So that though the son of a gouty parent may have a const.i.tution 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 const.i.tution 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 const.i.tution, 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 p.r.o.nounce 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 const.i.tution 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 r.e.t.a.r.ded 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 s.e.x; 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 appet.i.te 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 appet.i.te 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 acc.u.mulation 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 acc.u.mulates 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 quant.i.ty 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 circ.u.mstance which has misled pract.i.tioners, 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 pract.i.tioners, 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 quant.i.ty, after a few days abstinence; and this abstinence having in some degree acc.u.mulated the excitability, he would find himself much relieved by wine, and would exultingly tell them, that they were mistaken. Circ.u.mstances 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 pract.i.tioners, 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 const.i.tution, 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 quant.i.ty 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 const.i.tution, 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 a.s.sists to acc.u.mulate 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 const.i.tution.
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 quant.i.ty 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 circ.u.mstances.
If, during an asthenic inflammation of the lower, or upper extremities, the torpor and debility of the whole system increase, then the force of the circulation, or propelling force, being diminished, the symptoms of inflammation will suddenly disappear; but as great debility now prevails, the stomach will be apt to be affected with cramps or convulsions, or an asthenic inflammation of some internal part will take place: for, though the propelling force is not sufficient to overdistend the debilitated vessels of the extremities, it will distend those of the internal parts nearer the heart, which are now debilitated.
In this case, it has been generally, but absurdly imagined, that the gout is translated, or recedes from the extremities to some internal part: the term of retrocedent gout has therefore been applied to occurrences of this nature. From the explanation which has been given, it is evident, that this term is improper. The general debility being increased, the propelling force becomes unable to produce an inflammation of the extremities, and this is the reason why it disappears. The disease, however, is not at all altered in its nature by this variation of symptoms. It is still the same, by whatever name it may be called.
It sometimes happens, that after full living, the stomach becomes particularly affected, and the patient is troubled with flatulency, indigestion, loss of appet.i.te, eructations, nausea, and vomiting, with great dejection of spirits, pain and giddiness of the head, disturbed recollection, or muddiness of intellect, as it is termed, with all the symptoms, which usually precede a regular fit of the gout, yet no inflammatory affection of the joints is produced. This state has been absurdly enough called the atonic gout, as if there were a gout accompanied with vigour and sthenic diathesis: but the absence of inflammation in the extremities may depend on two causes.
First, the powers producing the disease, may have debilitated the stomach and first pa.s.sages, while the vessels of the extremities are not particularly debilitated, and the resisting force is able to counterbalance the propelling force: in this case, no morbid degree of distention or inflammation of the extreme vessels can take place.
Secondly, the general debility may be such, and the power of the circulation so much diminished, that, though the extreme vessels may be debilitated, no inflammation, or preternatural distention will take place.
Hence, we see, that this is still the same disease; but that physicians have erred in their explanation of the symptoms, by regarding that as the princ.i.p.al part of the disease, which is only a symptom.
We have seen then, that by the theory which has been unfolded, all the symptoms of this. .h.i.therto mysterious disease are plainly and naturally explained. We shall next see if the only method of cure which experience warrants, cannot be explained upon the same principles.
If, on entering this part of the subject, any one should expect that I should furnish him with a receipt, consisting of certain drugs, which swallowed, will cause this terrible disease to disappear, and health to take its place, he would be very much mistaken; for, can any person in his senses suppose that a disease, which he has been almost his whole life in contracting, and an exhausted state of the excitability, which has been gradually brought on by years of intemperance, can be dispersed by a pill, a powder, or a julep? Or, if the symptoms could be relieved by medicine, which they often may, can he suppose, that they will not return, if the same mode of living, which first brought them on, be continued?
I shall, however, proceed to give some directions, which if rigidly persevered in, will not only afford relief in the fit, but will prevent its return with such violence, and at last totally eradicate it, provided the const.i.tution be not completely exhausted, and almost every joint stiffened with calcarious concretions.
