Popular Lectures on Zoonomia

But no rational physician, or surgeon, would give a medicine with this view, in such a case as I have supposed; on the contrary, he would caution his patient against mounting precipices, scaling walls, or bringing himself again into a situation, such as produced the accident; and if he took his advice, he would, in all probability, escape a broken limb in future.

In the same way a rational physician would advise a person recovering from gout, to abstain totally and entirely from the course of life which brought it on; and this being complied with, we might venture to predict, with as much certainty in the one case as in the other, that he would in future escape it.

What I have frequently endeavoured to inculcate in the course of these lectures, always appears to me of the utmost importance: I mean, the general diffusion of physiological knowledge, or a knowledge of the human frame; this knowledge ought to form a part of general education, and is, in my opinion, as necessary for a person to learn as writing, or accounts, or any other branch of education; for if it is necessary that a young man should learn these, that he may be able to take care of his affairs, it surely can be no less necessary, that he should learn to take care of his health; for to enjoy good health, as a celebrated practical philosopher observes, is better than to command the world.

If knowledge of this kind were generally diffused, people would cease to imagine that the human constitution was so badly contrived, that a state of general health could be overset by every trifle; for instance, by a little cold; or that the recovery of it lay concealed in a few drops, or a pill. Did they better understand the nature of chronic diseases, and the causes which produce them, they could not be so unreasonable as to think, that they might live as they chose with impunity; or did they know any thing of medicine, they would soon be convinced, that though fits of pain have been relieved, and sickness cured, for a time, the reestablishment of health depends on very different powers and principles. Those who are acquainted with the nature and functions of the living body, well know, that health is not to be established by drugs; but that if it can be restored, it must be by nicely adjusting the action of the exciting powers to the state of the constitution, and the excitability; and thus gently and gradually calling forth the powers of the body to act for themselves. And though I believe that most general diseases will admit of a cure, yet I am confident, that no invalid was ever made a healthy man by the mere power of drugs. If this is a truth, should it not be universally known? If it were, there would undoubtedly be an end of quackery, for all quack medicines, from the balm of Gilead, to the botanical syrup, are supposed to cure diseases, or at least asserted to do so, in this mysterious manner.

Dr. Cullen, in his Nosology, gives us the following definition of the gout.

"Morbus haereditarius, oriens sine causa externa evidente; sed praeeunte plerumque ventriculi affectione insolita; pyrexia; dolor ad articulum, et plerumque pedis pollici, certe pedum et manuum juncturis, potissimum infestus; per intervalla revertens, et saepe cum ventriculi et internarum partium affectionibus alternans."

Now, though this definition comprises a tolerably good general character of the disease, it contains some notions, depending on the prejudice of hypothesis, which, on a careful examination, ought not, I think, to be admitted.

In the first place, I would deny, that the gout, considered as a diseased state of the system, is hereditary. This may perhaps excite some degree of surprise; and, "I had it from my father," is in the mouth of a great majority of gouty patients.

If the diseased state of the system, which occurs in gout, were hereditary, it would necessarily be transmitted from father to son; and no man, whose father had it, could possibly be free from it. There are, however, many instances to the contrary. Our parents undoubtedly give us constitutions similar to their own, and there is no doubt, that if we live in the same manner in which they did, we shall have the same diseases. This, however, by no means proves the disease to be hereditary.

We shall hereafter see, that the gout is a disease of indirect debility, brought on by a long continued use of high seasoned food and fermented liquors. There is no doubt that particular constitutions are more liable to be affected by this mode of living than others; and if my father's constitution be such, I, who probably resemble him in constitution, shall in all probability be like him, subject to the gout, provided I live in the same way; this however by no means proves the disease to be hereditary. The sons of the rich, indeed, who succeed to their fathers estate, generally succeed also to his gout, while those who are excluded from the former, are also exempted from the latter, and for very obvious reasons, unless they acquire it by their own merit.

So that though the son of a gouty parent may have a constitution predisposing to the gout; that is, more liable to be affected by causes, which produce this disease, still, if he regulate the stimuli to the state of his excitability, he will remain exempt from it.

This distinction is of much greater importance than is generally imagined; for if a person firmly believes that the gout, as a disease, is hereditary, what will be his conduct? My father had the gout, says he, therefore I must have it; well, what cannot be avoided, must be endured; let me then enjoy a short life, but a merry one: he therefore abandons himself to a luxurious mode of life, and, if the gout be the consequence, which most probably it will, he accuses his stars, and his ancestors, instead of his own misconduct.

