity. The injurious consequences which result
from drinking table beer in this state are, indeed,
i^uch greater to the temperate man, than those
which proceed from faulty wine -, since he will
take, perhaps, only two or three glasses of the
latter, whilst he may be in the habit of taking as
many half pints of the former, which, probably,
is much more abundant in acidity, than any wine
is which is ever drank* Indeed it is necessary to
add, that with respeqt to these, and other similar
liquors, an acescent state is sufficient to prohibit
their use ; since the stomach, in those who are
disposed to gout, possesses, in ^ particular degree,
tlie property of converting those substances, which
are only in an acescent state, almost immediately
into a state of absolute acidity.

The observation just made equally applies to
most other acescent substances, among which may
be placed many of the articles of confectionary
and pastry y particularly such marmalades of fruits.

5md tnich fruits as have been preserved in syrups,
which have been susceptible of some degree of
fermentation. A very intelligent observer, subject
to nephritic attacks, has informed me, . that re-
peated observations had convinced him, that the
employment of such ripe fruits, as currants, goose-
berries, &c. which naturally contained much acid
in their mature state, was always sure to increase
his sufferings. With respect to vegetable acids,
particularly those of the stronger kinds, such as vi-
negar, juice of lemons, &c. if the leading opinions,
in these pages be well founded, they must be in
the highest degree injurious. It is indeed very pro-
bable, but on this subject farther observation is
necessary, that they may be even more injurious,
than the stronger mineral acids^ in which the aci-
difying principle adheres to its bases, with a
stronger degree of attraction, ^d is therefore less
likely to enter into any new combination in the
human body.

To the rational^ and to those who will give
themselves the trouble to think on the subject, it
must be obvious, that perseverance is absolutely
necessary, in the employment of any dietetic ar-
rangement, from which a cure is expected. It has
been endeavoured to sliew, that the disease de-
pends on a morbid acrimony, generated from cer-

tain errors in the article of diet : the correction of
this error nrast, therefore, bd eflfected, if the re-
currence of the dreaded malady is intended ; if
the cause be allowed to exist, the effects, must be
expected to foltow. " Can," says Dr.. Cadogan,
^ any one in his senses suppose that diseases a
man has been his whole life contracting, suid to
which he is adding every day by perseverance in
unwholesome diet and bad habits, are to be re-
moved by a coup de main ou de baguette ? or
that they will not return, be they cured or con-
jured away ever so often, whilst he continues the
same mode of life that brought them on at fiirst ?''

A debilitated state of the stomach having been
here regarded as the fountain of that acidity,
> which, by its influence in the system, produces
those various symptoms which characterize gout,
it becomes necessary to ascertain what means are
best adapted for the correction of such a morbid
state of this organ.

For this purpose, the emjrfoyment of Peruvian
bark, and of the various aromatic and stomachic
bitters, must be regarded as likely to be produc-
tive of considerable advantages. It is hardly ne-
cessary to remark, that some care is> however, ne-
cessary in the selection to be made on this occa-

«OD. This must be directed by the state of the
liver and other viscera, the more or less predomi-
nance of acidity in the stomach, as well as the
greater or less degree of irritability possessed by
this organ. Thus, in some cases, in which the
liver and its appendages may be suspected to a
disposition to obstruction, it will be found neces-
saiy to employ, in preference to tonics, those bit-
ters . which exert a beneficial influence on both
organs. In most cases it will be found necessary
carefully to remove any accumulation of bile, and
to cleanse the stomach and intestines, from any
sordesy prefvious to the use of either bitters or
tonics. In doing this, the state of the stomach
must be sedulously attended to. If acidity is pre-
valent in a very higli degree, pure magnesia may
be regarded as the most appropriate medicine : if
the stomach is irritable to excess, small but suffi*-
cient doses of the least disgusting saline purga-
tives may be employed : but if a contrary state
of the stomach is present ; if it, as wdl as the in-
testines, are in a state of torpor, rhubarb, aloes,
and particularly calomel, may be employed with
considerable advantage. Cases also must some-
times occur, where the stomach will be so obvi-
ously oppressed by the accumulation of undigested
and other injurious matters, as to demand their
immediate refection 3 then the aid of ipecacuanha.

or the still more powerful operation of an anthno*
nial emetic^ will be demanded.

The fatal consequences which have been ob«
served to follow the unguarded emplo3mient of
bitters and tonics, by the subjects of this malady,
requires to be here particularly considered.

Dr« Cadogan, speaking of the Duke o£ Port'-
land's powder, long celebrated for its efficacy in
curing this disease, says. What was this medicine,
and what did it really do ? It was a strong spicy
bitter taken in substance, in a large quantity, for
a long time ; its effect was to keep up a constant
fever as long as it was taken ; this kept tlie gouty
matter always afloat, and prevented its fixing any
where. But there was no living long with a con-
stant fever ; accordingly many of those who took
it died very soon. I myself observed between
fifly and sixty of its advocates, some my patients,
some my acquaintance or neighbours, who were
apparently cured by it ; but in less than six years
time, omnes ad internecionem casij they all died
to a man*." Cullen remarks f, that in every in-
stance which he had known of the exhibition of

* A Dissertation on the Gout, p. 67.

t First Lines of Practice of Physic, yoI. ii. p. 104.

this medicine foir the length of time prescribed;
the persons who had taken it were, indeed, after-
wards free from any inflammatory affection of the
joints ; but they were affected with many sjrmp-
toms of the atonic gout ^ and all^^oon after finish-
ing their course of the medicine, have been at-
tacked with apoplexy, asthi^a, or dropsy, which
proved fatal.

Considerable difficulty accompanies the attempt
to explain j why this class of medicines: should
have been found to prove so injurious, in cases of
this kind. But, perhaps, some aid may be fur-
nished by the following remarks ; the opinion which
they contain requiring the adoption of no particu-
lar theory, respecting the nature of this disease. *

It is justly observed in the useful and elegant
Commentaries of the late Dr. William Heberden*,
that since gout materially injures the stomach, so
that the patient neither desires nor digests his
food as before, it is hot unlikely tnat this disease
may be so restrained and overpowered^ by those
means which give power to the stomach, as to give
reason to hope, that although the comfptete resto*

* GuUelmi Heberden Commentarii: de Morbonim Historic
^Curatione^ pagiD,49. • -t.- ' . •

9»

^iotk of (lealth be not effected, yet much rdie£
knay b^ thus obtained. That whatever good ef*
iects resuH frcmi this mode of treatment are pro-
diuced m.thismamier, there can be little doubt.
By tbpsame action on the stomach may the i]i|tt-
rious e^t8» which have been noticed, be also thus
prodttc^d. in every one who has been long,
under the dominion of this disease, a peculiarly
delicate state of the vascular system is observable.
The vefisel$, however, accomniodating tbeiiaiselves
to tb4 q^antity of fluids they contain, which,from
the impaired powers of the stomach and .intes*
tinesi may be expected to be not very abundant^
no mischievous effects follow. But wheiit from
the powerful stomachic effects of the bitters, not
only a gffeater portion of food is taken into this
$tomach, but a greater quantity of chyle, and con-
•equently of blood, is produced, a plethQcic stute
tnay be induced j the quantity of blpcwl may ex-
ceed the powers, of the ahei^y weakened vesseU
in which it is^ contained^ whence may proceed
tho^ congestions, on which the production of
asthma, diopay, apopleficy, &c. m^y depend. A
citiQumstoace< of pretty general occurrence will
strongly t&oA to procure this eflfect. The arthritic,
suffering under considerable debility, to which di-
ppi^is^qd app^tHe and iippaired digestion has much
contributed, delighted with the restored powers of

gratification, and eager to obtain a rapid remi^tr
tion of his health, indulges his appetite without
restraint, and thi^ totally destroys his healthy
which he was confidiefiUy hoping to establish;

• a

tJnder such a course ' of stomachics, therefore,
it would be necessary that the patient should not
only most cautiously guard against the emplo}^
ment of to<!) iar^^ a quantity of food, but should
also be careful in selecting that which is best
adapted for his case. Should the stomach not be
cc^aUeof digesting butcher's meat, fowls, galme,
rabbits, and fish, and particularly shcdl fish, should
be had recourse to ; if the stomach be not equal to
these, boiled milk or iiiilk pottage, light puddings,
custards, tripe, or calves feet, may be taken*
Wine and other acescents, pickles, heating spices,
and acids, should be carefully avoided. When the
stomach is capable of taking lamb, beef, mutton,
&c. tke^e should be taken^ but in moderate quan-
titles, with such vegetables as brocoli, asparagus,
cauliflower, cob lettuce, endive, &c. remembei^-
ing that bodily exetiGisQ diould always be used»
in proportion to the quantity and kind of food
which is employed. / .

Among the remedies which have been employed
in this disease, whose beneficial effects appear to

H 2

100

depend, chiefly upon the power of correcting tte
morbid state of the digestive organs, must be
classed those substances, which possess the power
of neutralising the acidity, which is so frequently
prevalent in the stomach of gouty subjects. The
most powerful of these, appear to be the fixed al-
kalies in a pure state ; but since the causticity
which they thus possess is so considerable, as to
render them highly obnoxious to many persons,
the same alkalies, in a carbonated state; are, per-
haps, preferable. The volatile alkali also, in a
carbonated state, is a remedy which may be oc-
casionally employed, with considerable advantage,
in those cases in which its stimulant or diaphoretic
powers are also required. Lime water and pure^
or, as it is termed, calcined magnesia, may also
be beneficially employed.

> k

Speaking of this class of remedies, Culien ob^
serves : " Another remedy which has had the ap-
pearance of preventing the gout, is an alkali in
various forms, such as the fixed alkali, both mild
and caustic, lime water; soap, and absorbent
earths. Since it became common to exhibit ihest
medicines in nephritic and calculous cases, it has
ofi;en happened that they were given to those who
wete, at the same time, subject to the gout : and
it has been ob^rved, that, under the use of these

101

medicines, gouty persons have been longer free
from the fits of their disease. That, however, the
use of these medicines has entirely prevented the
returns of gout, I do not know ; because I never
pushed the use of those medicines for a long tirne^
being apprehensive that the long continued use
of them might produce a hurtful change ux the
state of the fluids*."

The following case will shew, that the caustic
fixed alkali possesses very considerable powers in^
at least, preventing the access of the gouty pa^
roxysm^ if not, in even preventing the formation
of that morbid acrimony of the fluids^ on which
gout has been supposed to depend.

CASE.
J. F. wa3 of a sanguine temperament, and bora
of parents who had not been subject to either the

gravel or gout, i His food was generally plain ;
and his convivial indulgences we|*e by no means
frequent, but wine, or some other fermented li-
quor, was at these times generally employed.
Until nearly forty years of age he had €;njoyed
almost uninterrupted health; but at this period
he was first attacked with gout in the foot s th^

* First Lines, D-LVIir.

108

fit being ancommonly severe. During the suc-
ceeding six or seven years, he was sulgect to very
violent paroxysms, which, during the latter three
years, occurred twice eveiyyear, and confined
liim at least a month or six weeks each time.

Whilst recovering from a severe and te£ouft
paroxysm, he received a visit fix)m the late Dr.
Hugh Smith, who informed him, that a gentle-
flian of respectability, in Essex, who had befen
subject to both gravel and gout, had, three years
before, taken Blackrie's Lixivium (a soluttoa of
pure fixed alkali) for the cure of the gravd, and
had never since been attack«i by gout : he there-
fore recommended to him the trial of it as an
anti-arthritic. In consequence of this recommen-
dation, he took the lixivium for a twelvemonth,
avoiding wine and other acescents most carefully^
no s3miptom of gout making its appearance* wAk
the end of this^ time, finding no return. <©f gout,
he relaxed in his use of the soap4ye, and began
to drink of stale porter. Within about a twehre-i
month, from his thus resuming the use of thi$
powerftil acescfent, an acute pain took place im-
mediMely beneaJbh the pubis, which did not abate
of its excruciaiting Violence until two himdred
drops of laudanum were injected, mixed with a
proper fluid, into the rectum. He continued to

lOS

endure daily excruciating tortures m thU^ part for
upwards of two years, notwithstanding very frei
quent and large doses of opium were employed to
abate them. The nature of this oo^ifrfaint was
liever actually determined, although every cir*
cumstance attendant on it seemed, at one trnie^
to warrapt the supposition of its being a case <^
schirrous contracted rectum. At the end of rather
more than two- years, the pains considerably
abated ; but very soon after ascites was found to
have established itself^ the distressing attendants
on which closed the melancholy scene.

