GEN. XII. SPEC. III. Arthrosia Podagra. Gout. Diathesis may remain quiescent for years or through life: unless excited by some occa A gouty diathesis thus produced, like a phlogotic diathesis, to which in many respects it makes a near approach, may remain quiescent and not discover itself for years, till it meets with some occasional cause of excitement, when it shows itself by a sudden and painful disturbance of some part of the system, but a disturbance of a very different kind, as well as affecting very different organs, according to the temperament, constitution, manner of life, or some incidental circumstance of the sional cause: individual: where the general health is sound, fixing on one or more of the extremities in the form of a peculiar but very acute inflammation that runs through a regular paroxysm and gradually subsides; and, where the health is infirm, and the general form debilitated, exciting great derangement in some internal organ or set of organs, and particularly those of digestion; or shifting from one form to another, and thus proving itself under every form to be the same disease, and laying a foundation for the three following varieties :— when it shows itself differently in different organs. Pain, swelling, and inflammation of the affected joint considerable and acute; continuing for several days, often with remissions and exacerbations; then gradually resolving, and leaving the constitution in its usual or improved health. Disguised and lurking in the constitution, and producing derangement in the digestive or other functions, with only slight or fugitive affection of the joints. The disease fixing on some internal organ instead of on the joints; or suddenly transferred from the joints Predispos original tonic state of a the vessels. Hence the inflamma gular paroxysm bears relation to flammations produced by other in The predisposing cause of a gouty diathesis, when it first forms itself in an individual, it has already been observed, is plethora with entonic condition of the vessels. And hence in its origin, as well as in the symptoms it evinces under a regular paroxysm, gout makes a near approach to various other inflammations of which we have already treated; and is more disposed to show tion of a reitself, where it has been transmitted hereditarily in men of robust and large bodies, of large heads, of full and corpulent, and especially gluttonous habits, or whose skin exhibits a coarser surface in consequence of being covered with a thicker rete mucosum. Castration is action: said to act as a general preventive; but on what facts I know not though admitting the truth of the assertion, it is not difficult to explain the reason, from the entonic energy demanded for the first production of the disease. Such is a brief history of the origin, hereditary trans- must be dismission, and effects of the podagric diathesis; which tinguished must be distinguished from the paroxysms to which it oxysms. gives rise, and which constitute the only manifest indications of its existence. entonic and hence possibly eu nuchs not predisposed. Diathesis from par The paroxysms of gout are excited by certain occa- Paroxysms sional causes, some of which are obvious and some how excited. doubtful, or altogether unknown; but without the cooperation of these, the gouty diathesis may remain unnoticed or quiescent in the body for years, or perhaps, through the whole term of a man's life. And hence it is that we often see an individual, whose ancestors have been notorious for this complaint, pass the whole of his days without betraying any marks of it, while it appears in one or more of his children, perhaps in their very boyhood. The occasional causes are very numerous; for where Occasional the diathesis exists strongly, almost any thing that is causes, what. 7 SPEC. III. Arthrosia GEN. XII. capable of producing a general disturbance in the system, or of throwing it off the balance of ordinary health, is sufficient to become a cause; and this whether the incitement be of an entonic or an atonic character. And hence paroxysms in different individuals are often produced by intoxication, or excess of eating; violent emotions of the mind, particularly the depressing passions, as grief and terror; sudden exposure to cold when the skin is in a state of perspiration; wet applied to the feet; great labour of the body; severe application of the mind, especially when protracted so as to break in upon a due allowance of sleep: cold, flatulent fruits, and often acidulous liquors; a sudden change from a spare to a full, or from a full to a spare, diet; excessive evacuations of any kind; and, occasionally, a sudden cessation of such as are habitual, as the suppression of a periodic hemorrhoidal flux, the cessation of the catamenia, or even the closing of an issue that has long been in a state of dis-, charge. Violent and diathesis and It seems, moreover, indisputable that the more violent the attack of a paroxysm, and the longer its continuance, the more the diathesis is