I have enumerated among the remote causes of the gout, the use of strong tea. I infer its predisposing quality to that disease, from its frequency at Japan, where tea is used in large quantities, and from the gout being more common among that sex in our country who drink the most, and the strongest tea.
7. The exciting causes of the gout are frequently a greater degree, or a sudden application of its remote and predisposing causes. They act upon the accumulated excitability of the system, and by destroying its equilibrium of excitement, and regular order of actions, produce convulsion, or irregular morbid and local excitement. These exciting causes are either of a stimulating, or of a sedative nature. The former are violent exercise, of body or mind, night-watching, and even sitting up late at night, a hearty meal, a fit of drunkenness, a few glasses of claret or a draught of cyder, where those liquors have not been habitual to the patient, a sudden paroxysm of joy, anger, or terror, a dislocation of a bone, straining of a joint, particularly of the ankle, undue pressure upon the foot, or leg, from a tight shoe or boot, an irritated corn, and the usual remote causes of fever. The latter exciting causes are sudden inanition from bleeding, purging, vomiting, fasting, cold, a sudden stoppage of moisture on the feet, fear, grief, excess in venery, and the debility left upon the system by the crisis of a fever. All these causes act more certainly when they are aided by the additional debility induced upon the system in sleep. It is for this reason that the gout generally makes its first attack in the night, and in a part of the system most remote from the energy of the brain, and most debilitated by exercise, viz. in the great toe, or in some part of the foot. In ascribing a fit of the gout to a cause which is of a sedative nature, the reader will not suppose that I have departed from the simplicity and uniformity of a proposition I have elsewhere delivered, that disease is the effect of stimulus. The abstraction of a natural and habitual impression of any kind, by increasing the force of those which remain, renders the production of morbid and excessive actions in the system as much the effect of preternatural or disproportioned stimulus, as if they were induced by causes that are externally and evidently stimulating. It is thus in many other of the operations of nature, opposite causes produce the same effects.
8. The gout consists simply in morbid excitement, accompanied with irregular action, or the absence of all action from the force of stimulus. There is nothing specific in the morbid excitement and actions which take place in the gout different from what occur in fevers. It is to be lamented that a kind of metastasis of error has taken place in pathology. The rejection of a specific acrimony as the cause of each disease, has unfortunately been followed by a belief in as many specific actions as there are different forms and grades of disease, and thus perpetuated the evils of our ancient systems of medicine. However varied morbid actions may be by their causes, seats, and effects, they are all of the same nature, and the time will probably come when the whole nomenclature of morbid actions will be absorbed in the single name of disease.
I shall now briefly enumerate the symptoms of the gout, as they appear in the ligaments, the blood-vessels, the viscera, the nervous system, the alimentary canal, the lymphatics, the skin, and the bones of the human body, and here we shall find that it is an epitome of all disease.
I. The ligaments which connect the bones are the seats, of what is called a legitimate or true gout. They are affected with pain, swelling, and inflammation. The pain is sometimes so acute as to be compared to the gnawing of a dog. We perceive here the sameness of the gout with the rheumatism. Many pages, and indeed whole essays, have been composed by writers to distinguish them, but they are exactly the same disease while the morbid actions are confined to this part of the body. They are, it is true, produced by different remote causes, but this constitutes no more difference in their nature, than is produced in a coal of fire, whether it be inflamed by a candle, or by a spark of electricity. The morbid actions which are induced by the usual causes of rheumatism affect, though less frequently, the lungs, the trachea, the head, the bowels, and even the heart, as well as the gout. Those actions, moreover, are the means of a fluid being effused, which is changed into calcareous matter in the joints and other parts of the body, exactly like that which is produced by the gout. They likewise twist and dislocate the bones in common with the gout, in a manner to be described hereafter. The only difference between what are called gouty, and rheumatic actions, consists in their seats, and in the degrees of their force. The debility which predisposes to the gout, being greater, and more extensively diffused through the body than the debility which precedes rheumatism, the morbid actions, in the former case, pass more readily from external to internal parts, and produce in both more acute and more dangerous effects. A simile derived from the difference in the degrees of action produced in the system by marsh miasmata, made use of upon a former occasion, will serve me again to illustrate this part of our subject. A mild remittent, and a yellow fever, are different grades of the same disease. The former, like the rheumatism, affects the bones chiefly with pain, while the latter, like the gout, affects not only the bones, but the stomach, bowels, brain, nerves, lymphatics, and all the internal parts of the body.