REMARKS.

The foregoing case affords very strong evid^icie
of the anti-arthritic powers of the fixed alkali.
The attacks of gout, which had been regularly
made for a considerable time, were by this remedy
entirely prevented, and perfect health might have,
probably, succeeded, but. for the improper indul
gence in acescent liquors. It also displays a
striking instance of an uncommon and anomalous
complaint, succeeding to the interruption of the
regular progress of the gout, and of that disease
refusing to occupy that part which it once pos-
sessed, but from which it had been expelled. The
attacks had been constantly made on the feet, but
after^this correction ^tlie gouty acrimony b^ the

104

soda^ and af^reiit restoration to health, the dis*
ease which suoceeded, and which, though not ac-
tually proved to be gout, was the consequence of
an acknowledged exciting cause of that malady^
fixed its seat, not on the feet, but on an internal
part. The whole view of the case shewing, that
the progress of regular gout should never be in-
terrupted, unless sufficient resolution is possessed
by the suflferer, to enable him firmly to resist the
teifiptation of continuing in those injurious indul*
gences, which will create that acrimony on which
the disease depends.

Repeated instances of the successfiil employ-
ment of the fixed alkali, even in its more ordinary
form, the carbonate of soda, have plainly evinced
its efficacy in preventing the attacks of gout.

With respect to the modus operandi of this modi-
cine^nothing certain can,perhaps,asyet be asserted.
Whether its beneficial effects result from its action
on, the stomach and its contents, on the morbid
2VCi:imony existing in the blood, or on the gouty
matter when formed, must be determined by fiir
tjure and more successful observations. In the mean
time it must be allowed that conjecture, at leasts
leads to the opinion, that tiiepow(Br of this remedy
i$ chiefly .q^erci$ed on the contents of the stonijBicbi

105

cheeking the progress of the acid fermentation];
The mere neutralization of the acid matters, al^
ready formed in the stomach, could yield no ma-*
terial benefit; since their neutralization would
facilitate their admission into the blood, where
the developement of the acid would afterwards
take place.

It is not, however, meant to deny, that the
alkali may exert its influence, in some small de-
gree, in the correction of the morbid acrimony
existing in the blood. « From the experiments of
Dr. WoUaston we may conclude, that if the vege-
table fixed alkali were applied in a free state to

. the gouty matter, the urate of soda, whilst circu-
lating in the vessels, its deposition would be pre*
vented. If also it were to be applied to the gouty
matter, when deposited by the vessels destined for
its secretion, its dissolution might also be ex*
pected to take place. On this supposition, indeed,
it appears that the Doctor himself offers the fol-
lowing observations: — ^^ The knowledge of this;

, compound (the gouty concretion) may lead to a
farther trial of the alkalies which have been ob-
served by Dr. Cullen to be apparently efficacious
in preventing .the returns of this disease (First
Lines, D.LVIIL); and may induce us, when
correcting the acidity to which gouty persons are

iO€

frequently subject, to employ the fixed alkaliei?,
which are either of them cacpaiAe of dissolving
gouty matter, in preference to the earths (termed
absorbent) which can have no such beneficial
effect*/'

. • »

The fixed alkali, even when it is taken intd
the stomach in a free state, cannot, however,
but soon become saturated, in that organ, with
carbonic acid. In this state it most probably
passes into the blood; but whether it there
becomes applied to the urate of soda, in such
a state, as to produce its union with that sub-
stance to the degree of supersaturation, and
thus increase its solubility, and effect its dii^
.charge from the system, can only be deteraiin^
by such a knowledge of the agency of different
chemical affinities, in the vascular system, as is
little likely to be obtained.

The resolution of tumours, which apparently
arise from a deposit of this kind, and which^ it will
be shewn, sometimes takes place during a coarse,
of the fixed alkali, seems to point out such an
action on the accumulated morbid naatteri- Ori
the one side it may^ indeed,^ be supposed, that

* Philosophical Transactions, 1797, Part 11. p. jf8f^*

107

the absorption of the deposited matter may be the
result of the combined action of those Tessels^
whicii bring to the spot the liquifying alkali, and
of those absorbents which immediately take np^
and remove the morbid matter at the moment of
its having undergone this remedial diairge. But,
on the other side, it appears to be as probable a
conjecture, that the source of the gouty matter
being destroyed, and no more deposited, the ab-
sorbents, merely by continuing that action, whidfl
may have never been suspended, but has been
only ^exceeded and overpowered "by the morbidly
increased action of those vessels which separated
the gouty matter, may efiect the complete ib-
movai of that which has been already deposited.
How &r sudht an effect is produced, by the absor* •
bent^ possessing a power of election* — an- ability
to effeot the separation of some particular princi*
pies of bodies froipi others, and of thus com*
mencing a chemical resolution of the body to be
absorbed, should not, perhaps, be here examined.
It is however^ probable j that in the performanee
of ^ecretioh, of exhalation, of absorption, and jof
otfa^ important Aiciction& in the animal system,
ishemical^ action performs. a more important part
of the task^ than caii be readily conceived;. \ \

Biit to retum^Th^t the greater part ctf the

108

$alutary effects, succeeding to the use of tlie fixed
alkali in these cases^ proceeds from its action on
the stomach and its contents, will, it is presumed,
not SLppeor improbable, when it is recollected how
rapidly generative is every morbid acid ferment
in the stomach, of a similar state, in eveiy sub-
stance which it meets with in that organ. Thus^
by neutralizing the gastric acid, its power is de-
stroyed of extending that fermentation by which
it was formed. Hence, according to the length
of time required for the restoration of this ferment
tative process, will be the diminution of the for-
mation of acid, not only in the stomach, but even
in the bowels : and thus, the poison being checked
in its formation, the curative powers of the ani-
mal system become equal, not only to the task of
repairing the injuries it may hitherto have occa-
sioned, but also of sufficiently correcting the les-
sened quantity which may happen occasionally to
be formed.

The opinion which has been proposed, respect-
ing the nature of gout, and the correction of the
acrimony, on which it is supposed to depend^
derives considerable support from the beneficial
effects which succeed to the employment of the
fixed alkali in those other diseases, which that
hypothesis supposes to depend on a similar acri«

109

mony. In those neplfritic cases, in which the pre-
sence of sabulous matter is marked, by consider-
able pain in the region of the kidnies, the most
speedy and salubrious effects have resulted from
the free use of this remedy. It bias been • seen in
numerous instances, that within a very small time
after taking the quantity of fifteen or twenty
grains of carbonated soda, a large portion of gra-
vel has passed away, "by Which immediate relief
has been obtained. Inf chwnic rheumatism some
good effects have followed from the use of this
remedy; but these, perhaps from the medicine
not -liaving been employed a sufficient length of
time, it must be admitted have not been strongly
marked : but in acute rheumatism, the effects
have been repeatedly seen to be most decidedly
beneficial. This was particularly observable in ^
two cases, which occurred just before this «beet ^ .^^
wait to press. Jn one of these, cases, in which' tlie ^^—
wrists, elboivs, ankles and knees, were most se»-
verely affected, and in which the redness of the
integuments and the pain were more than coin-
monly great, Dover's powder was freely employed
without benefit for three » days. The soda was
then given on the fifth day of the disease, i n doses
of'dffht arrains^very six hours^ with one dose of
the Dover's powder, often grains at night. The
fallowrag^day great rejief was experiencedy.and by

110

three days further perseverance in this plaki^ m
complete cure was elFected.

That the volatile alkali also possesses consider-
able efficacy, in correcting a disposition to gont^
may be inferred from its possessing, as well as the
fixed alkali, the property of neutralizing acid sab-
stances. In addition to this, its possession of
anti-arthritic powers may be concluded frcnn the
remarkable coincidence of practice, in the em-
ployment of large doses of the volatile alkali, both «
in the cure of gout, and of its prototype the acute
rheumatism. The use of this medicine has been
recommended in rheumatism by almost every
writer on that disease. Dn Dawson, more than
thirty years ago, recommended its liberal employ-
ment in the acute rlieumatism ; .seldom prescrib-
ing a less dose than six drai!ds of the volatile tinc-
ture of guaiacum, and, in general, with the hap-
piest effects. Dr. F. Warner, formerly Vicar of
West ham, Essex, who had suffered much from the
tortures of the gout, experienced so much benefit
in the treatment of his own case, and of those of
others, by the use of opium, in combination with
large doses of the volatile alkali, that as a perform-
ance of an indispensable duty, he published an
account of those cases, in which this remedy had
appeared to be eminently succes^l. The use erf

Ill

this medicine in diseases in which an inflamm^ory
disposition: maAifests itself, as in the gout, and par*
ticiilaiiy in the acute rheumatism, might be consi^
dered as liaUe to be productive c^ some degree of
inconvenience, from its stimulant effects on the
system. But, that it manifests no injurious ef-
fiscts in these cases, is agreeable to repeated ob-
servation. Even Dr. Kinglake, who, es^ceedingly
averse to the employment of any heating or sti-
mulating means in the cure of gout, would doubt-
lei^ superintend the operation of this medicine
with extreme vigilance, found that no circum-
stance occurred which prohibited his employment
of the volatile tincture of guaiacuin with the cam-
phorated tincture of opium, in doses to half an
«unce of each at intervals of four hours.

It does not appear to be necessary to dwell
much on the importance of recruiting the strength
and of restoring the general tone of the systen^
The necessity of doing this, and the means by
which it may be accompUshed, are in general ^mSt
ficiently known. A continued attention to those
rales of diet and exercise which have been already
laid down, with the occasional use of tonics,
among which the preeminence must, perhaps, be
allowed to preparations of bark and of steel, will
be required in most cases. Ailer what has been

112

already remarked on the emplo3rment of this dasisr
of medicines, as well as of bitters, whilst treating
of the best mode of complying with the indication
of amending the state of the stomach, nothing
more seems necessary to be added here.

To promote the removal of that portion of acid
which already exists in the system, it is plain» that
much advantage may be derived, from the occa-
sional use of those means which increase the dis-
charges, by which its removal from the system
appears to be naturally effected. These, as has
been attempted to be shewn, are the urine and
the matter of perspiration. When either of these
manifest the presence of acidity, the increase of
that particular discharge is evidently indicated 5
since, as the quantity of the vehicle is augmented,
so must be its power of sustaining and carrying
off the injurious saline particles. Thus when the
urine, in those disposed to arthritic affections and
urinary concretions, is loaded with a pink sedi-
ment, those articles should be en^ployed which
possess a diuretic power. On this principle, (Ji»
luting liquors should be freely taken, and such
substances used in diet, as manifest a power of
promoting the urinary discharge, such as leeks,
onions, garlic, &c. should be liberally employed.
Thus also when the matter of perspiration is dis-

113

covered to be of an acid nature, every means, not
forbidden by other circumstances, should be em-
ployee!, by which its discharge can be promoted
and increased*.