The inflammation of the extremities may at any time be relieved by means of electricity, or by stimulant embrocations applied to the part, and this without any danger whatever of throwing the complaint on some more vital part, as has generally been imagined. If I were to apply any debilitating means to the part, I should then probably relieve the pain; but, by debilitating the whole system, should cause an attack of the stomach, or some other internal part, as has been already explained; but by a stimulant application to the inflamed part I run no such risk. The inflammation is of the asthenic kind, depending upon a debility of the small vessels, whereby they do not afford sufficient resistance to the propelling force, and therefore become morbidly distended, or inflamed, as it is termed, though this term is certainly improper, even in a metaphorical view: but a stimulant application to the part excites the debilitated vessels to action; their contraction diminishes the morbid quant.i.ty of blood; and the balance between the propelling and resisting forces being restored, the inflammation of course ceases. This is not a mere deduction, a priori, from the theory of inflammation, which I have delivered; it is the result of repeated experience. I have seen several very violent gouty inflammations very speedily removed by electricity. Small sparks should be drawn from the part affected, at first through flannel, and increased as the patient can bear them: sparks alone are necessary; recourse need never be had to shocks. But though we thus remove a very painful part of the disease, yet still a formidable debility remains, and unless this be removed, the inflammation will be apt to return. In endeavouring to remove this general debility, we must recollect, that it is of the indirect kind, or depends upon an exhausted state of the excitability; our great object therefore, is to allow the excitability to acc.u.mulate. But this acc.u.mulation depends as well upon the proper action of the different functions, as upon the withdrawing of stimulants: we ought therefore to guard carefully against costiveness, by which the proper action of the stomach and bowels is very much injured: but we must use warm laxatives. An infusion of senna and rhubarb in proof spirits, made still stronger by aromatics, has always seemed to me to answer the purpose best, and this should be taken of a temperature rather above blood warm; for instance, about 100 degrees. This is particularly necessary, when the gout attacks the stomach, and I have several times seen a severe attack of it removed in half an hour, by a tincture of this kind. Indeed, the most violent attacks of the stomach may be relieved; and are only to be relieved by spirits, ether, and opium.
It is on this organ, that the hurtful powers have produced their greatest effect; for to it they are immediately applied. It is by no means surprising, that the constant application of highly seasoned foods, with fermented and spirituous liquors, should at last wear out the vital principle of this organ. Indeed it is often so far exhausted, that the most terrible cramps and convulsions take place, which would soon end in its total extinction, unless it were roused to somewhat like a proper action by the most powerful stimulants.
Still, however, their effect is but temporary.
With respect to a regular fit, after the inflammation of the extremities has been subdued by the means I have mentioned, a generous, but not full diet should be used. A person who has been for a long time accustomed to wine, cannot easily be deprived of it at once; but he should drink Madeira, and those wines, which neither contain much carbonic acid, nor deposite much tartar. His food should be of the plainest kind, and generally boiled, instead of roast. The great thing is to keep the spirits and excitement rather under par, but not to let the patient sink too low. In this way, the exhausted excitability will gradually acc.u.mulate, and the healthy state be reestablished. When this is once effected, the gout may be prevented in future with the greatest certainty, if the patient will have resolution. The whole secret consists in abstaining, in toto, from alcohol, in every form, however disguised, or however diluted. He must not take it, either in the form of liqueurs, cordials, wine, or even small beer.
I believe there never was an instance of a person having the gout, who totally abstained from every form of alcohol, however he might live in other respects: and I doubt very much, if ever the gout returned after a person had abstained from fermented or spirituous liquors for two years.
Temperance in eating, and exercise, are, no doubt, powerful auxiliaries, and tend very much to promote health; but still they will not secure a person from a return of the gout, without this precaution. There seems something in alcohol, which peculiarly brings on this state of the const.i.tution, and without it, it would seem that gout could not be produced. Here then is an effectual method of curing the gout, which will no more return, if this method be strictly persevered in, than the smallpox will attack the const.i.tution after inoculation.
During the fit therefore, I would say, nearly in the words of Dr.
