A LETTER, &c.

THE liberty which I take of addreſſing you on the preſent occaſion, very naturally ariſes from that indulgence which you have always ſhewn to me, and from the opportu⯑nity which, both as Preſident of the College of Phyſicians and as a private gentleman, you have conſtantly granted for freedom of communication. Eaſy acceſs very often in⯑vites intruſion; and, therefore, if your doors have been open and I have not denied my⯑ſelf the ſatisfaction of walking in, you muſt lay to that account the viſits which I have ſometimes made you, and blame yourſelf alone for the interruption. I know not, however, whether at this time I ought to [4]preſume to conſider myſelf as a welcome viſitor, ſince the ſubject which I ſhall pro⯑poſe for your examination (and on which I ſhall ultimately hope for your approbation) will be an attack upon old opinions—in which, perhaps, I ſhall find you fortified by numbers againſt me; but which I conceive to have been defended by a ſuppoſed imprac⯑ticability of the approach, rather than by the real ſtrength of the fortreſs.

The opinions to which I allude, are ſuch which the world in general, medical as well as other men, have hitherto held concerning thoſe two very frequent diſeaſes, rheumatiſm and gout; and which floating, as it were, in the minds of mankind, without any compaſs to direct, or rudder to ſteer their courſe, have been toſſed about by prejudices, and at laſt loſt in uncertainty. It is no argument to ſay, that in one of them ſometimes, and in the other often, we ſail on proſperouſly and reach the expected coaſt, ſince this is more the effect of chance than of any well concerted plan, and is owing rather to the nature of the veſſel itſelf, than to the regular management of the pilot—which being well [5]built is blown over ſhoals by ſtrong popular gales, and is driven, not conducted into har⯑bour.

Our ideas on the diſeaſes of rheumatiſm and gout, have long, indeed, been very vague and very indeterminate; for although each practitioner might be guided in the treatment of them by a particular theory of his own, yet I ſhould ſuppoſe that every one of us has obſerved phenomena, both in one and in the other, which he was unable to reconcile either to any preconceived opi⯑nion of the diſeaſe, or rationally and ſatis⯑factorily to deduce from the laws of the ani⯑mal machine. For myſelf I will candidly confeſs that I have always conſidered rheu⯑matiſm as a diſeaſe as little underſtood, and as great a reproach to the faculty of phyſic, as the gout—having been equally at a loſs to ac⯑count for facts as they occurred in both: for although I have now paſſed ſeveral years of medical life, and have had the honour (I will alſo ſay the pleaſure) of ſpending ſome of them in the largeſt hoſpital of this me⯑tropolis, as one of its phyſicians, where there is annually admitted a number exceeding 10,000 patients; and although I have been, [6]and (I mention it with pride) am ſtill con⯑nected with gentlemen of the firſt rank in their profeſſion; yet theſe opportunities have merely been ſufficient to convince me that all the notions concerning theſe diſeaſes, are almoſt as unſettled and precarious, as the ſymptoms of them are anomalous and irre⯑gular.

It is ſomewhat ſingular amidſt the contra⯑riety of opinions which have been held con⯑cerning theſe two diſeaſes, that all practi⯑tioners ſhould hitherto have agreed in one point, that both of them are inflammations: but notwithſtanding the maſs of aſſertion which we may find induſtriouſly collected in the earlieſt, as well as in later writers, I feel myſelf not only altogether unwilling to allow it, but muſt contend decidedly and unequi⯑vocally againſt it. We know the ſeveral ways in which inflammatory action termi⯑nates, and when uninterrupted by art, we generally find that it ends in ſuppuration or in gangrene, for the ſlow kind of inflamma⯑tion which now and then ends in ſchirrus, may here be left out of the account; but I believe none of us ever ſaw the rheumatiſm [7]or the gout terminate either in the ſuppurative or the gangrenous proceſs. It may, however, be told me that the termination of every rheu⯑matic and gouty caſe may be by reſolution, the other only remaining way in which in⯑flammation is known to ceaſe; and, there⯑fore, that every argument in ſupport of a contrary doctrine muſt become unneceſſary: but (to ſay nothing of the improbability of every caſe, though unaſſiſted and left to itſelf, neceſſarily and uniformly ending by reſolu⯑tion, when the very great majority of real inflammations, treated by every means which ſkill can dictate, are known to terminate otherwiſe) if meeting the queſtion fairly I ſhall ſhew what may be the ſeat and natural progreſs of theſe diſeaſes, and ſucceeding as I hope I ſhall be found to do in thoſe parti⯑culars, I truſt I ſhall then be thought to have eſtabliſhed a more direct theory, however in⯑dependent it may prove to be on the doctrine of inflammations.