■

Agreeable to the advice just offered, and to the
opinion respecting the nature of this disease,
which has been adopted in these pages, is the
opinion given, on this subject, by the celebrated
Cullen. So firmly did he believe in the salutary
powers of exercise, that he gives it as his opinion,
that the gout may be entirely prevented by con-
stant bodily exercise, and a Jow diet ; even in
persons who have a hereditary. disposition to the
disease. So confident was he of the efficacy of
such a mode of treatment, as to be persuaded, that
even in those who have had repeated paroxysms
of the gout, labour and abstinence would ab-'
solutely prevent any returns of it for the remain-
der of life. Indeed, when the extensive effects of
exercise, on the system, are contemplated, the
beneficial consequences of its employment, in this
disease, must be obvious. Besides the benefits de-
rived to the system by the acquisition of a higher
degree of tone, and by an improved state of the

* Dissertation on the Gout, &c. by William Cadogan,
M.D. page 68.

114

Stomach, there cannot exist a doabt, bat that by
the increase of the discharge from the enmilctories
of the skin, the system is also freed from various
effete and acrimonious substances, the remoyal of
which must contribute to the preservation of the
general health. It has been already shewn, that
amongst the various matters whidi are thus re-
moved from the system, certain saline particles
are constantly present; and in arthritic'^ habits^
and particularly from parts suffering under gouty
action, a pungent acid is particularly observed.
Hence it is concluded, that, by perq[>iration9
the superabundant acid is frequently removed,
which, being retained, might become the cause
of gout.

Free and even laborious exercise, not emplojred
to the extent of inducing considerable fatigue,
may be regarded then, on this principle, as one
of the most effectual means of preventing the
existence of that morbid state of the system, for
the correction of which, the gouty paroxysm ap-
pears to be produced.

With the view of still frirther promoting the
removal of this peculiar saline matter, by per-
spiration, every means should be employed to
secure the free exercise of the frinctions of the

115

e:!thalant vessels, from which the matter of perspi-
ration flows. With this intention, warm bathing
might be sometimes beheficisdly employed. For
this purpose also, flannel should be worn cx)nstant-
ly, in the daytime, next the skin. Particular
care should be likewise taken to correct, as much
as possible, that coldness of the lower extremities,
which is almost constantly observable, in those who
are disposed to gout. This may be, in a great
measure, accomplished, by having the worsts
under-stockiiigs of so coarse and rough a tex-
ture, that they may not only be efleetual, in pre-
venting the dissipation of the heat, but may, by
their irritating the surface, keep up. the action of
the extreme vessels. As this unpleasant and in-
jurious state of the lower extremities takes place,
particularly whilst in a sitting posture, much be-
nefit may, perhaps, be derived frcmi supporting
the feet, so as to raise the legs nearly to a level
with the thighs : the interruption to the passage
of the blood, by the pressure of the inferior and
lower part of the thighs, on the edge of the seat,
being thereby diminished, and the return of the
blood through the veins being thereby also
promoted.

The correction of the morbid acrimony existing
in the blood, it must be sufficiently obvious, must

116

chiefly depend on a strict adherence to a properly
adapted regimen: the principles on which the
necessary regulatiotis> in this respect, may be
founded having been already explained, nothing
more need be here added.

As to the power of different alkaline or earthy
medicines in this respect, as has been just re-
marked, nothing certain can, perhaps, at present
be known. The probability however is, that by
a continued use of medicicies of this class^ such as

have been already recommended, for their eflfioacy
in diminishing the creation of acidity, by the
gastric fermentation, a very beneficial influence
may be exerted by the neutralization of that
acidity, which already exists in the blood. Nor
can there exist a doubt, that by these means^
unless due attention is paid to the effects pro-
duced, the opposite state of the system may be
induced; and as gout, gravel, and acute rheu-
matism, had been produced by a prevalence of
acidity, so scurvy, the other extreme of the scale,
might be found to proceed from the too free intro-'
duction of fixed alkali into the system.

117

CHAPTER VIL

TREATMENT DURING THE FIT DIFFERENT INDICA-
TIONS NOTICED^-OPINION OF CULLEN — OPIATES —

TOPICAL APPLICATIONS.

If the Opinions and principles, respecting the na.
ture and cure of gout, have been delivered with
sufficient perspicuity, very little need be said of
th^ tre^tnient necessary during the paroxysm. If
these be kept m view, apd such measures be
^opted as may serve, to correct that acidity which
already exists, to prevent its formation anew, and
to. promote its escape from the affected part, the
rest of the treatment will require but little devia-
tion from that recommended by Sydenham and
CuUen.

To obtain the correction of the prevalent aci-
dity, an attention to the general rules, which have
been already laid down, will be requisite. Every
acid or acescent matter should be carefully avoid-
ed 'y and small doses of the volatile or fixed alkali,
in appropriate vehicles, should be frequently given ?

118

the choice of these two remedies, it may be pro-
per to suggest, may frequently be directed by the
state of the skin and bowek.

Should the skin^ as is sometimes the case^ be
hot and dry, the increase of perspiration, on every
account, would be highly desirable. In this casei
the volatile alkali would be preferable ; since, aided
by the free use of diluents, it would hardly fail to
produce a relaxation of the exhalants on the surface,
and procure that flow of perspiration, which would
not only diminish the feverish state, but might also
carry off a considerable portion of the morbific
matter. Some advantage, doubtlessly, would also
be derived frpm its antacid property ; this, how-^
ever, would not extend much beyond the sto-
mach ; since it is highly probable, that it would,
V^hen introduced into the animal system, soon
suffer decomposition, and, being resolved into its
constituent principles, would, of course, no longer
possess the power of neutralizing any acid matter.

But if the perspiration be sufficiently free, the
fixed alkali, in doses from fiv^ to eight grains may
be given every six^ hours in a suitable vehicle,
which should be in a sufficient quantity, never
less than two or three ounces. Should the bowels
appear to be loaded, and, especially, if in a qonstin

119

pated state, stools sliould be procured freely, so
as effectually to remove any accumulated sordes.
This may, in some cases, be effected by proper
doses and combinations of manna, rhubarb and
magnesia : but, in most cases, to be assured of
this being effectually performed, a sufficient dose
of calomel should be had recourse to.

Should sharp sour eructations, with sickness and
pain at the pit of the stomach, make it evident
that the stomach itself is loaded with acid sordes,
an appropriate emetic might' even be had recourse
to. Thus might the source of the materies morbiy
on which depends the protracted morbid state,
constituting thie paroxysm, be at once dried up,
and the sufferings of the patient safely abridged.
To this practice we are directly led, by the fol-
lowing interesting case, related in the Medical
Observations and Inquiries.

The subject of this case was Mr. Major Rook, of
Upper Shadwell, forty-five years of age. This gen-
tleman was attacked by a fit of the gout in both
feet, March 1753. The pain in his feet, heels, and
ankles, increased with great violence for about ten
or twelve daysj till at length he was in the most
extreme agonies ; such as he had never felt before,
and such as almost made him mad. In the height

120

of this extremity, the pains (it is his own expres-
sion) from the feet, heels, and ankles, flew as quick
as lightning directly to the calves of his l^gs; but
remaining there not half a minute, -and not in the
least abating of their extreme violence (though
the feet, heels, and ankles, were left; entirely free
from pain) ; from the calves, after a short ^t ay of
about half a minute, the pains ascended with the
same velocity as before to both the thighs, at the
same time leaving the calves of the legs free : from
the thighs, in less than the space of one minute^
and as quick as before, they arrived at the abdo-
men, and after giving the patient one most severe
twitch in the bowels, they reached the stomach 5
here the pains, and here the fit ended, upon the
patient's vomiting up a pint and a half qf a
green aqueous liquor, but so extremely corrosive^
that he compared it to the strongest mineral acid.

This extraordinary crisis happened at about
two in the morning. Immediately after this dis-
charge he fell asleep, and slept till seven or eight,
and waked perfectly easy in every part, no signs
of the distemper remaining, but the swelling and
tenderness of his feet, both of which went off
gradually, so that in two days he was able to walk
about his business. It was observable, that this
gentleman bad other fits, which terminated in the

tf«

121

same manner, by the vomiting of a corrosive acid*,
and that during the whole course of his fits his
breath was uncommonly stinking, his urine was of
almost as deep a red as claret, and a profuse
sweat broke out every morning, during the whole
course of the fits, which was extremely oflfensive*.

By the foregoing case we are not only taught
the necessity of attending to the state of the sto-
mach, in the treatment of gout ; but are also fur-
nished with strong evidence of the connection, be-
tween this disease and a morbid acid, generated in
the stomach.

That opiate s, when given in sufiicient doses,
yield most certain relief from pain in this disease,
frequent observation has proved. But, in the opi-
nion pf CuUen, when given in the beginning of
gouty paroxysms, they occasion these to return
with greater violence. Opium^ not po jssgssing any
particular curative power in this malady, it is not
to be wondered, that when its influence hs^l sub-
sided, the violence of the pain shpuld return with,
at least , as much violence as ever. Its oply use-
fulness, therefore, in this disease, mujst proceed
from its power of alleviating the sufferings of the

^ Medipal Observations and Inquiries, Vol. I. p. 42.

122

patient, during the progress of the natural cure,
or the employment of those means by which this
process is accelerated.

Dr. Tavares, a Portogueze physician, relates,
that con8ider4rt)le benefit is produced by the freely
taking of Peruvian bark, after a drastic purge, in
the paroxysm of gout. The beneficial effects
Ihxis stated, are such as will not be difficult to
ticcount for, on the supposition, that the disease
^lepended oti a morbid acid, derived from a dis-
ceased state of the stomach. By the drastiQpurge,
the acid sordes accumulated in the primaB vise
would be removed; and their renewal would be
prevented, at least for a time, by the tonic
powers of the bark exerted on the stomach.

The general dietetic management, during the fit,
must necessarily vary considerably, according to
the age, sti'ength, habits, and former complaints
of the patient. In the strong and otherwise
iiealtMul, spirits, wine, animal food, and every
thing of a stimulant or acid nature, shoukl be care-
fully avoided. In those who are more advanced
hi years, or who have been reduced by frequent
attacks of this or of other diseases, a more gene-
rous regimen may be permitted: but even in
tl^ese cases it has frequently appeared that the

123

continued use of wine has most certainly had the
etfect of considerably protracting the fit,

Paradoxical as it may appear, there is no doubt
but that the practice of giving wine, with the in*
tention of curing gout, has been sometimes
adopted, in conssequence of its having been suc-
cessfully employed in producing this disease. It
has been frequently had recourse to, for the pur-
pose of inducing a podagfal attack in those caseer^
in which other more alarming complaints have
appeared to follow, from the suspension of the
gouty action in the feet. The uninformed^
noticing the beneficial effects thus produced in
those disposed to the gout ; and learning that to
such persons Madeira has been recommended vrtth
great advantage, by the most eminent physicians,
have fallen into the error, that wine must ne*

cessarily be good for the gouty. Dr. Heberdea
has remarked, that plenty of good wine has been
supposed to be particularly beneficial to the gouty 5
but he justly suspects, that this doctrine has been
spread abroad, not so much from its being gene-
rally believed, as from those who arefond of win^
wishing it to be true*.

* Gulielmi H^berden Commentarii de Morborum Histopa
& Cu^atione^ p. 44,

Aware- of the wide spread of good or of evil,
which depended on the soundness of the princi-
ples which he taught, the justly celebrated Cullen
laid down no maxim respecting the treatment of
diseases, UQtil it Had undergone the nicest and
most accurate investigation; He appears to have
considered that precepts, on points so essential to
the comfort and happiness of mankind, ought not
to have a chance of obtaining the general recep-
tion, which he must have been apprised, the autho-
rity of bis name would obtain for them, until he
was thoroughly convinced, that no injurious con-
sequences could result from them. Agreeable to
this opinion, the strongest marks of anxious consi-
deratipn, and of the most diffident exercise of his
excellent judgment, may be plainly traced in the
advice which he offers on any subject, which is at
i>nce doubtful and important,

« •

Strong marks of this benevolent caution are
obvious, in the following monitory observations
respecting the moderating of the inflammiation of
gout. " That no irritation is to be added to the
system, during the paroxysms of the gout, (ex-
cept, he observes, in some particular cases which
he had just mentioned,) is entirely agreed among
physicians : but it is a more difficult matter to
determine whether, during the time of paroxysms.