On the contrary, if a person be convinced that he has received from his ancestors a constitution liable to be overpowered by the use of high seasoned food, and fermented liquors, and excited into gouty action, what will be his conduct? Surely, if he reason at all, it must be in this way: my father was dreadfully afflicted with the gout; I have frequently witnessed his sufferings with the deepest concern. But is not my constitution, which resembles his, liable to be affected in the same manner, by similar causes? To avoid his sufferings, therefore, I must be very temperate; more so than those who have not the hereditary propensity; for the exciting powers, which would only keep them in health, would, if applied to me, infallibly bring on the gout. In consequence of this reasoning, he adopts a temperate mode of living, and avoids the disease.

From this you must be convinced, that it is not a matter of small moment to determine, whether the gout is hereditary, and consequently unavoidable, or not. The next part of Dr. Cullen's definition is "oriens sine causa evidente". This too, I can have little hesitation to pronounce erroneous. The cause of gout, namely, the use of highly seasoned food, and the use of fermented liquors, with, in general, a luxurious, and indolent mode of living, are quite evident enough in most gouty cases, and are amply sufficient to produce the disease.

There is another part of the definition, likewise, to which I would object, as it gives a false idea of the nature of the disease, and therefore causes the preventative plan to be pursued with less confidence. I mean that part where he says "per intervalla revertens."

That the gout, when once cured, is apt to return, if the mode of life which brought it on be not abandoned, no one will deny; nay, the fits will increase in violence, because the constitution gets more and more debilitated. This, however, is not peculiar to the gout, but common to most diseases.

In describing a broken leg, it would surely be wrong to say, that it is a disease which returns at intervals, after being cured; yet, it will return as infallibly as the gout, if a person take the same kind of leap, or expose himself to the same accidents as those which brought it on. Let those, therefore, who wish to avoid a return of the gout, totally change their mode of living: otherwise, if the attacks return, let them blame themselves, and not the nature of the complaint.

These observations were thought necessary, with a view to do away some prejudices, which very much retarded our inquiries into the nature and cure of this disease. I shall now proceed to give an account of the symptoms by which it is usually attended.

The gout generally attacks the male sex; but it sometimes, though more rarely, attacks also the female, particularly those of robust and full habits. It does not generally make its appearance, till the period of greatest strength and vigour is past; for instance, about the fortieth year; but, in some cases, where the exciting causes have been powerfully applied, or where the hereditary predisposition is very strong, it attacks much earlier; such cases are, however, comparatively rare, and can, in general, be easily accounted for.

This disease is seldom known to attack persons employed in constant bodily labour, and who live temperately; and is totally unknown to those who use no wine or other fermented liquors.

If then a person of a full strong habit have for several years accustomed himself to full diet of animal food, and a regular use of wine, and malt liquor, though he may for a long time find that he can perform all the functions with vigour, his strength will at last fail: the mind and body become affected with a degree of torpor and languor for which he cannot account, and the functions of the stomach become more or less disturbed. The appetite becomes diminished, and flatulency, and other symptoms of indigestion are felt. These symptoms take place for several days, and sometimes for several weeks before the fit comes on; but often, on the day immediately preceding it, the appetite becomes greater than usual.

In this state, if the person have fatigued himself by violent exercise, or if he have exposed the extremities to cold, or if his mind have been particularly affected by any anxiety, or distressing event; or in short, if any directly debilitating cause have been applied, the fit will often follow. It sometimes comes on in the evening, but more commonly, about two or three o'clock in the morning; the pain is felt in one foot, most commonly in the ball or first joint of the great toe; but sometimes in the instep, or other parts of the foot. With the coming on of this pain there is generally more or less of a cold shivering, which as the pain increases, gradually ceases, and is succeeded by heat, which often continues as long as the pain; from the first attack the pain becomes by degrees more violent, and continues in this state, with great restlessness of the whole body, till next midnight, after which it gradually remits, and after the disease has continued for twenty four hours from the commencement of the first attack, it often ceases, and with the coming on of a gentle perspiration allows the patient to fall asleep. The patient on coming out of this sleep in the morning finds the part affected with some degree of redness and swelling, which, after having continued for some days, gradually abate.

Still however, after a fit has come on in this manner, although the violence of the pain after twenty four hours, by the excitement that it produces, cures itself, and is considerably abated, the patient is seldom entirely relieved from it. For several days he has every evening a return of considerable pain and fever, which continue with more or less violence till morning. This return is owing to the exhaustion of the excitability by the stimuli of the day, and its remission is caused by the accumulation of the excitability, by sleep.

After having continued in this manner for several days, the disease often goes off, and generally leaves the person in much better health, and enjoying greater alacrity in the functions of both body and mind, than he had for some time experienced. This is owing to the general excitement produced by the pain, which removes the great torpor and debility which preceded the fit; and from the inability to take exercise or food, the excitability accumulates again. This is the true explanation: it does not depend on any morbid matter, which the gout hunts from its lurking places, drives to a joint, and thence out of the body, as has been imagined by many.