Although in the ſequel of this letter I ſhall produce arguments for a cloſe analogy be⯑tween the two diſeaſes, yet I will, to avoid confuſion, conſider them diſtinctly from each [8]other, as what I ſhall advance concerning rheumatiſm will then more eaſily apply, and perhaps be better underſtood in the explana⯑tion of gout which will afterwards follow.

I need not bring to your recollection that the ſyſtem of arterial veſſels has a two-fold termination, and that it very gradually dimi⯑niſhes by branching firſt from the trunk, and by ramifying again from the branches, until it ends, either in moſt minute capillary tubes which convey the blood into continuous veins, or in ſecerning extremities, which pre⯑pare and depoſit the matter of which the body is compoſed, and which like ſpiracles give vent as it were to a portion of fluid ſe⯑parated from the common maſs, which, as a kind of irriguous exhalation, bedews and ſoftens every interſtice of the animal ma⯑chine. Theſe from their office have properly enough attained the name of exhalants, and would very ſoon diſtribute throughout the whole cellular texture, as well as every other cavity of the body ſuch a quantity of moiſ⯑ture as, when collected, would neceſſarily occaſion dropſy, were not this extravaſation almoſt immediately corrected by another ſet [9]of veſſels which have been denominated ab⯑ſorbents or inhalants, and which at their ori⯑gin are of inconceivable exility: for if, as Arbuthnot has ſtated, ten capillary arteries are not equal in ſize to the fineſt hair, and the leaſt lymphatic veſſel be more than an hundred times leſs than the ſmalleſt capillary artery, the inhalant or abſorbent veſſel muſt, at its commencement, be minute almoſt be⯑yond computation. But we need not at all go to the extent of ſuch a ſuppoſition, ſince it will be ſufficient for our purpoſe to conſider the lymphatic ſyſtem, as beginning by innumera⯑ble orifices leading directly to tubes, which in their capacities, are collectively equal at leaſt to the exhaling extremities of the arteries, and which may be conſidered together as forming a ſeries of veſſels, which in their turn are alſo collected into another ſeries, and ſo on until we are able to trace them into a diſtinct and regular arrangement, convey⯑ing fluid back again into the ſanguiferous ſyſtem: It is in theſe exquiſitely fine and ſlender radicles of the lymphatic veſſels that I place the ſeat of rheumatiſm.

[10]I think we may be allowed to aſſume it as an incontrovertible fact, that any obſtacle to the free paſſage of a fluid through a ca⯑nal, muſt of neceſſity occaſion an accumula⯑tion in the ſeveral ſtreams from which the canal is ſupplied; and that theſe alſo, having their current interrupted, muſt thereby as ne⯑ceſſarily impede the courſe of the numberleſs rivulets which ſhould otherwiſe ordinarily flow into them. And this we find univerſally to be the caſe with reſpect to the lymphatic ſyſ⯑tem: for whatever may be the obſtructing cauſe, every veſſel immediately leading to the part obſtructed muſt be filled, and conſe⯑quently the veſſels forming the next ſeries muſt be alſo diſtended; a ſwelling and tur⯑geſcence muſt therefore always ariſe in ex⯑tent proportionate to the ſize and number of collateral and anaſtomoſing branches which may for a certain ſpace divert the fluid, and then circuitouſly convey it into the regular trunk again.