125

any measures may be pursued to moderate the
violence of reaction and of inflammation. Dr.
Sydenham has given it as his opinion^ that the
more violent the inflammation and pain, the pa-
^ roxysms will be the shorter, as well as the inter-
val between the present and next paroxysm
longer : and if this opinion be admitted as just,
it will forbid t!he use of any remedies which might
moderate the inflammation, which is, to a certain
degree, undoubtedly necessary for the health ^f
the body. On the other hand^ acute pain presses
fi^r relief; and although a certain degree of inflam-
mation may seem absolutely necessary, it is not
certain but that a moderate degree of it may an-
swer the purpose : and it is even probable, that,
in many «cases, the violence of inflammation may
weaken the tone of the parts, and thereby invite
a return of paroxysms. It seems to me to be in
this way, that as the disease advances, the p^^
roxysms become more frequent*."

Under the influence of the same considerate
caution, after admitting that it seems probable
that some measures may be taken to moderate the
violence of the inflammation and pain, and parti-
cularly that in first paroxysms, and in the young

* First Line^ Vol, II. § DLXIL

,126

and vigorous, blood-letting at the arm may be
practised, and thai the application of leeches to
the inflamed part may be employed even with
greater safety, he hardly ventures to attempt any
thing &rther. Warm bathing, emollient poultices,
blistering, the application of moxa, of csHnphor>
and of aromatic oils, all excited his suspicion so
much, that fearing some danger must attend every
external application to the parts affected, during
n par(Hcysm, he concluded that, therrfore, the
common practice of committing the person to pa-
tience and flannel alone is established upon the
best foundation.

In agreement with the opinion of Cullen, and
with the theory advanced in these pages, it is sub-
mitted, that the indication to be fulfilled, as to the
treatment of the parts affected, is so to manage
the inflammation, that, although the extreme vio-
lence of the pain may be moderated, the parts
shall not be interrupted in the functions they are
now called on to perform ; and, at the same time,
the escape of any injurious matter from the pore^
of the part affected shall be promoted, as much as
possible.

It is, however, obvious, that the treatment must
vary, with the degree of inflammation, and the

powers and strength of the patienti In the
younger and more athletic, and in the first pa-
roxysms, if the pain be excessive and the inflani«
mation extremely violent, even bleeding with
leeches, near the part, may be adopted, and the
accumulation of heat, by heavy, dense clothing
avoided. The -part therefore, if the weather
should be mild, may be but lightly covered, or
very lightly enveloped in loose v^rool, over which
may be disposed an oil silk bootikin, brought'
pretty close together at its aperture. By this
treatment, the exhalation of the part being con*
fined, the skin will become relaxed, by immersion
* in its own vapour, and the evaporation from its
innumerable exhalants be necessarily increased.
Thus may the violence of the pain and inflamma-
tion be moderated, whilst an opportunity is ^ven^
by the increased action of the exhalantis, and the
relaxed state of the skin, for the expulsion of tfad
materials of any morbid accumulation, which misbt
have been about to be deposited on the part. By
closely surrounding the part affected with a cab-
bage-leaf, the vapour exuding from the part is so
confined and condensed, as frequently to occasion,
a very free perspiration from the part, and a very
rapid alleviation of the complaint.

Even m more advanced stages of Kfe, and whene

128

the paroxysms have been several times repeated,
if the pain and inflammation be urgent, this mode
of promoting the perspiration of the part appears
to be admissible with safety. The process which
nature has instituted is not likely to be hereby
interrupted ; but may be thus conducted to its
termination, with much less pain and inconveni-
ence, than might otherwise have taken place. In
those cases where the pain and inflammation is
intense, the good eflfects of this mode may be ac-
celerated by moistening the wool previously to its
application. This may be done by dipping it in
lukewarm water, and then allowing it to drain ;
or, which will be still better, by suspending it
over the steam of boiling water ; by which latter
method, the wool will not be made to collapse to-
gether. In either case, it will not be of any ma-
terial consequence, if the wool, thus wetted, should
be rather lower in temperature than the part,
since, from the mode of application, an equili-
brium of temperature will soon take place.

In many cases, of very urgent pain, the greatest
relief has been experienced, from the gentle ap-
plication, with a feather, of equal parts of tinc-
ture of opium, soap liniment, oil of almonds, and
rose water. But even this application, so simple
and mild, has appeared, in one or two instances.

129

to have had the effect of making the inflammation
shift to some other part ; proving how well founded
is the observation of CuUen, that some danger
must attend every external application to the
parts affected, during a paroxysm. But since
tHe contrary opinion has been recently and stre-
tiuously promulgated, and has been adopted and
even acted upon, to a very considerable extent, the
following chapter is appropriated to its exar
ftiination. ,

130

CHAPTER VIII.

REMARKS ON DR. KINQLAKf/s PRACTICE — RETRO-

CEpENT GOUT APPUCATION OF COLD WATER

DANGEROUS.

It has been seen in the preceding chapter, that
every interference with the regular progress of
the fit of gout, by any application to the
part suffering the gouty inflammation, is gene-
rally considered as a practice fraught with much
danger. But a late writer, who has most zeal-
ously endeavoured to disseminate opinions of a
contrary nature, has asserted, that, " gout differs
in no essential circumstance from common injlam-
mation — that, goiU is not a constitutio7ial, but
mereli) a local qffectiofi — and that, parts, tinder
the inflammation of gout, may, with perfect safety,
be subjected to a long and unremitted continuance
of application of cold tvater, in cases of even the
worst state of constitutional health.

In a work, the object of which is to establish
a mode of treatment of a particular disease, which
long experience, and the highest authority in the

isi

healing science^ had taught to be fraught with the
greatest danger, at least under certain circum^
stances, those ciroumstafices might be expected
to be^^xaitiined with sortie considerable degree of
attention. But this tadc is, however, not per->
formed ; «uid yet Dr. Ktnglake conceives that his
doctrine is sufficiently established to allow him
contemptuously to speak of the opposite opinions,
^ the adoption of popular prejudice, occasionally
sanctioned with the solemn gravity of medical
erudition.

The most celebrated writers on this disease
have particularly urged the necessity of attending
to the sudden suspension of its morbid action, in
that part of the body which it first attacks, and
its almost immediately affecting some distant
part : always regarding this secondary affection,
from its most frequently taking place in some
vital organ, as a circumstance highly to be
dreaded.

' No one who has attended to the progress of this
disease, in a moderate number of cases, can have
failed of witnessing that alarming symptom, kndwn
generally by the term of gout in the stomath j i
tferW derived from popular obtefvation, )vhich has
determined the depeUidence of this symjitom, oti

K 2

132

the presence of gout in the system, and has
marked its coincidence, with the sudden disappear-
ance of tlie gout from the extremities. In this
most afflicting state of the stomach, the pain is
often so violent, as to excite considerable appre-
hensions even for the life of the patient, the alarm
being heightened, by his pale and shrunk counr
tenance, and by the great degree of oppressive
anxiety under which he is seen to labour. But
the degree of alarm, and indeed, the degree of real
danger, which belong to such a state, could never
possibly be expected by any one wha relied on
the account which Dr. Kinglake has given of this
affection. Whilst reading Dr. Kinglake's ac-
count, an uninftMTmed reader would suppose he
was treating of a complaint only, which, with-
out pain, occasioned little more inconvenience
than interrupting the process of digestion. The
Doctor's words are :

" If any particular organ should be previously
disturbed by any unhealthful conditions of its mo-
tive powers or excitability, on that part tl^g gouty
excitement is liable more particularly to^ be ar?
reisted, where it will endure, with greater or less
yiolencp, as it may happen to bq i^pessantly deriv-
jng its support from the gouty s^urc?, or beconir
jng independent of i$se?aci|t^ng, cause. ;., . , .; *

13^

"The stomach, for example, durtn^ a pa-
roixysm of goutj may have its excitability so pain-
ftilly irtipress€?d by a sympathetic w associative
exteriston of the stimulant influence of that ma-
lady, a^ to be rendered une^tial^ either to its di-
gestive funciiofiy or to that of supporting a sort of
regulating tone and energy for the salutarily mo-
trOereldti&ns of the system generally. In that
case, an ailmetit at the stomach may cohtinue to
prevatit aftCT the^ extinction of g6uty pain, owing

to thfe deep impression made on its native powers,
unh*ke the transient effect arising from the slighter
ittfluence of morbad sympathy*."

Nothing in this account can lead to the neces-
sary csiution and just alarm, which such a cafie
ought to excite. Here, not only no mention is
made of the anxiety, i^ckness, and violent pain,
spoken of by Cullen ; nor of its being one of those
symptoms which Sydenham considered ais placing
the life of the patient in danger 5 'but, on the con-
trary, neither pain nor danger is once mentioned.
This affeotion, which is given as an example, of
the other cases of retrocedent gout, no other in-
stances even being adduced, is described in terms
so mild, that were the probability of its being

* Dissertation on Go«t, p. 22.

134

produced by the propo^ remedy, immeision in
cold water, even to be proved^ it would, in all
likelihood, appear to those who had derived theif
only knowledge, respecting these circumstances^
from the Doctor's account, as of too jnsignificcmt
a nature to deter them ffom the experiioent.

This. affection of the stomach, pn the coptrary^
is not only of an alarming and dangerous nature^
but calls for the utmost slpU in determimog ^qu an
appropriate mode of treatment. The first point
necessary to be ascertained is, whether or not'thq
age of the patient, the symptoms, and other cir*
cumstances of the case, warrant the suspicion of
the. presence of active inflammatidn, Wban this
can with certainty be ascertained, the next Object
of investigation is, whether any offensiv^e matter
eyLists in £he. stomach, or not. Should a disagree-
able ttiste in the mouth, sour and offensive risings,
and frequent useless urgirigs to vomit be observa-
ble, the emptying of the stomach should be ob*
tained by freely drinking of warm watery or an
appropriate dose of ipecacuanha, or in some cases
even of Emetic Tartar. When vomitings have so
long continued, as to givemiore reasbn to suppose
that this symptom proceeds, rather from a spasaiodic
affection, than the presence of any offensive matter
in the stomach, afreedosie of , opium may be ad-

isfe

Bliinistered i^ feUf fte^uently wh^re theliischarge of
Kle gives^rt^i^fli- to fear that th^ peristaltic motion
of the intestihes fe becoming inverted, a foil dose
of thift tihct^re of sena has beeti giyfen With great
saocess. The application of a blister ib the pit
of the ^omaeh, should also be had recourse to if
these means sfeordd not succeed: the part from
which^the gOut has removed should aJsb be imme-
diately itomeri^ in warm water, and be covered
.by a sinapism of a moderate degree of strength.
On similar principles, it appears, every other case
of rei^iwedent gout should be treated. The action
of the vessels in the part which has been deserted
by the gout, should be increased by the applica-
tions of stimuli ; whilst by the application of a
bli^er on the parts forming the covering of the
affected tiscus, the morbid action which it has
taken on may be stopped ; with the hope of pro-
moting this desirable end, such medicines as are
app^ropriated to the nature of the part, and of the
morbid state, must also be exhibited.