At first the attacks of the disease are confined to one foot only: afterwards both feet become affected, though seldom at the same time; but when the inflammation appears in one, it generally disappears in the other, and as the disease continues to recur, it not only affects both feet at once, but is felt in the other joints, especially those in the upper and lower extremities, so that there is scarcely a joint in the body that is not on one occasion or other affected. After frequent attacks, the pains are commonly less violent than they were at first, the joints lose their strength and flexibility, and often become so stiff as to be deprived of all motion.

Concretions of a chalky or calcarious nature are likewise formed upon the outside of the joints. This arises from an inability of the capillary vessels, which ought to secrete the calcarious matter, and deposite it in the bones, to perform their office, from debility: hence by sympathy other vessels ta ke up the matter and deposite it in the wrong place. These concretions, though at first fluid, become at last dry, and firm: they effervesce with acids, and are totally, or in a great measure, soluble in them.

After this short description of the gout, when it occurs in its regular form, as it is called, I shall now proceed to inquire how the exciting causes produce this disease, and what is the state of the body under which it occurs.

The gout seldom occurs but in those who have for several years lived upon a full diet of animal food, often highly seasoned, and at the same time been in the habit of taking daily, or at least very constantly, a greater or less quantity of fermented liquors, either in the form of wine, or malt liquor, or both. The affection of the limb has all the appearance of an active inflammation: the part becomes swelled, hot, red, and intolerably painful. It is this circumstance which has misled practitioners, who have supposed it a case of sthenic, or active inflammation: not only the appearance, but the causes which produced it, induced them to think so; hence they were naturally led to employ the debilitating plan: a little time and observation would, however, be sufficient to convince them of its inefficacy. They would find that the application of leeches to the part, and of the lancet to the arm, instead of subduing the inflammation, would increase it: or if it did not, that the pain often attacked some internal part, which was ascribed to a translation of the morbific matter from one part to another, but which is merely owing to an increased debility: a little attentive observation would convince practitioners, however mysterious it might seem to them, that this violent inflammation was not to be cured by debilitating: on the contrary, they would see cases, in which the patient, though contrarily to the strict orders of his physicians, could not forego his old habits; but would take his wine as usual, or in greater quantity, after a few days abstinence; and this abstinence having in some degree accumulated the excitability, he would find himself much relieved by wine, and would exultingly tell them, that they were mistaken. Circumstances of this kind seem to have staggered their faith a little, but still the idea of active inflammation which they believed was visible, and almost palpable, dwelt so upon their minds, that they were but half convinced. The favourite idea of increased action of the vessels of the part had so interwoven itself with every other, that we find it never lost sight of, in the indications of cure. Hence, though bleeding is not now generally practised with the lancet, yet leeches are often applied; but the most usual plan is to consign the patient to patience and flannel; strictly forbidding wine, or fermented liquors. As an exception to this general mode, it is however observed, by some practitioners, that when the stomach is weak, and when the patient has been much accustomed to the use of strong liquors, a little animal food, and even wine, may be allowable, and even necessary.

Thus has an erroneous view of the disease been the cause of an inert practice, which wavers between the suggestions of a favourite hypothesis, and the conviction of facts.

On inquiry, however, we shall find none of the increased vigour in the system, which has been suspected, nor increased action in the part more particularly affected; on the contrary, the whole body is in a state of indirect debility, or exhausted excitability, and the part more particularly affected, in a state of asthenic inflammation.

If the gout were of a sthenic or inflammatory nature, might we not ask, why the causes which produce it, do not produce it in the meridian of life, when they produce their greatest effect, and when real sthenic diseases are most apt to occur? or, why the symptoms of the inflammation, like all other real sthenic inflammations, are not relieved by the debilitating plan? The contrary, however, points out to us clearly the nature of the disease: the gout is not a sthenic disease, or a disease of strength: it does not depend upon increased vigour of the constitution, and plethora, but is manifestly asthenic, like all the rest of the asthenic diseases. The mode of living is such as brings on indirect debility, or exhaustion of the excitability, such as the use of rich and highly seasoned food, and a daily use of fermented liquors. These at first certainly produce vigour, or strength, and will be the cause of sthenic diseases; but they are generally taken in such a manner, that, though they produce a degree of excitement above the point of health, still they only approach the line of sthenic disease, without in general falling into it. They continue, however, to exhaust the excitability, and by the time that the vigour of the body begins naturally to decline, the system of a person who has lived in this manner is unusually torpid; all the blood vessels, which have hitherto been distended with rich blood, begin to lose their tone, from their excitability having been exhausted by the use of these powerful stimulants; but this torpor is particularly and first experienced in those parts which have been more immediately subject to the action of the exciting causes; viz. the stomach and bowels: symptoms of indigestion occur, and the excitability of these organs having been almost entirely exhausted by the violent action of the stimulants applied, cannot now be roused to any healthy action; the food is not properly digested, but runs into a kind of fermentation, which causes an extrication of gas: this distends the stomach and bowels, and produces pains, uneasy eructations, and all the distressing symptoms of indigestion. Nor is this in the least surprising, when we consider that many people who have brought on complaints of this kind, have been in the habit of eating heartily of rich and highly seasoned animal food, and of drinking from a pint to a bottle of wine, and perhaps a quantity of malt liquor, almost every day of their lives for years. This mode is sufficient to wear out the powers of the stomach, were it three times as capacious as it is, and of the constitution, were it ten times as strong.