Every body knows what uſually happens when a gland in the axilla has been ſo great⯑ly enlarged (no matter from what cauſe) as [11]to prevent the fluid not only from paſſing through it, but alſo by preſſing upon the neighbouring lymphatics from paſſing through them alſo; that the arm ſwells, and for a time remains in almoſt intolerable pain until the ſwollen gland ſubſides, or until the fluid finds a paſſage by other more indirect courſes. If it be objected that the ſanguiferous ſyſtem is here alſo obſtructed from the ſame cauſe, and that thence alone may ariſe the painful diſtenſion of the limb, I would anſwer, that where lymphatic glands have been cut out by the knife, as muſt be the caſe when in the removal of a cancerous breaſt they have been found to be diſeaſed from the abſorbed ſanies, that then where there is no tumor, but a conſiderable vacuity from an actual loſs of ſubſtance, an interruption takes place from the deſtruction of the uſual paſſages, tumefaction is produced, and pain equally excruciating follows. When a diſeaſed gland is extirpated from the groin, as now and then has been practiſed in ſome ſyphilitic caſes, the leg and thigh will long afterwards continue in a painfully tumeſied ſtate, until [12]the collateral canals ſhall be capable of con⯑veying forwards the accumulated fluid. We have all of us ſeen, after ſome difficult caſes of parturition, that one or both of the lower extremities have become oedema⯑tous and exceſſively painful during a very conſiderable length of time, until the lym⯑phatic veſſels of the pelvis, which have ſuf⯑fered by the difficulty of the labour, ſhall have recovered from the injury then ſuſtained, or until others in their vicinity ſhall, by gradual enlargement, be fully competent to diſcharge their office for them. I know how⯑ever that there are inſtances where the pain is not ſo great as I have generally ſtated it to be in the examples which I have here ad⯑duced of obſtructed lymphatics; but I be⯑lieve thoſe will only be found to happen in very debilitated ſyſtems, where there muſt conſequently alſo be a very diminiſhed energy in the action of the abſorbents.

The caſes which I have juſt enumerated will be ſufficient to ſhew not only the ge⯑neral effect produced by any obſtruction in the courſe of a lymphatic veſſel, but will very [13]much tend to elucidate the doctrine which I am now about to deliver concerning rheu⯑matiſm. I have already ſaid that I conſider the ſeat of this diſeaſe as eſtabliſhed in the minuter ſeries of thoſe veſſels, which after⯑wards may more viſibly be demonſtrated to be lymphatics. I ſuppoſe that the common cauſes producing rheumatiſm, ſuch as the ſudden application of ſevere cold to the body when greatly heated, and more eſpe⯑cially of cold and moiſture at the ſame time, affect all the different ſeries of the lymphatic ſyſtem, by occaſioning a preternatural con⯑ſtriction of the veſſels, and conſequently di⯑miniſhing their diameters. I need but men⯑tion the ready communicability of heat in bodies of unequal temperatures (as it is a law ſo univerſally underſtood), to ſhew that a part poſſeſſing a given degree of warmth, may ſuddenly be deprived of it, and con⯑tracted in its dimenſions (according to an⯑other general law), by expoſing it to a me⯑dium intenſely cold: for as the lymphatics about the joints uſually run more ſuperfi⯑cially than in other parts, and as there we generally find fewer collateral branches, ob⯑ſtruction [14]ſtruction may perhaps really happen more frequently from cold in thoſe parts than in others; but ſhould it be otherwiſe, yet from the paucity of veſſels, and the conſequent difficulty in the tranſmiſſion of their fluid, when thoſe veſſels have been conſtricted, obſtruction muſt from any common cauſe be oftener there produced, accumulation muſt take place, and tumor, heat, redneſs, and pain muſt follow. When any ſet of veſ⯑ſels have thus had their natural arrangement altered, and their uſual offices interrupted, the diſtenſion may have been ſo great as not only to have weakened them for the preſent, but to have deprived them of the power of diſcharging their duty afterwards. In ſome inſtances indeed even actual rupture of a lymphatic, as I have occaſionally ſeen in rheumatiſm, may be the conſequence of diſ⯑tenſion; for as the fluid which is abſorbed cannot poſſibly regurgitate (notwithſtanding the doctrine of retrograde abſorbents in a late popular work), becauſe abſolutely pre⯑vented by the intervention of valves, and as the extremities of the abſorbing veſſels are here in a conſtant ſtate of activity ſtill taking [15]up freſh matter, the lymphatic muſt either burſt and diſcharge itſelf into the neighbour⯑ing cellular membrane, or the anaſtomoſing and collateral veſſels muſt adapt their capaci⯑ties to the reception and tranſmiſſion of the increaſed quantity of fluid. In either caſe, however, whether of rupture, or of ſuch preternatural diſtenſion, we may eaſily ob⯑ſerve, that if the part itſelf be not deſtroyed, yet the economy of it muſt be extremely diſturbed, and in conſequence of ſuch diſ⯑turbance, that there will always be a liability to ſimilar attacks in future, although the cauſe ſhould even be leſs forcibly applied. I would even venture to ſay, that whenever either of thoſe caſes (rupture or diſtenſion) has happened, that almoſt any increaſed ac⯑tion of the ſanguiferous ſyſtem, whether ac⯑companied by expoſure of the body to cold or not, may produce rheumatiſm more or leſs violent, according to the continuance of that action, and according to the previous injury which may have been done to the lymphatic. Here then we ſee the preciſe difference between acute and chronic rheu⯑matiſm: The firſt always depending upon [16]the operation of external and evident cauſes, which, when powerfully applied, produce a proportionate conſtriction of the lymphatic veſſels, and conſequently an accumulation of fluid in them; the other ariſing from cauſes leſs evident indeed, yet not leſs certain, but connected already with circumſtances which now always neceſſarily exiſting muſt conſti⯑tute a prediſpoſition in the ſyſtem to be af⯑fected by ſuch cauſes, and ſubject it at all times to the effect of their immediate action.