But Dr. Kinglake imagining that those S3mip-
toms which have been considered as proceed-^
ing from retrocedent gout, may 'be explained on
principtes different from those which have been
hitherk) had recourse to ; and induced, by hav-
ing observed, in several cases^ that the inflam-

156

matiou of goat might be promptly remored by
considerably reducing the temperature of the
diseased part, without any ill consequence ; ha3^
with the utmost benevolence and zeal, ; endea*
voured to, establish this as the general practice»
not doubting its efficacy and safety in every cas^:
the Doctor asserting, that " no case of gout can
occur, in which. either curative or benqficiul effi-
cacy is not promptly derivable from reduced tern*
perature*,"

That the retrocedence of gout is frequently oc^-
casioned by apparently very trifling causes, is .a
fact which medical observation has so often re^-
corded, that to bring proof of it here is unneces^
sary. The cases which are here mentioned are,
therefore, not introduced so much for the pro(^$
they yield on this pointy as for the sake of other
practical deductions, which it is thought may be
made fi-om them. It is, however, expected that
they will shew, contrary to the opinion of Dr.
Kinglake, that cases may occur in which the sud-
den extii^ction gf gputy inflammation is, not only
unsafe, but highly dangerous ; and that the sudden
stoppage of the diseased action in the inflamed
parts by cold mcdluy or by any other external ap^
plication, is not justifiable, in any case of gout or

. ^ Dissertation on Gout, p. 107,

137

of apute rheumatism ; since, although no mischiev-
ous effects may be immediately discovered, there
is great probability, that consequences, of the most
serious and distressing nature, may occur at a
distant period. . ^

., Dr., Kinglake considers I the prompt extinetton
of the disease as a complete cu^-e, and as a sediifQ
defenee f(x>m $ entaiiUng - on <^er parts an active
state of the disease. .. But the prompt extinction
of the origi:nal inflammation has been witnessed by
many arthritics, and by maAy medical men, btit
most frequently, so far from being tbllowed by
a complete oure, it has been succeeded by com-
plaints still more' grievous and intolerable.
■' . - • '

A lady,;ibout sixty-five years of age, suffering
much f(om an attack of gout in the ball of the
great toe, which had began the preceding night,
was, about the middle of the following day, ih^
duced to bathe it with opodeldoc ; applying after-
wardis over it, only a piece of fine linen, which was
occasionally wetted with the same liquid. In a
few hours all appearance of gout was removed in
the foot ; but an excruciating pain in the head
was experienced. Alarmed liy this new com-
plaint, and attributing it to the sudden cessation
of the gout in the foot, she applied a pretty strong

198

sdiuipism to the ball of -the great loeV at the sam^
time enveloping the foot and leg in a thick worsted
9tockingJ . In a few^ hours the arthritic inflamma*-
tion was again e$t2J>Iished' in • her* foot> and the
head became entirely relieved. ^ .i .

In ibis casp4 'ao^ extiihetion of the ^ciMyinflam-
mAtioa took ))lace>' with sufficient'^yrotnptnesB to
huve ; warrantee^ a cure if > it.oboid' have been thmi
obtained ; but instead oT a .cure, one of those
evils, which experience would lead to the expecta-
tion of, . appeared to be. thereby induced. •

. i

In another instance^ Which occun^ within the
last six or seven months, a lady between 'fifty and
sixty years of age, who bad been several years
subject to attacks of gout<,~ and who had on that
account been long obliged to abstain from wilie»
e:sperienced some \tery slight attacks of goat in
the ankle and instep of the right foot, which con-
tinued with but very little inconvenience for -two
or three days^ when they ceased. Soon aib6il'<the
foot had become perfectly eiasy, a severe vomiting.
With considerable pain of the stomach, ensued. In
^bout two or three hours these symptoms were, by
the adoption of appropriate measures, consider-
ably abated, and in about six hours entirely re-
moved, the pain again possessing the instep and

139

anSd^. ;She thus continue two days longer^ frdd
of every complaint excepting the slight inconv^
nience she experienced in her. foot. On the even-
ing of the second day, disgusted by the unplea^
^nt acidity of the matter of perspiration, which
flowed spontaneously, but gently, she sat up
about two^hourd, when the perspiration, as weH
as the pains, in the feet, ceasing, her respiration
became almost stopt, by ap^in extending from
the top to, the bottom of thesternUm, and spreads
ing under the clavicles to , the point of the.chin^
and down the middle of the upper parts of the
arms. The mediastinum appeai^ed now to be the
part which Jlad taken up the morbid action 5 the
fear, therefore,; of either immediate mischief, pr 6f
so dreadful a chronic malady as angina pectori^^
urged the employment of the most powerful
means. The volatile. alkali with camphor and
laudanum were exhibited; ;a blister was applied
between the shoulders, a sinapism to the chest,
and another to the foot. She was immediately
jeplaiQed in bed, wrapped . in flannel, and fre^
quently supplied with draughts of gruel, to whkJi
a small portion of brandy was added. The pain
of the chest, hbwever, did not much abate for
nearly three hours, but in about eight hours it
nearly subsided ; and towards the evening, when
a little tenderness and inflammation manifested

140

tRemselves on the upper part of the ball of the
l^at toe of the same foot, the pain of the chest
was quite removed. She now remained for three
or four days longer, in bed, experiencing only
dight inconvenience from her foot> but much
more from the continual, but moderate, acid per-
spiration. Again disfgusted with this, and also
fearing the loss of strength from its continuance,
she ventured to attempt again to remain a little
out of the bed. A similar, but rather more vio^
lent attack on the chest, placed her under the
necessity of recurring to the same medicines, sina-
pisms, &c. as before. The blister -being now
placed at the pit of the stomach. By the next
day, the acid perspiration having again returned,
the pain of the chest was again removed*

\ I * *

On the following -day, the internalxondyle of
the left OS humeri bad become considerably in-
flamed aiid painful. The patient now, convinced
of the necessity of submission, remained in con-
finement to her bed for about ten days longer,
daring all but the two or three last days of
which, the pain at the elbow joint, and the aeid
perspiration continued, and then both gradually
subsided. Slie now, oii getting up, not only
found that her strength was not so much dinii«
nished by the perspiration, as she had expected^

141

Imt that her general state of health ^as consider^
ably amended.

In this, as well as in theformer -case, the secon-
dary affection took place soon after the first symp*
torn of gouty affection had appeared ; miKJi
sooner, indeed, than the system could have pos-
sibly experienced any debilitating or atonic in-
jury fi'om its continuance. In this case also the
extinction of the primary inflammation was com-
plete 3 so that if the cure of the disease had de-
pended on that circumstance, it could not but
have taken, place.

In both the cases as complete extinction of the
inflammation took place as cold water itself could
have effected. Indeed in the first case the itteans
were not unlike, since the extinction proceeded
from the diminished degree of temperature, result^i-
ing from the evaporation of the spirits with which
the t^bii^ linen cloth, laid on the inflamed part;
was ^w^ttedl Could less alarming effects liav-e
been expected to have been produced, if cold water
had been applied ? or can it,' by any mode of
reaaoningy be attempted to shew that the appli-
i^ation of cold, water was recommendable in tliess^
xBases ? On tlie answers :to .the&e questions mtich
must, depend; since these are ^ot delivered as mni

aad extraordinary cases^ but as cases of commOBi
>^occurrence to every physician.

. The advisers <^ the refrigerant system must
either boldly assert, that the application of cold
water to the parts first afiected is recommendable
in all such cases ; or, it must be admitted, con*
trary to the positive opinion of Dr. Kinglake, that
cases occur in which, instead of beneficial eflfects,
the most injurious consequences may follow from
the chilling plan.

A gentleman, aged fifty-three years, of a robust
habit, and much addicted to a free mode of living,
had tea years before been frequently troubled with
gout in the feet; but discovering that it most
conunonly succeeded to intemperance in wine, he
almost relinquished that liquor, and substituted
for it spirits diluted with water. In consequence
of this change he seldom experienced any gouty
complaint, except when he indulged in drinking
wine for a day or two; when, as sure as^ he thus
trans'gressed, so sure he was to experience somb
menaces, or some actual attack of gout. Having
given up the reins to indulgence, and devoted
bimself for nearly a^ week ,to convivial excesses^
witlifvdiiferent liquors, he became cbmpletdy de«-
lirtQUft: . his pulse jvas low, ISO iii tl;^^ miautey ar-

143

regular and^ trmuloiis :; his . tongue differed hat

little from its . natural stBte^ being rather white

but moist : bis skin i^aaifested uo , fevemh heat i

nor was he sensible of any pain> althQUgh he fren

quently applied his hand to his head: hiisc^es

were constantly employed in examining son^ fear

cied object, and his fingers engaged in picking

up flocks or straws^ whili^t his mind was perp^-^

tually engaged in preparing to oppose some &ci*

cied plot against him.r, In consequence of the

prevalence of this idea, he. was perpetually aU

tempting, and with difEcplty restrained from, thei

commission of some extravlkgant and violent ac<»

tion. Having obtained no sleep all the previous

night and day, although confined, to bed in a

quiet room, a catliartic medicine was given to

him ; and, after its second operation, forty drops

of tincture of opium were ordered for him, which

with great difiiculty he was prevailed on to take,

and in about two hours he fell asleep, and re-^

mained so between three and four hoursw He

awoke not in the least amended^ and was at thia

period seen by Dr. Gurry, physiciafn to Gny*a

Hospital, who strongly suspected the' prevalence

of a disposition to gout, and that the present dis*-

eased state of the brain might proceed from some

action dependent thereon. The Cathartic, Which

^ffis calomel,,, was repe^etii, a blister, which

144

had refused to submit to have applied; was placed
high up on the back of his heck, and the opiate,
combined with volatile, salhie, camphorated me-
dicines, wds repeated, Inconsequence of these
means, he passed two more copious discharges,
and slept the greater part of the succeeding night ;
waking the next morning quite sensible : but in
the afternoon of the same day he found the gout
had seized on the ball of the right foot, which by
"' evening had become very red and painful. From
this instant he required no more medicine ; the
gout continued in the foot about ten days ; and
having gradually imbsided, left him completely
recovered.

That the affection of the brain, in the preceding
case, might have depended on the prevailing dis-
position to gout, must be admitted to be at least
probable. Certain it must be, that no medical
man could have determined that the connection
was so unlikely, as to have warranted him in pre-
suming to check the regular progress of the po-
dagml attack. The most zealous friend to the re-
frigerant plan would hardly, it is presumed, have
veatiired to have employed it in this case. ,

Although the identity of nature in the two
diseases, gout and acute rheumatism, is by itio

145

Aieans precisely ascertained ;' yet their strict simi*
litude, in many respects, warrants the isuspicion,
that they may, in their rtlaturey be very closely al-
lied. On what particular icirctiiftstances, ^nd on
what particular variations in tbef system, the difFe-
reiice may depend, remains to Rediscovered. ' Ohe
point of resemblance must have been noticed by
most medical men— that of some of th^ irit^rftal
parts sometimes suffering from an affection; appa-
rently connected with that of the extremittes; and
dependent on a similar diathesis. An interestirig in-
stance of thiskind is yielded by the following Case :

• »' A gentleman, thirty-three years of age, in whom
the sanguine temperament was prevalent,.who had
been always healthy, and who had b^en ihodei^ate
in his diet:, 'W*s ^eizied, in the spring of the year
'lS03i With acute rheumatism, which was treated
with gentle diaphoretics, in the early stages of the
disease ; '^and with barfc, guaiacum, '&c. • in the
. more advanced statel The disease was removed
in about three tveeks, and he speedily regained
his strength.-

• I*

In the fortowitig spring, after undergoing con-
siderable^ eixfeftions; he experienced a second at-
k^k. 'Having ' b^n told^ that his fortne'r illness
woirtd have Wen of irfi0rt*r duration, if bfe had