Darwin, Drink no malt liquor on any account. Let the beverage at dinner consist of two gla.s.ses of Madeira, diluted with three half pints of water; on no account whatever drink any more wine or spirituous liquors in the course of the day. Eat meat constantly at dinner, without any seasoning, but with any kind of tender vegetables, that are found to agree. When the fit is removed, use the warm bath twice a week, an hour before going to bed, at about 93 degrees, or 94 degrees of heat. Keep the body open by means of lenitive electuary and rhubarb; for there is an objection to the tincture I mentioned, as containing alcohol. Use constant, gentle exercise; but never so violent as to bring on great fatigue. The grand secret, however, in the cure, as has been already observed, but which cannot be too often inculcated, is to abstain, in toto, from every thing that contains alcohol.
In short, though in acute diseases medicines are highly useful, a chronic disease can never be cured, and the healthy state reestablished, by them alone. To effect a cure in such cases, we must reform our mode of life, change our bad habits into good ones; and then, if we have patience to wait the slow operations of nature, we shall have no reason to regret our former luxuries.
LECTURE XIV.
NERVOUS COMPLAINTS, &c.
In this lecture I propose to take a view of some of those affections, which have been commonly, but improperly known by the appellation of nervous complaints, because it has been supposed by many that they are owing to a deranged state of the nerves, which, however, is by no means the case; for I hope to be able to make it appear, that these symptoms arise from a general affection of the excitement of the system. In short, by far the greater number of these complaints, arise from such a state of the excitement as approaches predisposition, or perhaps ranges between predisposition and disease, but does not in general actually reach disease; or rather, it is a state of the excitement, so far departing from the point of perfect health, that the functions are not performed with that alacrity, or vigour, which ought to take place; but labour under that disturbed and uneasy action, which, though it cannot be called actual disease, yet deviates considerably from the point of perfect health.
This is a new view of these diseases, but the more I have examined it, the more I am convinced that it is just. Indeed, the name, nervous, has generally been given to an a.s.semblage of symptoms, which the physicians did not understand; and when the patient relates a history of symptoms, and expects that his physician shall inform him of the name, and nature of his complaint, he generally receives for answer, that his complaints are nervous, or bilious; terms which convey no distinct ideas, but which serve to satisfy the patient, and to conceal the ignorance of the physician, or spare him the labour of thinking.
Indeed, the idea of nervous diseases, which I have already pointed at, is not only new, but could only have arisen from such a view as we have been taking of the states of excitement and excitability.
This view will not only lead us to form a more just idea of the manner in which these diseases originate, but will point out a distinction of them into two cla.s.ses, of the utmost use in practice, but which distinction has totally escaped the attention of pract.i.tioners; for though these complaints have been generally thought to arise from a lowness of the nervous energy, or some kind of debility, or weakness of the nervous system, and, on this account, the stimulant and cordial plan of cure has been recommended, I am convinced, from observation, that nearly one half of them, if not more, originate from a state of the excitement verging towards sthenic disease; and in these cases, this general mode of treatment must be highly improper.
It has been already shown, that when the common exciting powers which support life, act in such a manner, that a middle degree of exciting power, acts upon a middle degree of excitability, the most perfect state of the system, or a state of perfect health, takes place: it is, however, seldom in our power so to proportion the state of excitement and excitability to each other. The action of the exciting powers is continually varying in strength; and the excitability, from a variety of stimulants, and other circ.u.mstances, which are not entirely under our direction, is sometimes more, and sometimes less abundant, than this middle degree. There is, however, a considerable lat.i.tude, on each side the point of health, within which the excitement may vary, and yet no disease, nor any disturbance of the functions may take place: but this has its limits, beyond which if the excitement be brought, on either side, it is evident that an uneasy or unpleasant exercise of the functions must take place. There is not, however, any precise line or boundary between this state, and that in which the functions begin to be disturbed; on the contrary, the law of continuity and gradation seems to extend throughout every part of nature. This departure from the healthy state, and approach to disease, in which what has been called the nervous state consists, is gradual and scarcely perceptible; but is apt to be produced by any circ.u.mstances, which lead the excitement beyond its proper limits.