Medical Inquiries and Observations, Vol. 2 / The Second Edition, Revised and Enlarged by the Author

by Benjamin Rush

Of the above morbid affections of the nerves, stomach, and bowels, the hysteria, the sick head-ach, and the colic, appear much oftener in women than in men. I have said that dyspepsia is a symptom of gout. Out of more than 500 persons who were the patients of the Liverpool infirmary and dispensary, in one year, Dr. Currie informs us, “a great majority were females[60].”

VI. The gout affects the glands and lymphatics. It produced a salivation of a profuse nature in major Pearce Butler, which continued for two days. It produced a bubo in the groin in a citizen of Philadelphia. He had never been infected with the venereal disease, of course no suspicion was entertained by me of its being derived from that cause. I knew a lady who had periodical swellings in her breasts, at the same season of the year in which she had before been accustomed to have a regular fit of the gout. The scrophula and all the forms of dropsy are the effects in many cases of the disposition of the gout to attack the lymphatic system. There is a large hard swelling without pain, of one, or both the legs and thighs, which has been called a dropsy, but is very different from the common disease of that name. It comes on, and goes off suddenly. It has lately been called in England the dumb gout. In the spring of 1798 I attended colonel Innes, of Virginia, in consultation with my Edinburgh friend and fellow-student, Dr. Walter Jones, of the same state. The colonel had large anasarcous swellings in his thighs and legs, which we had reason to believe were the effects of an indolent gout. We made several punctures in his feet and ancles, and thereby discharged a large quantity of water from his legs and thighs. A day or two afterwards his ancles exhibited in pain and inflammation, the usual form of gout in those parts. In the year 1794 I attended Mrs. Lloyd Jones, who had a swelling of the same kind in her foot and leg. Her constitution, habits, and the sober manners of her ancestors, gave me no reason to suspect it to arise from the usual remote causes of gout. She was feverish, and her pulse was tense. I drew ten ounces of blood from her, and gave her a purge. The swelling subsided, but it was succeeded by an acute rheumatic pain in the part, which was cured in a few days. I mention these facts as an additional proof of the sameness of the gout and rheumatism, and to show that the vessels in a simple disease, as well as in malignant fevers, are often oppressed beyond that point in which they emit the sensation of pain.

Under this head I shall include an account of the mucous discharge from the urethra, which sometimes takes place in an attack of the gout, and which has ignorantly been ascribed to a venereal gonorrhæa. There is a description of this symptom of the gout in the 3d volume of the Physical and Literary Essays of Edinburgh, by Dr. Clark. It was first taken notice of by Sauvages by the name of “gonorrhæa podagrica,” in a work entitled Pathologia Methodica. I have known three instances of it in this city. In the visits which the gout pays to the genitals, it sometimes excites great pain in the testicles. Dr. Whytt mentions three cases of this kind. One of them was attended with a troublesome itching of the scrotum. I have seen one case in which the testicles were affected with great pain, and the penis with an obstinate priapism. They succeeded a sudden translation of the gout from the bowels.

From the occasional disposition of the gout to produce a mucous discharge from the urethra in men, it is easy to conceive that it is the frequent cause of the fluor albus in women, for in them, the gout which is restrained from the feet, by a cause formerly mentioned, is driven to other parts, and particularly to that part which, from its offices, is more disposed to invite disease to it, than any other. The fluor albus sometimes occurs in females, apparently of the most robust habits. In such persons, more especially if they have been descended from gouty ancestors, and have led indolent and luxurious lives, there can be no doubt but the disease is derived from the gout, and should be treated with remedies which act not only upon the affected part, but the whole system. An itching similar to that I formerly mentioned in the anus, sometimes occurs in the vagina of women. Dr. Lettsom has described it. In all the cases I have known of it, I believe it was derived from the usual causes of the gout.

VII. There are many records in the annals of medicine of the gout affecting the skin. The erysipelas, gangrene, and petechiæ are its acute, and tetters, and running sores are its usual chronic forms when it appears in this part of the body. I attended a patient with the late Dr. Hutchinson, in whom the whole calf of one leg was destroyed by a mortification which succeeded the gout. Dr. Alexander, of Baltimore, informed me that petechiæ were among the last symptoms of this disease in the Rev. Mr. Oliver, who died in the town of Baltimore, about two years ago. In the disposition of the gout to attack external parts, it sometimes affects the eyes and ears with the most acute and distressing inflammation and pain. I hesitate the less in ascribing them both to the gout, because they not only occur in gouty habits, but because they now and then effuse a calcareous matter of the same nature with that which is found in the ligaments of the joints.

VIII. Even the bones are not exempted from the ravages of this disease. I have before mentioned that the bones of the hands and feet are sometimes dislocated by it. I have heard of an instance in which it dislocated the thigh bone. It probably produced this effect by the effusion of that part of the blood which constitutes chalk-stones, or by an excrescence of flesh in the cavity of the joint. Two instances have occurred in this city of its dislodging the teeth, after having produced the most distressing pains in the jaws. The long protracted, and acute pain in the face, which has been so accurately described by Dr. Fothergill, probably arises wholly from the gout acting upon the bones of the part affected.

I have more than once hinted at the sameness of some of the states of the gout, and the yellow fever. Who can compare the symptoms and seats of both diseases, and not admit the unity of the remote and immediate causes of fever?

Thus have I enumerated proofs of the gout being a disease of the whole system. I have only to add under this proposition, that it affects different parts of the body in different people, according to the nature of their congenital or acquired temperaments, and that it often passes from one part of the body to another in the twinkling of an eye.

The morbid excitement, and actions of the gout, when seated in the ligaments, the blood-vessels, and viscera, and left to themselves, produce effects different in their nature, according to the parts in which they take place. In the viscera they produce congestions composed of all the component parts of the blood. From the blood-vessels which terminate in hollow cavities and in cellular membrane, they produce those effusions of serum which compose dropsies. From the same vessels proceed those effusions which produce on the skin erysipelas, tetters, and all the different kinds of eruptions. In the ligaments they produce an effusion of coagulable lymph, which by stagnation is changed into what are called chalk-stones. In the urinary organs they produce an effusion of particles of coagulable lymph or red blood, which, under certain circumstances, are changed into sand, gravel, and stone. All these observations are liable to some exceptions. There are instances in which chalk-stones have been found in the lungs, mouth, on the eye-lids, and in the passages of the ears, and a preternatural flux of water and blood has taken place from the kidneys. Pus has likewise been formed in the joints, and air has been found in the cavity of the belly, instead of water.

Sometimes the gout is said to combine with the fevers which arise from cold and miasmata. We are not to suppose from this circumstance, that the system is under a twofold stimulus. By no means. The symptoms which are ascribed to the gout, are the effects of morbid excitement excited by the cold, or miasmata acting upon parts previously debilitated by the usual remote causes of that disease.