confirmed, and the oftener quicken the the attack is renewed. On which account it is of great return of fits. importance to alleviate and abridge the paroxysms as much as possible, and especially when they are as yet new to the system. Whether particular others dis- gout. Whether particular climates or countries are more disposed to favour the existence of gout than others, separate from the occasional causes just adverted to, may be doubted. Such an opinion, however, has prevailed among the vulgar as well as among many of the more learned in most ages. Thus, among the Greeks, it was a popular belief that Attica was the hot-bed of gout, as Achaia was of ophthalmy; whence Lucretius, Atthide tentantur gressus, oculeique in Achæis finibus*. Fails in Achaia. * De Rer. Nat. vi. 1117. GEN. XII. SPEC. III. Gout. And thus, too, in more recent times, we are told that China *, and even some of the German provinces, Arthrosia are exempt from the attack of gout, while in our own Podagra. country it exercises an almost irresistible sway. The last assertion is true enough, but we are not driven to the variable nature of our climate to account for the fact. cause variously ac Thus far we can proceed safely respecting the gene- Proximate ral pathology of this Proteus-disease. But the moment we enter upon the field of its PROXIMATE CAUSE, we are counted for. bewildered in a hopeless labyrinth, without a thread to guide our entangled footsteps amidst the growing darkness. There has, indeed, been no want of attempts to explain the subject, but thus far they have been attempts alone-ingenious conjectures rather than enucleated facts. Thus some, among whom was the learned Hypothesis Boerhaave, resolved the proximate cause of gout into a haave morbid texture of the nerves and capillaries; and others, into a peculiar acrimony of the fluids; respecting the nature of which, however, those who adopted this view were never able to agree; several of them, like of Boer Hoffman, affirming it to be a tartaric salt, several, a bi- of Hoffman, lious salt, several again, an acid, and several again, an alkali. This morbid material, in whatever it consists, was supposed to be separated from the system and thrown offt during the continuance of the paroxysm, which, consequently, it became the duty of the physician to encourage. And by some pathologists it was held that the morbid matter thus despumated has, in various instances, proved contagious, and this not to man only but to other animals as well: thus M. Pietsch informs us that he has known dogs affected with the same disease by licking the ulcers that have followed upon a fit of gout accompanied with chalk-stones. Le Conte, Nouvelles Mémoires sur l'état present de la Chine. Paris 1696. Morbid matter by these posed to be writers sup thrown off. Has been said to be contagious; and even to affect dogs. GEN. XII Arthrosia Podagra. Most of opposed by favour of his own. Dr. Cullen has taken great pains in a series of nine SPEC. III. consecutive arguments to prove the error or absurdity of most of these opinions: and then he proceeds to establish his own; which consists in regarding the proximate cause of a gouty diathesis as dependent upon a certain Cullen, in vigorous and plethoric state of the system; and the proximate cause of a gouty paroxysm as produced by an occasional loss of tone in the extremities, often communicated to the whole system, but especially to the stomach, succeeded by a powerful re-action in the same quarter which constitutes the pain and inflammation, and is an effort of the vis medicatrix naturæ to restore the tone thus injured. But by this hypothesis we gain as little as by any of the preceding. It is obviously a mere extension of the Cullenian doctrine of fever to the disease before us, and is chargeable with the same incongruity: for here, as in fever, the stage of strength or increased energy is made to depend upon the stage of weakness; as the weakness or loss of tone is made dependent upon a peculiar vigour and plethoric state of the system. There is, indeed, no great difficulty in conceiving how loss of tone may follow upon excess of energy; but by what means recovered energy is to be a result of loss of tone, is a problem of more laborious solution. " A. Pod agra regularis. Regular fit of the gout. its course. I have dwelt the longer upon this subject because it involves a very essential point in the remedial process, and one which has rarely been sufficiently attended to: before we enter upon which, however, it may not be inexpedient to take a fuller glance at the symptoms by which the different varieties of the disease are characterized. One of the marks by which a REGULAR PAROXYSM of GOUT is said to be distinguished from that of rheumatism, is the suddenness of its onset. This is true, as Sydenham has correctly observed, with regard to the general course of regular or entonic gout, in which the constitution is in other respects perfectly sound. But in other cases the Pract. of Phys. Part 1. B. 11. Ch. XIV. DXXXIII. |