II. In the arterial system the gout produces fever. This fever appears not only in the increased force or frequency of the pulse, but in morbid affections of all the viscera. It puts on all the different grades of fever, from the malignity of the plague, to the mildness of a common intermittent. It has moreover its regular exacerbations and remissions once in every four and twenty hours, and its crisis usually on the fourteenth day, in violent cases. In moderate attacks, it runs on from twenty to forty days in common with the typhus or slow chronic state of fever. It is common for those persons who consider the gout as a specific disease, when it appears in the above forms, to say, that it is complicated with fever; but this is an error, for there can exist but one morbid action in the blood-vessels at once, and the same laws are imposed upon the morbid actions excited in those parts of the body by the remote causes of the gout, as by the common causes of fever. I have seen two instances of this disease appearing in the form of a genuine hectic, and one in which it appeared to yield to lunar influence, in the manner described by Dr. Balfour. In the highly inflammatory state of the gout, the sensibility of the blood-vessels far exceeds what is seen in the same state of fever from more common causes. I have known an instance in which a translation of the gouty action to the eye produced such an exquisite degree of sensibility, that the patient was unable to bear the feeble light which was emitted from a few coals of fire in his room, at a time too when the coldness of the weather would have made a large fire agreeable to him. It is from the extreme sensibility which the gout imparts to the stomach, that the bark is so generally rejected by it. I knew a British officer who had nearly died from taking a spoonful of the infusion of that medicine, while his arterial system was in this state of morbid excitability, from a fit of the gout. It is remarkable that the gout is most disposed to assume a malignant character, during the prevalence of an inflammatory constitution of the atmosphere. This has been long ago remarked by Dr. Huxham. Several instances of it have occurred in this city since the year 1793.
III. The gout affects most of the viscera. In the brain it produces head-ach, vertigo, coma, apoplexy, and palsy. In the lungs it produces pneumonia vera, notha, asthma, hæmoptysis, pulmonary consumption, and a short hecking cough, first described by Dr. Sydenham. In the throat it produces inflammatory angina. In the uterus it produces hæmorrhagia uterina. It affects the kidneys with inflammation, strangury, diabetes, and calculi. The position of the body for weeks or months on the back, by favouring the compression of the kidneys by the bowels, is the principal reason why those parts suffer so much in gouty people. The strangury appears to be produced by the same kind of engorgement or choking of the vessels of the kidneys, which takes place in the small-pox and yellow fever. Four cases of it are described in the 3d volume of the Physical and Literary Essays of Edinburgh, by Dr. David Clerk. I have seen one instance of death in an old man from this cause. The catheter brought no water from his bladder. The late Mr. John Penn, formerly governor of Pennsylvania, I have been informed by one of his physicians, died from a similar affection in his kidneys from gout. The catheter was as ineffectual in giving him relief, as it was in the case of my patient. The neck of the bladder sometimes becomes the seat of the gout. It discovers itself by spasm, and a suppression of urine in some cases, and occasionally by a habitual discharge of mucus through the urethra. This disease has been called, by Lieutaud, “a catarrh of the bladder.” Dr. Stoll describes it, and calls it “hæmorrhoids of the bladder.” But of all the viscera, the liver suffers most from the gout. It produces in it inflammation, suppuration, melena, schirrus, gall-stones, jaundice, and a habitual increased secretion and excretion of bile. These affections of the liver appear most frequently in southern countries, and in female habits. They are substitutes for a gout in the ligaments, and in the extremities of the body. They appear likewise in drunkards from ardent spirits. It would seem that certain stimuli act specifically upon the liver, probably for the wise purpose of discharging such parts of the blood from the body, as are vitiated by the rapidity of its circulation. I shall, in another place[58], take notice of the action of marsh miasmata upon the livers of men and beasts. It has been observed that hogs that live near brewhouses, and feed upon the fermented grains of barley, always discover enlarged or diseased livers. But a determination of the blood to the liver, and an increased action of its vessels, are produced by other causes than marsh miasmata, and fermented and distilled liquors. They appear in the fever which accompanies madness and the malignant sore-throat, also in contusions of the brain, and in the excited state of the blood-vessels which is produced by anger and exercise. I have found an attention to these facts useful in prescribing for diseases of the liver, inasmuch as they have led me from considering them as idiopathic affections, but as the effects only of morbid actions excited in other parts of the body.