146

been blooded at its cotnmencefnent, some blood
was taken away at his particular desire : but
scarcely had six ounces flowed, before he fell into
a syncope, so alarming, that for nearly five mi*
nates it was expected to ph)ve fatal. Three or
four days of es:treme languor succeeded this ; but
the pains of his wrists, ankles, &&. were by no
means diminished. A gentle diaphoretic plan
having been found beneficial before, this was
again adopted. At a week's end, the rheumatic
affection not being diminished, a contrsuy plaa
was recommended and adopted. The windows
were set open, all the upper bed clothes were re-
moved, except the coverlid and sheet, the arms
were kept out of bed, and the legs alkiwed talay
uncovered, when the pains were urgent. Relief
was almost directly experienced, and the patient
was highly gratified ; but at night he, for the first
time, became delirious. The delirium being* con-
sidered as proceeding, in a gi^eat measure, firom
debility, he was allowed to take wine in moderate
quantities, and was ordered the bark. This plan,
nearly, was persisted in for about a week or ten
days, when he complained o( a troublesome pain
in the side, accompanied with palpitation of the
heart. These symptoms being considered «8 also
depending on debility, the same pleunt? was still
pursued : a blister was appli^ to thie 5ide» aiid'the

patient was removeid into jthe country, to an airy
and elevated situation, Xhe pulse now became
irregular, tremulous^ and intermitting; and the
breathing short and laborious, on the least motion.
The air and situation were repeatedly changed,
but without, effecting any beneficial alteration :
on the contrary, every symptom became worse;
and so readily was he affected by motion, that
if, after sitting some time perfectly still in his
d;iarr,his pulse had become tolerably distinct, the
effcHTt to rise out of the chair Vvould prove suffi-
cient to quicken the pulsations so considerably,
pnd to render them sp irregular and tremulous, as
to become innumerable. A strong /eeling of
buiguor: and exhaustion atteiided the whole pro-
gress of this diseased state, inducing him to.be
pei^tuaHy requiring the aid of scnnething nutri-
tious or stimulating. As. the complaint pro-
oeeded, trhe pulsations of the carotid arteries be-
canie verjrjmudi increased, and for the last two
or three mouths wei-e inordinately violent. The
lower extremities also became oedematous, and
at last were distended to the utmost degree.
E^ery oth^r symptom also increased, in defiance
of ail .which was attempted by the utmost medi-
cal skill ; and, in about a twelvemonth, death re-
li|{u^,^imiirom a.mo$t jdreadfol state of suffering.

Is Q

Upon the examination of the body, the heart
was found to be enlarged to more than twice its
natural size, and the pericardium every where
adherent to it. No other mark of disease was
observable, either in it or in the large vessels, im-
mediately proceeding from it ; nor was any other
morbid appearance observable in any of the the*
racic or abdominal viscera.

Without ptetending to determine whether, in
this case, the morbid affection was transmitted
from the extremities to the heart, oir wjiether the
heart only partook, in common with other parts,
of the general morbid state ; it is thought that
sufficient grounds exist for c^ncludidg, tbat the
affection of the heart was undoubtedly off the rheu-
matic kind. Dr.Bailiie, remarks, that ''the causes
which produce a morbid growth of the heart are
but little known ; one of them seems to berheu*
matism attacking this organ ;" and adds^ la a
note, that Dr. Pitcairn has observed this in seve*
ral cases*.

■ I

In the following melancholy case, no slight
grounds existed for supposing, that the fatal eyent

* The Morbid Anatomy of some of the most am{>OTlaitt
Parts of the Human Body. By Matthew Baillie^ M. D. &c.

149

was the result of a rheumatic affection of the
heart, or of gome of the muscular parts concerned
in respiration.

A gentlewoman, about five and thirty years of
age,' of a sanguine temperament and of healthy
parents, was seized with acute rheumatism, un-
der the sufferings of which she lay upwards of a
month, notwithstanding the utmost care of the
physician who attended her.

Soon after her recovery, she experienced consi-
derable uneasiness from erratic pains in the point
of the shoulder, under the clavicles, across the
chest, and in different parts of the limbs. During
thcv summer these considerably abated, but on
change of weather she was generally more or less
affected by them. In this manner she passed
upwards of two years, never confined to her bed,
and seldom prevented from entering into the usual
engagements of care or pleasure, with her family.

One evening, full two years from the attack of
acute rheumatism, after having been exposed
about half an hour, without any extraordinary
covering, to the night air, she experienced, just as
she attempted to step iQto bed, a considerable

I5d

tightness across her chest, with extreme difficulty
of breathing. After a little time, these symptonom'
went off, she passed as comfortable a night a»
usual, and had no particular complaint on the
next day. She was, however, advised to takfe a
didiihoretic medicine at bed-time^ and to aid its
operation by drinking freely of warm gruel. She
went up stairs in the evening, at the usual iimev
purposing to take her medicine and the grudy
after being in bed : but the servants hearing m
uncommon noise, ran up stairs, where they found
their mistress on the staircase, hardly able to arti-
culate the word, " Help !" and evidently sufiering
under almost suppressed respiration. J^ inime^
diately sunk into their arms, and expired withikt
two minutes after being laid on her bed. This
great distress of her affectionate faihily pre-
vented that examination, which was so extremedy
desirable.

The following case has been thought proper to
be introduced here, from the close analogy which
it bears with the foregoing : its most remark-
able termination also renders it particularly in-
teresting, whilst the reflections it occasions may
serve to determine the most appropriate mode of
treatment of similai* affections.

151

A. B. in whom the sanguine temperament was
predominant, and whose parents were not known
to have been affected with any disease which could
have been likely to have occasioned the transmis-
sion of any particular hereditary disposition, was
attacked, at twenty-two years of age, with consi-
derable pain, swelling and inflammation, extending
from the instep over the ankle. This Complaint,
which was deemed to be gout, by the medical
gentleman whose opinion was asked, rendered him
lame for a few days and then gradually subsided.
From this time he suffered no particular injury to
his health, until he had passed his forty-sixth year.
Then, at the latter end of the year 1 803, having
experienced a considerable share of anxiety, and
having been obliged to exert himself particularly
in his business, which was of a commercial nature,
he begaa to suffer much from extreme languor
mid debility, which sometimes existed to such a
degree, as to interfere considerably with the per^
formance of his usual engagements. Sometimes
on his return home, towards the evening, he
would be so overcome, and his strength would be
so exhausted, that some nutritious and refreshing
matter was obliged to be speedily given to him to
prevent Jiis fainting.

On Saturday the fl6th of November, whilst

153

walking in the city, much fatigued, he was sud-
denly affected with a violent palpitation of the
heart, a slight pain at the pit of the stomach, ancl
such a failure of strength that he could hardly keep
fropi falling. He, however, remained in town,
and having . completed the business of the day,
walked in the evening to his dwelling-house, being
a distance of about two miles. The following
morning he returned to town, passed through
the business of the day with considerable inconve-
nience, and returned in the evening still more
languid and exhausted. Thus he continued to
persevere in exertion, walking daily to town, as-
cending and descending repeatedly two or thre^e
lofty pair of stairs, traversing difierent parts of
the city, and returning home on foot ir^ the evert-
ing, until the sij^th d^y^.

Late in the evening of the sixth day, he was
first seen by the author, who found him with a
countenance denoting a high degree of languor,
and requiring every hour almost some highly nu-
tritive matter to be taken into the stomach, to di- .
minish the distressing sense of debility with which
he appeared to be borne down. He complained
of slight pain at the pit of the stomach, an un-
common palpitation of the heart, accompanied -by
a peculiar iadescrihable sensation resemb^ag a

153

fluttering within him. His breathing was shorty
but chiefly oil moving ; his pulse w^s quick, tre-
mulous, irregular, and intermitting five or,.$ix
times in the minute.

,<-: -i'

Struck with the near resemblance of these symp-
toms to those described as characteristic of iaflamr
mation of the heart or pericardium, the first jSUg-
gestion was to take away some blood : but in op-
position to this intention, ^were opposed, the pre-
vious continued existence of harassing circum-
stances, by which his nervou? system had been
evidently much alBfected : the extreme lowness of
the pulse ; the relief experienced immediately on
nourishment, or vinous or spirituous stimuli, being
taken into tlie stomach ; and lastly, the time which
the disease had existed in its present form, this
being the sixth day. It was resolved, therefore,
to omit bleeding for. that evening, and to make
trial of some cardiac volatile draughts until the
morning ; when the advice of a physician should
be obtained ; with whom the determination with
respect to bleeding should rest.

The symptoms on the following morning (De-
cember 2,) were better; the draughts had ap-
peared to revive him; but the chief difference
seemed to proceed from his having not undergone
any fatigue. An early visit was obtained from a

154

plrf9fci«i^ of much e3q[>erie]ice and respectaUIity,
who, after investigating the particulars of the case,
eondnded it to be rheumatisip of the heart ; and
as the abdomen appeared to be much distended,
he ordered an opening powder with three grains
of calomel, with a due quantity of powder of
"riinbarb and jalap ; after which the plan already
adopted was recommended to be persisted in, and
bleeding not to be employed.

On the following day, December 3, no mate-
rial change had occurred. There appeared, un-
doubtedly, to be an amelioration of the symptoms,
but not to a greater extent than, perhaps, might
be caused by his having continued in. a state of
rest. The demand for solid nourishment, and oc-
casionally of wine, still continued. The pre-
scription was as follows :

5^. Mist camph.

Aq. puleg. an. §ss.

iEther. vitriol, gtt.xxx.

Tinct. castor. 3J. M.
F. haust. sextis horis sumend.
5r. Pulv. rhei.

Sal polychrest. an. 9 ij.

Conf. aromat. 9j\

Aq. menth, sativ. jxM.
F. haust. eras niane sumend.

AppcariBfg to be better on the Mowing diy,
the same draughts were ordered to be oontmned :
and as there appeared to be a regular, though
$low amendment, the same plan was perinsted in
for the five foliowing days.

On the 9th of December bis physiciati cotiiU
dered him to be in nearly a convalescent jstate j
and prescribed the following :

^. Tinct. colombse ^ ij ss. sum. cochl. parv.
omne die circa meridiem ex quovis vehieulo.
5t. Pulv. fl. chamsem. gr. x.
Pulv. piper, longi gr. iij.
Pulv. aides socotriii. gr; j. M.
F. pulv. omne nocte temp, decub. sumend.

These remedies were persisted in until the 19th
of December, when he found himself able again
to go to business, although with great difBcidty '
and uneasiness. He, however, persevered for
three days, and on the last day walked both to
and from town. This exertion proved highly in-
jurious ; all his complaints were thereby increased,
and he was again confined until the 6th of Jimoun
arys during which period, various means were
employed, as suggested by different s3rmptoms and
occurrences: among the other means now adopted

156

writhe administration 'of two strong caloipel
porges, but without any evident good effects,

• • • • , . • • : ■ . ■

.;; About. this period a blister was appHed to the

pit of the stomach, which appieared to augment

his internal unpleasant sensations so much, as to

induce him to say, that he feq.red he should not

have CQurage to. venture to make trial of another^

if it should be recommonded.

He again returned to business^ and persevered
in his eqdeavo)Lirs, without any particular medic^
attention, until the 4th of FebrjUary^ whcjn he
applied for the opinion and assistance of Dr.
Baillie, and aftervyards of Mr. Cliae, who exeri:ed
themselves for him wjth much kindness and care.
He had now become nearly twice the size he had
been two months before, and, undoubtedly, by
an accumulation of fat. His difficulty of breath-
ing, pain at the pit of thp stomach, and indeed
every other symptom increased ; and on^ March
the 26th he again became confined. He now soon
became unable to lay down in his bed, or be re^
moved out of the room. Thedifficulty of breatlii-
ing, palpitation and pain at the pit of the stor
mach, continued to increase daily; and, at length,
from be jag perpetually obliged to sit up in a chair^
the fe^t, legs, thighs, scrotum^j ^. became ei^ofr

151

moBsly swelled'; and were <)iil)r diiniiifelied for n
short time, by ifree scarificatriotf;^' ' • ^*'

About the middle of ' Apf il, the paitt ' being
mo^e acutev and' the breeithyg shorter thjan;uk«al,
about three ounces of blood Vrere taken 'ai^y^by
cupping, byi which he'iexfWi'il^ftced so muc4i reJtefi
that he requested to h^ive thf* bperation. repeated
the following day. It ^ was accordingly perfoWr^j
but hardly two ounces were tsiken away, before h6
fell into a most alarming syncope ; and continued
iu so exhausted a state for several hours, as tO
give the greatest reason to fear that he would sink
. irrecoverably. \^ ^ ' ■

On the l^th of April, when his breatlimg
seemed' to be carried on only by convulsive caitch-
mgs; when^ in a wordi,>all around hitri> -Sitippo^
him to be at the point of death,* he was*fii*srt seen
by Dr. Babington. The Doctor hafppfly' i-ecol*
lected having- been called to a case, which, in its
latter stage, bore a very n^i" resemblance ta the
preserit, ^and in which he bad experienced .Ihte
most beneficial effects from drastic purges. The
following was therefore administered : • • .