I hope I may preſume to ſay, that the ſudden alteration both of the ſtate and ſeat of the diſeaſe, as well as its tendency to frequent and unexpected recurrence, cannot militate againſt the doctrine which I have juſt ad⯑vanced. The very inconſiſtent idea of me⯑taſtaſis, or tranſition of humor from one place to another, where there is no actual communication of veſſels, ought not certainly to be adduced in argument to the contrary, unleſs it can be proved by ſomething more than aſſertion: for whoever can ſuppoſe a lymphatic capable of being ſuddenly con⯑ſtricted, may reaſonably alſo imagine that conſtriction may ſometimes be as ſuddenly [17]removed, and that the tenſion of the joint may therefore ſubſide; and if an enlarge⯑ment even of the oppoſite limb ſhould then take place, with all the uſual concomitants of heat, and pain, and redneſs, I ſhould think it much more likely to have happened from the general diſpoſition to contractibility, which then particularly exiſts in the lym⯑phatic ſyſtem, and which may poſſibly have been aided by the concurrent though un⯑heeded circumſtance of an unguarded expo⯑ſure to cold, than that the fluid ſhould ſo ſuddenly have paſſed to a diſtant part of the body through veſſels hitherto unobſerved; and ſurely there can be nothing very ab⯑ſurd in the ſuppoſition of an increaſed con⯑tractibility, if we allow that the fever, as it is uſually called, which attends rheumatic caſes, can be ſo propagated as to affect the ſyſtem generally; ſince that very affection in the then very irritable ſtate of the body, may carry along with it, even into the re⯑moteſt lymphatic veſſel, a greater contractile tendency: for every body knows that there are circumſtances in which there is almoſt an excluſive affection of ſome parts of the ani⯑mal [18]machine, without much diſturbing the reſt; that opium, for example, ſhall more eſpe⯑cially affect the nerves, mercury the abſor⯑bents, and antimony the exhalants, that fat ſhall be generally depoſited in the cellular membrane, oſſeous matter in arteries, ve⯑nereal virus in bones, impetiginous acrimony on the ſkin: there is nothing therefore very wonderful that under certain circumſtances alſo the lymphatic ſyſtem ſhould be more liable to be affected than at other times; and if we can believe it ever to be brought into that ſort of inactive or languid ſtate, which we generally denominate relaxed, we ſhall find no difficulty in allowing that it may ſometimes be influenced by an unuſual de⯑gree of energy, and thence deviate into that morbid exceſs of it, which I have called, I know not whether properly or not, its con⯑tractibility.

From this general view which I have taken of the lymphatics, the frequent re⯑currence of the diſeaſe may eaſily be ex⯑plained; and if we alſo recollect what I have ſaid above reſpecting their rupture and diſten⯑ſion, the probability of that explanation will be placed beyond all poſſible doubt, whether [19]it be applied to the acute or to the chronic rheumatiſm.