IV. The gout sometimes affects the arterial and nervous systems jointly, producing in the brain, coma, vertigo, apoplexy, palsy, loss of memory, and madness, and in the nerves, hysteria, hypochondriasis, and syncope. It is common to say the gout counterfeits all these diseases. But this is an inaccurate mode of speaking. All those diseases have but one cause, and they are exactly the same, however different the stimulus may be, from which they are derived. Sometimes the gout affects the brain and nerves exclusively, without producing the least morbid action in the blood-vessels. I once attended a gentleman from Barbadoes who suffered, from this affection of his brain and nerves, the most intolerable depression of spirits. It yielded to large doses of wine, but his relief was perfect, and more durable, when a pain was excited by nature or art, in his hands or feet.
The muscles are sometimes affected by the gout with spasm, with general and partial convulsions, and lastly with great pain. Dr. Stoll describes a case of opisthotonos from it. The angina pectoris, or a sudden inability to breathe after climbing a hill, or a pair of stairs, and after a long walk, is sometimes a symptom of the gout. There is a pain which suddenly pervades the head, breast, and limbs, which resembles an electric shock. I have known two instances of it in gouty patients, and have taken the liberty of calling it the “aura arthritica.” But the pain which affects the muscles is often of a more permanent nature. It is felt with most severity in the calves of the legs. Sometimes it affects the muscles of the head, breast, and limbs, exciting in them large and distressing swellings. But further; the gout in some cases seizes upon the tendons, and twists them in such a manner as to dislocate bones in the hands and feet. It even affects the cartilages. Of this I once saw an instance in colonel Adams, of the state of Maryland. The external parts of both his ears were so much inflamed in a fit of the gout, that he was unable to lie on either of his sides.
V. The gout affects the alimentary canal, from the stomach to its termination in the rectum. Flatulency, sickness, acidity, indigestion, pain, or vomiting, usually usher in a fit of the disease. The sick head-ach, also dyspepsia, with all its train of distressing evils, are frequently the effects of gout concentrated in the stomach. I have seen a case in which the gout, by retreating to this viscus, produced the same burning sensation which is felt in the yellow fever. The patient who was the subject of this symptom died two days afterwards with a black vomiting. It was Mr. Patterson, formerly collector of the port of Philadelphia, under the British government. I was not surprised at these two uncommon symptoms in the gout, for I had long been familiar with its disposition to affect the biliary secretion, and the actions of the stomach. The colic and dysentery are often produced by the gout in the bowels. In the southern states of America, it sometimes produces a chronic diarrhœa, which is known in some places by the name of the “downward consumption.” The piles are a common symptom of gout, and where they pour forth blood occasionally, render it a harmless disease. I have known an instance in which a gouty pain in the rectum produced involuntary stools in a gentleman in this city, and I have heard from a southern gentleman, who had been afflicted with gouty symptoms, that a similar pain was excited in the same part to such a degree, whenever he went into a crowded room lighted by candles, as to oblige him to leave it. In considering the effects of the gout upon this part, I am led to take notice of a troublesome itching in the anus which has been described by Dr. Lettsom, and justly attributed by him to this disease[59]. I have known several cases of it. They always occurred in gouty habits. A distressing collection of air in the rectum, which renders frequent retirement from company necessary to discharge it, is likewise a symptom of gout. It is accompanied with frequent, and small, but hard stools.