Jv j^. Elaterii, gr. rij.

i , Tartar, crystal!, in pulv. trit. 3 ss. '

* ^ V.

Syn^zinzib. cj. Si tit f. b9iu^.

.■..'\A\'.

The (^erttiaw of itfais dose (was very moderate ;
but some little ameaadment was observable. Xhe
ne3ct dose was, therefore, increased to four grains.
TUs OQoasioned some sickness aijtd several watery
stools; and was ev<idently productive of relief.
Xhe numerous distrassing symptmis were com*
bttbed by appropriate palliatives, and in two days
the cilaterium was r^>eated in lilie swoie dose^ with
fitiU rPK»!e decided bweficial effects. It was thus
Wpeafeed, as theweakened powecs^of , life would ad*^
mit,tthfee times more. The good . effects now were
very evident ; .the breathing became relieved^ the
pain was diminished, and the Jawer ^^teemities
and scrotum, from being most enormomsly swoln^
were almost reduced to their natural size. In
little more -than « {fortnight fromi^he ootnmence^
ment of this plain, the palpitiation ^abp n^as much
dimuushed ^ and, with ;tbe utmost pleasure and
^tonishment, it was discovered tiiat theante(rmi&»
sion pf . the ^iilseJiad ceased. .

Frpm tbj^ period bis jrecoveiy iproqeeded regiir
larly ; his i^aaQndmi^t^iQgigvadualiand with;lnit
few and imimppi^tfint jnterruptioAcF. The elate*
Hum, after th^furM; .fcnrtjiight, was repea^^ed about
once a week, as occasion seeI^ed to dictate; and
on the 20th of May he Wwt ,a i|OUl*ney of more
than .tw(9n.ty:miies,itp a.<?^antoy residence, whence
he return^ in; jEi.fqiw we^s«p^ect^/jtecovered.

159 ,

The followittg case, it is presumed, will serve
to ^cdrrobate several q£ tlie opinions offered m tfat
preceding pages :— . . ;

J. P. whose father was much afflicted wrt)i
gout*, is evidently of fthat temperament «FUcb:i^
supposed to be most prone to that disease,; aii4
always 'possessed a peculiar lidiosyncrasy, in ooiw
siequence of which the taking df any acid, or evie^
acidulous matter, into the stomach, occasioned^
in a few minutes, a considerable glow of heat im
the face and in the extremities. In youth, chiir
blaitts, with cramps in the calves of the legs ; an4
through life, coldness, particularly in the evening^!,
<witk dryness of the feet, have seemed to ipoint
out a languid circulation in the lower extremities.
The functions of the viscera forming the \prmi^
jvue have always appeared to be duly iperformedt;
<no dyspeptic symptoms having ever Occurred, ex-
cepting, very rarely, slight flatulency in the -sto-
mach, happening generally for two or three dajyss
Iprevious to any arthrUic attack* His diet ,haiK
.been generally iplain and simple ; sudbi ^as a hum-
^bte table has afforded : wine has been dFaok but
seldom, and then .sparingly, not exceeding two
-or < three glasses at a time.

tsktediat p. IQU

160

At thirty^ight years of age be experienced the
first feittiack'bf goat in the ball of the right foot \
this, however, was so slight as * not to occasion
more than a week's inconvenience. In the spring
6f thesetrond' succeedihg year, ftn attack of more
Viote^c^ and of longer duration was suffered in
*h€f l^ft 4iattd J' the pain and swelling lasting about
teri days. / 'Jn tb^ summer of the year following^
haX^ing' walked a little way out of town, dmnk
hearty a pint of wine, and been exposed to a
l^eavy rain -in' the evening, he awoke about three
o'clock Jh^i^i^ Vnorning in such severe pain in the
inst^^of! th^^ right foot, as excluded all hopes of
rregaining sk^p. 'Convinced of its being a gouty
jEtffectioiij'attd wishing to induce perspiration on
the part^'hd quitted his bed, but found himself
entirely incapable of standing on that foot : he,
however, drew on a woollen stocking, and re-
-gained the bed. The pain now soon became so
exceedingly acute as to be almost beyond endur-
ance, ifecoltecting the Case of Mr. Alexander
Small; related in the sixth volume of the Medical
ObsfervBtio«=*arid 'InqiiiricSi in which great relief
was-obttlinedby te^senittg the temperature of the
part, he tiow 'Gripped off the stocking, and laid with
it J about ten minutes, on the outside of the bed-
clothes, exposed to the open air. The pain soon
abated, but at tli? eiid of about a quarter of an

' ,

164

licfuf^ the abatement not proceed thepai&i

though much jessened^being still severe^he resolved
on trying the effects of cold water. Putting the
foot, th^re^:^, ipto^a,4a]:ge wash-hand bason, he
empj^oyed twp,qi;^s of cold water, by repeatedly
pouring it, on the foot, for about twenty minutes^
the pai|i rapidly diminishing ui^til the end of that
time*^ Little or no pain being, theii felt^ he tho-
rqug^DJT soaked^/ia. fine, napkin in^ the watery and
wrapt it loosely rotund tb^ foot. With the foot in
this state^ be retijimed to he^, resting the leg,
without any other CQverjngi in , a chair at the
side , of ^ the bed. ^ : J^^g ^^ow , entirely freed fi-om
pain, he soon ^U i^leep,p^d awoke in the morn-
ing, without ih» Je^t, tenderness in the foo^
.and capable, of walkifl^. with his wonted ease and
freedom^

I > • . • 1 .

Delighted with his i^>eedy cure, and not ekpe-
riencing -the. least inconvenience firom this mode
of treatment, he fiiUy resolved on pppbsing all fu-
ture attacks on himself; in the same manner^ Dur-
ing the next six weeks, he was so peculiarly cir-
cumstanced^ as to be led to submit to a consider-^
able deviation fix>m his general mode of living,
drinking every day after dinner two glasses of
wine. A|^ the eiid of this period, a slight stin^-
ii^i aching pain in the last joint of the third finger

I«f

t>f the left bandv excited i^ att^tion ; ahd
first perceived a slight enlargement of that jo&st.
The uneasiness, however, beihg but tiiflmg^ he
was not induced to pay much i^timtion to ii, tm«
til about a month aftenvard^ ; wfteti finding it tiirti
evidently still fertlier increased, be made trnd '<tf
various applications, whidi ptVwiug li^ess, db
attempts to remove it were stiikpefided. About
twelve months after this, being between tliirtee^
and fourteen months fiom the dmiiloytnent of tii^
cold water, the bip became 'fi-eqinently the seat cfiT
dull aching pain, which was 'always iiicrett^ hf
walking. This complafait. With the acoonkj^t^-
ing inoonvenienceii, contintiied Viny '^prad^ fti-
creasing; the pain beiiig vi^iy'tniich aogtheiilj^
by walking, arid manifesting ^di^ diUra^tei^
of sciatica ; the pain bemg felt also in tfae'kii^,
down the leg, and about the ankle. To mitieate
the pain and iticoiiviiniettde of this, i^kftift*^Ci^ing
palomd andopiiim, trith iand'withbutiub^xiiiflitil;
cathartics, varices forms of stimulatihg i^fl^ii^dSi-
live embrocations, sUdortfics, &c. l i fe fed di fe ^^Wfe
had to blisters applied over'the hi^rs^^b bli^i^M
parts being kept 6y6h, for abtJiitt^'^Bs^ ^br^a
fortnight each time. The relitf yT^fed ijr 4!ie
blisters was such, nk ^^ii^lty' thj^^^
greater fkcility of wWk%T<ir'ii3C%«^$ w^#o
•monthriiftcrwaWs; • . ';-' •iti-i i-*-i;^^^'-^=' .\^^i

16J

<»' IJBetMTden three /aiid -four more years passed
away ^ during wfaich the complaint of the hip
edritifiued' increasittg, the enlargement of the
joint of . the ' * third * fingier of the left hand in*
creascfl' in size, and a similar enlargement took
{Jacc, . in r the last, joint of the forefkiger of
lifae bright h&pd. After two or three years had
idapfcd^ l^eAfst joint of the finger of the left
Mui3 vra3 attiKsbed with proper artfai'itic ioflam*
jbaCiop/ikiarfcdi ^tiy almost crinlsdn redness, ^-
tr^e'A^devbess^ idnniiig tumefaction extendiiig
to^ the 'Wriet,* and. pain so severe as to render the
jcieist'tnotioa tHgiity-inoonvenient, and the least at-
tention lb ibusiaess diistisessing and irksome, in the
highest degree. Most unfortunately, the moment
«ub*^bich^this oCc\^red> was that in which he was
Sinp^rioosly urged by iparticular circumstances, to
ieofijkitiii^ in the exercise of his {»x)fessional duties.
'A#l1t)y<'herefore, recourse was had to cold water :
4ifetbMd wasimmeitsed in it and enveloped in
cloths wetted with it, until the pain and inflam-
mation was removed, which happened in a few
houi«; (Being able tb <|eturn to business the next
^kf^mitirAy r^i^ved from pain, and ^ven^possess-
iifi'g^hefreeiise of the handv he hailed- the new
^MIMedy ad ^ ^blessing of the highest, valpe,. and
grM«fillly{pioclaiinedtlie obligations he osmd to
it. ; By It i^rangeinciMiSist^Doyv h^^ be oau*

M 3

164

tioned every one against emplojring it, until he bad
made fiuther trial of its efficacy and safety on
himself. In about nine months after, unawed by
an enlargement of the last joint of the second
finger on the right hand, which had appeared
about a month before, he had again recourse to
the chilling process, by which he stopt, at itscom^
mencement, a second severe and decided attadc of
gout, on the first joint of the first fingar of the
left hand. Within three months fixmi this period,
the last joint of the forefinger of the right hand
began to enlarge, and in about ibur months after-
wards, a similar enlargement took place in the
last joint of the thumb of the same hand.

Almost constantly engaged, he seldom paid
attention to the ills with which he was beset ; and
when he did, finding himself unable to judge of
the nature of the complaints, or to discover atfy
indication of cure, he soon ceased to direidt Us
ieittention, voluntarily^ to them.

In the year 1802, the pain of the hip had be-
come considerably augmented, btit wfts mudi re-
lieved by twice blistering : the enlargement pf^
finger joints was also inoreased. Now additional
anomalous complaints began to manifest them*
selves. After walking abmt Mf an. bottrjrjHpaiit-

165

fill giJ^ting sensation would be felt across the mid*
die of the forepart of the thigh and the calves of
tli^legs, occasioning considerable inconvenience.
Much pain also was felt in the knee and ankle
joints, on attempting to walk quickly, and on going
up stairs, accompanied with much .crackling and
snapping of the joints. These symptoms and the
paia of the hip wi^re much augmented by the cold
of the winter, and much amended by the sum-
mer's warmth. .