When a torpor, or state of exhausted excitability, of the whole system, has been induced in this manner, and symptoms of indigestion produced, any directly debilitating cause applied to the extremities, adding to the indirect debility, causes a total torpor, or inactivity of the minute vessels of the part, and thus totally destroys the balance between the propelling and resisting force; hence the vessels will be morbidly distended with blood, a swelling and redness will take place, and an asthenic inflammation, produced in the way which I fully pointed out in the last lecture, will be established. Hence the pain, and other symptoms, which accompany a fit of the gout. Hence likewise we see, why debilitating powers applied to the part will not reduce the inflammation; and why a warmth, which aggravates every really sthenic inflammatory affection, is so comfortable in this.

Almost any debilitating cause, when the system has been brought by intemperance to the torpid state, which I have described, will bring on a fit of the gout, but nothing more certainly than cold or moisture: hence if a person have his feet chilled or wet, he will be almost certain to have an attack.

Hence we see that the asthenic inflammation is not the disease, but merely a symptom of it; and like other symptoms, fallacious in its appearance; the disease is a state of indirect debility, to which our attention ought to be directed.

When this inflammation is violent, and accompanied with great pain, after several hours continuance, it excites the action of the minute vessels, enables them to propel the blood, by which they are morbidly distended, and restores the balance between the resisting and the propelling force; and thus the inflammatory appearances will for a time subside, but the torpor of the whole system remaining, and the debility of the vessels returning, when their excitement, which was the consequence of their action, has ceased, another asthenic inflammation will take place, which will again cure itself as before; so that during a paroxysm, several remissions will take place, as was mentioned in the description of the disease. As, during the paroxysm, the pain causes a considerable degree of excitement over the whole system, the action of the stomach and other parts is roused by it; during the fit likewise, little nutriment is taken, so that by the action of the stomach and bowels, they get rid of their load; rest likewise assists to accumulate the excitability, so that from all these causes together, the body becomes restored to a state of vigour, which, compared with its former torpidity, makes the patient imagine that this friendly disease has restored him to a state of unusual health, and even renovated the powers of his constitution. Under this mistaken idea, he does not, when the fit leaves him, abandon the mode of life, which brought on the disease; highly seasoned food, and the usual quantity of wine, are again resorted to: after a time the torpor of the system, and symptoms of indigestion return, and he again hopes that his friend the gout will come and cure him.

By a continuance of this plan, the inflammation again appears; but the system having become more torpid, the inflammatory action is by no means so great as it was before: if it has power to restore the equilibrium between the resistance and propelling force, and thus cure itself, this effect is entirely confined to the inflamed part. The other foot labouring under similar torpor, or debility, now feels the effects of the propelling force, and an inflammation takes place in it, which having cured itself in the same manner, and the torpor of the foot first affected being returned, or even greater than it was before, on account of the previous excitement; the inflammation again attacks this foot, and thus the gout is supposed to emigrate from one limb to another. The gout, as a disease of general debility, however, remains the same; and it is only these symptoms, which form but a small part of the disease, that vary according to circumstances.

If, during an asthenic inflammation of the lower, or upper extremities, the torpor and debility of the whole system increase, then the force of the circulation, or propelling force, being diminished, the symptoms of inflammation will suddenly disappear; but as great debility now prevails, the stomach will be apt to be affected with cramps or convulsions, or an asthenic inflammation of some internal part will take place: for, though the propelling force is not sufficient to overdistend the debilitated vessels of the extremities, it will distend those of the internal parts nearer the heart, which are now debilitated.

In this case, it has been generally, but absurdly imagined, that the gout is translated, or recedes from the extremities to some internal part: the term of retrocedent gout has therefore been applied to occurrences of this nature. From the explanation which has been given, it is evident, that this term is improper. The general debility being increased, the propelling force becomes unable to produce an inflammation of the extremities, and this is the reason why it disappears. The disease, however, is not at all altered in its nature by this variation of symptoms. It is still the same, by whatever name it may be called.