It will be told me perhaps that as tumor, heat, pain and redneſs, rigor, thirſt, occa⯑ſional vomiting, quickened circulation, and other ſymptoms of inflammatory action are preſent, that the rheumatiſm is an inflamma⯑tion of a peculiar kind, having its own diſ⯑tinct and particular termination; but ſtrong as theſe ſigns certainly are, and characteriſtic as they may be thought to be of the pre⯑ſence of actual inflammation, yet who can⯑not, almoſt immediately, produce the whole of them by the application of a tight band⯑age? The limb ſhall ſwell, feel hot, look red, throb, and be exceedingly painful; and yet although the pulſe ſhall beat more fre⯑quently, ſhivering come on, ſickneſs ſome⯑times ſupervene, and the tongue and fauces even become dry, theſe ſymptoms of inflam⯑mation ſhall immediately ceaſe by the mere removal of the bandage. But here, by the way, it may be ſaid, that ſomething more than ob⯑ſtructed lymphatics are concerned, and that the ſanguiferous ſyſtem is obſtructed alſo: but if where a general obſtruction has taken [20]place, as to produce at once ſuch a powerful combination of ſymptoms ſo ſtrongly indica⯑tory of inflammation, and yet without in⯑flammation actually ariſing, the argument taken ſingly, with reſpect to the lymphatic ſyſtem, will certainly go to prove that in⯑flammation is not very likely to be the con⯑ſequence of an obſtruction there, ſince it is not at all produced when we make the ap⯑plication to both of them together. I might go on to ſay, that even the very ſigns of in⯑flammation, which I have mentioned, are ſometimes very ambiguous; for the paſſing of a ſtone from the kidney into the bladder, or of a biliary calculus into the duodenum, will be accompanied with moſt of them: The ſpaſmodic colic from lead, and cholera, and ſome other diſeaſes which might be in⯑ſtanced, are attended alſo by ſeveral, and yet none of us ever dream of any thing like actual inflammation: and with reſpect to the idea of the rheumatiſm having its inflam⯑matory action terminated in a manner pe⯑culiar only to itſelf, the ſame might, with equal propriety, be ſaid of thoſe diſeaſes which I have juſt enumerated, and where [21]we know for certain that inflammation never happens: Neither will the buffy and ſizy ſtate of the blood, I ſuppoſe, be now inſiſted upon as an infallible proof of inflammation, ſince we all know that in any of the diſeaſes to which I am alluding, and in others where the ſyſtem is acting ſtrongly, the very ſame appearance will undoubtedly occur. But the truth exactly is, that the rheu⯑matiſm can only terminate, as I have before ſtated, by the lymphatic recovering its uſual office, or by neighbouring branches perform⯑ing its duty for it, or by its rupture and the conſequent effuſion of fluid into the cellular membrane; terminations ſufficiently diſtinct (except that of reſolution, which I have above conſidered) from thoſe of inflammation.

It may be needleſs for me to enter into the hiſtory of the ſymptoms of this diſeaſe, as it is in general ſo well deſcribed by others, and, as I ſhould ſuppoſe, known almoſt to all. There is no ſeaſon of the year in which the rheumatiſm does not very frequently occur; but thoſe in which the viciſſitudes of temperature are moſt ſudden produce it of⯑tener than others. Expoſure to cold and [22]moiſture after violent exerciſe, ſitting in a ſtrong current of air when the body is heat⯑ed, going into a damp bed, wearing wet clothes, or any ſuch ſimilar cauſe, will ge⯑nerally produce it. Rigor, heat, reſtleſſneſs, thirſt, and all the common ſymptoms of fever uſually precede a ſenſe of ſoreneſs and ſtiffneſs, which in a day or two are followed by pain and ſwelling all over, but more eſ⯑pecially about the joints of the body. Theſe ſwellings, increaſing in ſize, look red, and become ſmooth and gloſſy; they now and then ſuddenly ſubſide, and ſometimes as ſud⯑denly appear again in the ſame or in other joints: they do not receive the impreſſion of the finger like anaſarcous tumors, except to⯑wards the termination of the complaint when they will occaſionally recede a little upon preſſure. The tongue is commonly white through the whole courſe of the diſ⯑eaſe. The bowels are uſually coſtive, and the urine is of a paliſh amber colour, with a floating ſemipellucid cloud. The fever, after an uncertain duration, diminiſhes by degrees, the water becomes turbid, and depoſits a pink-coloured ſediment, the ſkin feels cool [23]and moiſt, and the pain irregularly abates, al⯑though it does not often entirely ceaſe; and the ſwelling diminiſhes in the order in which it aroſe, firſt in the larger branches of the lym⯑phatics, then in the ſmaller, firſt, for example, in the wriſt, then in the hand, and afterwards in the fingers; but diſtorſion, with little knotty protuberances, containing a glary fluid, and ſometimes an indurated cretaceous-like mat⯑ter, too frequently continues. The patient remains weak, and recovers very ſlowly from a ſevere attack of this diſeaſe, and which, from its aptitude to recur both with and without fever, generally haraſſes him more or leſs through the reſt of his life.