In the beginning of the year 1803, the afiec*
tion of the muscles of the legs and thighs was
considerably amended ; but, in the spring, great
inconvenience was experienced in walking, from
pain and tenderness in. the internal malleolus
of each ankle. These, in about three or four
months, were evidently enlarged^ and suffered a
slight degree of stinging burning paii^. During
the summer, in consequence of a ^ght, but
sudden twist of the body, an acute pain, on
motion, was ocqasioned in the spine, in the lum-
ber region. From the effects which were pro^
duced, and particularly from the small space to
"which the pain wasi ccmfined, th^re appeared to
be every reason to suppose, that this was^ an affect
tion of some part .of the ligaments, by which the
vertebras are ponneicted. Jhis complaint,, fii>

cdmpanifed hy veiy gMstt mconrenienoe^ la^t^^
ilearly a month and gradimUy abated. Ih thll^
sommer, he also experienced a considerable ciiiii^
mition of his strength, so as to be incapable b(
enduring half th^ exertion which he Was ci^ble
6f before. The pain of theJiip was frequitetihf
Tery troublesome, and the joints of the finger con*
fihued enlarging rapidly through th^ wintek^w

About the beginning of the year 1804, he first
felt a very distressing sensation in the bones form*
iog the arch or vault of the foot, * givfi% Aeidea
of the metatarsal bones being crushed felicibly to^
gether« This affection elf ;th^e parts oaatinmdf
with slowly incresksing pain and incohvenieiiDe^
until Mardi, .when the sensation became ea?
treitidy distressing^ every tim^ the weight of the
body was thrown on either foot} tb&wdglit'6ftiie
body appearing to be ^toomudi, for tbe^-ieA to
bear ; and the walking of ti mile was safficitMlt
to excite a considerable degree of burning peMj in,
the feet, for same time after. Thepain^- sH^eiifig^
«nd tenderness of thb intemal mallffffH *a£ -tbh
«tikles wete also ' bonsider^bly augmented, - as wdl
at; tihe pain of t^ iiij>. • IHoe debility also ' i>e0ame
-so l^eat, that iafter ^(vsdik^^' slowly forjxBiS fst
hbari /idbotbdr blaiJf bour wIeIs' almost required 'tt
test, befdre walking could be.<^ain £^ttein|ited.

16? v.

^i^ sjtuatiqiijivfu;,^ U)i9 period> highly distressing;
l^e appeaf^ tpb^, linking under the infirmities o(
premature 9^ ;f)g^ ^d to be rapidly advancing
to sfidi a i^l^e, ^s, ^ould l)^ entirely incompati-
ble with those exertions, which his business . ret
quired of him: he therefore resolved to apply him-
.^If earnestly pq fhe adoption of i;oai^ plan, from
iwhich he mig(it obt^n neli^.

Repeated obs^ations had taught him, that
wine andiu^idulous fermented liquors, even in the
smallest quantities, were injurious. Frequently,
.within an hour frpm drinking a glass o/wine, or a
drjatught of beer^ in the state in which, it is ysually
.4i^k, he would liie reminded of his transgression,
Py. pain in the hip, and a stinging and burning
j^nsation in tb^,fnilarged joints of the fingers, &9.
T^ese ad^lOIlit^p9S», he not only, for some time,
slighted; but , even blja^ied himself for, as l)e
fupposed, ^imericaliy imputing these temporary
ex^rbations to^.what he could not, on conside-
ration, but regard as a^ inadequate cause. The
. fyict^ however, became indisputable : either piMa
fa the hip, or in some of the enlarged joints,
.jWaa constantly, felt, within an hour or two, {torn
. drinking even a single glass of wine. The fir^t
coc^usion to which this led was, that the present
morbid state might depend on a prevalence pf

168

acidity in the system. To correct that whidi at
present existed, and to prevent its fiiture accur
mulation, appeared to be the indications, by at-
tending to the guidance of whidi, a cure might be
expected.

In agreem^it with this plan» an appropriate regt-

•

men was adopted. For break&st, tea with bread
and butter was taken : the dinner consisted of the
ordinary provision for the family; but vinegar,
and pickles of every kind, were carefully avoided.
Vegetables of the least acescent kind were used,
and articles of pastry, which had often been in*
dulged in, were employed under somfe restriction.
Wine and fermented liquors of every kind were
almost entirely avoided. Bread and milk, or milk
pottage, formed the supper. To correct any pro-
vailing acidity already existing in ihe system, and
also to neutralize any acid generated in the ^st^
xnach, and thereby check its action as a ferment,
from eight to sixteen grains of soda^ in its car-
bonated istate, was taken daily. - The swellii^
on the finger joints being now consideirable; aiid
thitt ion the third Enger of the left hand itiaii-
festing a disposition to .inflammation, a.le^li^
was applied to it, ^d the bleeding promoted Tas
much as possible. Almost direcUy after the bleed-
ing from this joint, the stinging burning sensi^tiphj^

169

jbiEfj^'td ab^t^^ and was iii tW6 '6rtKre6 days
removed. In about a fortnight's tim^ tliq' swelling
iifas' suspected to be rather dimitii^h^; find. 14
kbbtlt six weeks the' dimihttttbii Wa^ evident : a
leech was therefore applied id each bf tfcei enMrgi^
Jiinfe, and with the same beneficiareftffec4:s'''as
'wisre' prodtteed on the other, * The mieididihal
plan just mentioned being prettjr feirly persevered
in for about two months, essential benefit was
€xpi^rienced : the j6ints to whidh the leedpe^ had
beenf applied Were considerablji^bced, and 6V611
the swellings of the thumb and forefinger, to
Which the leeches had riot been applied, were evi-
dently diminished; The pain and tenderness
of the feet and sihkles were almost entirely re*
jmoved: evte the pain of the hip was trouble-
some' otaly after walkiiig, Wfiicli a cbnsiderable re-
tttrh df strength ^^nabled him to perform to xdudi
gteater distiances than before.

1 <

-'' Apprehensite lioW leiSt, by too long a perse-
^MMteice in the presenf plan, ^an iiijurious tendency
in tbe fluids tb anf'iipriiiibny '6f the alcale^
WiAm^^hi be t^^ced; he iiow'«iuSpended ttiis use
of the sbdd; taid i^ed ilpon the Hhie regulation
fif the diet. He W&S j^attlBeS% amend-

jfiWfitfor tWw indhi&f Idhgefi mirmg whidi per

nod be did not driid^ three g^ssm ^^fy^ if^
lojp :«ftener of m^lt liquor. T^ %g^^ J^^^ M

9^17 regwied their patund sif^e ; #njl;^g)epi^fit^
^.hoJth the condyles of the righl; Q9/moris,w\»f^]i
bad^app^ared^ and bM rapidly iQc^^ests^ justl^^prf
t^pias^ was eoQuneaced^ had aim n^y ^mpf
fff^liTfd: all fmn W03 removed, jexK«^ thaf; of ^
tups which w^ however, muob f^tffit^

^ the ra^ of tbi^ period, t}ifs ,][^eQy»r^^f^g[}j)g
And jbnrniojg pa»i, already 4e9crM* «eH^ jt^
Jower eii4 of jthe ^td^, qp »r)y(^ a^^j^g ajifp
yncoeEsded^ 9fu)Jn^,fpw d^ya^ilieriprarfU^ ^ WwJ^

jKsasstiou.wBf felf ;i»j thei^econ^, y^.fj^ iifj^
fiDg^ qf .t|i^ rigbf hand^ 3y)i(tc^ fi^ ^ )iK?|^^
t^upjiell^tioja i{if^ d,i*90j^fr^le^ Piongfitt^ b|r .tJe^flp
mq^ltioo^iitie. ^^iprefi^med the use <^thew^U,;w\4
lie^vored ija. it3 jiji^ about, a fortptg^^ wkeaf^.fiie
remission of every di^t^reeaj^le' sympt^ ff fffCT flj^
to authorize the opinion, that the morbid acrimoiij
iKM^ojrreptpdf thefodawas agaia qmij^t^^vand
yf99 ppt resumed fffit^ ob^ut thr^ pioatlvs ag9»
wh^ifher^turaofp^gD^^^^j^ ^n^rg^

IPpftt of the first joiut of tbj? thwnbt with tefidffi-
^f Jj?fpver thq patella, s^qoicd to.domigid it, 1 T^he

1^ employed ,»t,t^»i8 time vas tew -grains iu, ^

these symp€t)nKf Tdisapp^ar^dy and the ttse of tto

uledicuie .was; again suspended.

' ■ t

•''••;■■', • . : i i ' » ,/..•.■.

.... ••» 'i-.'j

It may be proper to (remark^ that aboyt ; tfaii
time at which the last enlargement of the finger
jatnts took Iplace, the upper eftd of the itecond
1^1 tox dftlC^ bones of the little finger was broken
hy the accidental applioatioabfcbni^iderableforoeb
When the fractured bone was United, the enlarger
nient at the juncture was so considerable as to
give to the joint an appearaioce, similar to that
which has been desoribed as belcmgitig to these
libdes of the joints. > Upon the «soda producing ita
foil beneficial •effect, those enlargements, as hare
been just related, diss^pfpeared ; but this, upon tho
friCtwed bone, rema^med unchanged.
■" . . •■"

' Dr; HajrgaM^h relates, that in one of the caset
of iiodes of the joints seen by him, the full tsdvjBiA^
tinge tooirid not be derived from 4;fae use of leeches^
oit^ing to^the^^bnsiderabie degree of mflainmatioii
they occasioned. In the case of the aufhtn^, thilB
peculiar idiosyncracy existed in a high degree.
;Aftet**the (ippliOMion of evety leeoh, the hand
swelled t^ry ^ucb, beeame of ^a^^deep -ferio^Mm
^our, was very hot/ and tfn ahnost intolerable
degree of itching existed all round the wound
which the leeches had made. At one time, when

17a

^. the leedi had been applied over the first joint of
the forefinger, the swelling and redness extended,
beyond the elbow, almost to the shoulder, not al-
bwiiig the shirt sleeve to be closed.

I •* Tonic, atonic, retrocedent, and erratic, or
misplaced gout, are, according to Dr. Kinglake,
insignificant distinctions, more fanciful than real j
they arise from different states of sympathrtic
energy, and visceral susceptibility for associative
or sympathetic impression. The erratic, or mis-
placed gout, has no admissible signlficancy in
either the theory or practice of the disease. It
implies visceral or systematic affection, arising
from its declining or shifting station on the joints.
This revolves itself wholly into the greater or less
transient effects of sympathetic irritation. — Mis-
placed gout is a misnomer ; when it holds not its
natural situation, when it occupies not its in-
.dispensable structure (ligamentous and tendi-
nous), its e:£istence is no where but in branular
fiction*."

Such are some of the principles, on which Dr.
Kinglake endeavours to establish the utility and
^ety of suddenly extinguishing gouty inflamma^

* Dissertation on Gout, p. 33 if mj.

17S

tion/m every case. But surely the cases^ which haV^
beenh^re related^ and which it is conceived are such
as may have been observed by most physicians^
contain circumstances which prove^that these prin-
ciples are inadmissible; and that the practice^
which they are intended to support, is dangerous
and highly reprehensible.

Several of these circumstances, it is presumed,
also yield powerful evidence, in favour of the opi-
nions which have been proposed, in the foregoing
pages. From them it may be safely coilcluded,
that indulgence in acids is a frequent cause of
gout ; that an acrimony is thus produced, froin
which is formed a peculiar matter, which is sepa-
rated and removed from tbe system, by the inflam-
matory action of the parts affected with gout ;
that this process being suddenly checked in the
extremities, is liable to be taken up by some
other part, whose healthfiil state is much mor^
important to the preservation of life, than that
which had been primarily affected; that even
when no sudden violent affection of any internal
part is thus secondarily occasioned, low chronic
inflammation, perhaps of a peculiar kind, seems to
be oftentimes .produced^ and that tbe-iMids of ttie
bones, or rather their' Ix n in e diate coveriiigs, be-

come affected in a peculiar manner, in those casein,
in which tl^e gouty inflaxnmatioki has been sud-
denly checked) or in which circumstances exist
which prerent its taking {dace, notwithsts^ing
the gouty diathesis is present

■ »

FINIS.

■I

CWHITIINGHAlii Ffimtirt Dean Sirti^

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