The different appellations, which have been given to this diſeaſe, ſeem only to be of conſe⯑quence, as pointing out to us the part af⯑fected; for under whatever name it may be known, the method which we employ for its cure, after we have exactly aſcertained its nature, is commonly the ſame. There are ſome indeed who think that a particular re⯑medy is more proper in one variety of rheu⯑matiſm than in another, and will uſe that in lumbago, which they never think of in ſcia⯑tica; [24]but if there is general fever throughout the ſyſtem, and great pain, with tumor of a part, it is not material with reſpect to the curative intention, whether it may be ſeated in the loins or the ſhoulders, in an arm or a leg, an upper or a lower extremity. The thing moſt neceſſary therefore for us to deter⯑mine in the method of cure, is the ſimple diſ⯑tinction of the diſeaſe into acute and chronic rheumatiſm; and when that is once exactly known, we ſhould employ that mode which reaſon and experience tell us to be the beſt: and if the caſe be rendered ſometimes obſcure, by being as it were blended, and by partak⯑ing of the nature both of one and of the other, we muſt be guided by ſymptoms, and regulate our conduct accordingly: for if merely the part affected was to determine the remedy, and nothing more than juſt know⯑ing it to be rheumatiſm was judged neceſſary for its cure, I am afraid that lameneſs and deformity would but too frequently be the reſult of ſuch irregular and unſcientific prac⯑tice.

One would ſuppoſe, from the preciſion with which men ſpeak and write upon this [25]diſeaſe, that there was nothing ſo eaſy as the diſtinction of it into the acute and chronic ſtate; and that putting the patient to bed, and increaſing the external heat by covering him with a great number of blankets, would at once determine it; but although in the ge⯑nerality of caſes we can from circumſtances certainly declare which is of one kind, and which of the other, yet I can by no means either allow that the application of external heat is the beſt criterion by which we are to be directed, or that it always increaſes the pain in the acute, whilſt it diminiſhes it in chronic rheumatiſm.

It neceſſarily falls to my lot, in the diſ⯑charge of my public duty (for I would not be thought vain and oſtentatious by arguing from what I may obſerve in private practice), to ſee annually a great number of patients afflicted with this diſeaſe; but I do not find their pains ſo regularly increaſed by external heat as common opinion would have us to ſuppoſe: nay, I will even venture to affirm, that where heat can be applied without preſ⯑ſure, as in warm and vapour baths, and ſweating rooms, the reverſe is the fact, and [26]that not only chronic rheumatiſm (as is al⯑lowed by all) will be thereby relieved, but that the acute alſo will be conſiderably miti⯑gated. The idea of comfort which we at⯑tach to a warm bed, has become ſo habitual to us, that when the accuſtomed reſt does not follow, it is no wonder in our diſap⯑pointment that we ſhould ſometimes con⯑found terms together, and deduce an effect from a cauſe incapable of producing it: for I think it much more reaſonable to ſuppoſe that a patient who cannot bear the preſſure of the hand, as is almoſt always the caſe in acute rheumatiſm, ſhould experience pain equally intolerable by preſſure upon him in bed, than that warmth which under other circumſtances undoubtedly relieves, ſhould here act otherwiſe:—but if I ſhould be told that external preſſure is ſo guarded againſt in many caſes that increaſed pain cannot thence be ſuppoſed to ariſe, I would rather hazard the opinion, that from the patient being placed in a reclined and horizontal poſition, the muſcles muſt be put into other ſtates than they were in before, and that in this devia⯑tion from their ordinary poſture, preſſure [27]more or leſs muſt conſequently be produced upon the diſtended lymphatic, than to allow any thing to the agency of external heat: during this muſcular alteration alſo, we are impreſſed with the idea that rheumatic pain purſues the courſe of the muſcle, when, in reality, it is felt in the direction of the lym⯑phatics, and is no farther connected with muſcle, than water is with muſcle in dropſi⯑cal ſwellings of the cellular membrane; which lies indeed contiguous to it, but does not oc⯑cupy it as the actual ſeat of the diſeaſe.

It has generally been the fate of thoſe diſ⯑eaſes, which have not been well underſtood, to have been treated in very different and even very contradictory methods; and as nature often prevails over the moſt irrational practice, each of theſe ſeveral methods has at one time or other ſucceeded: we need not therefore wonder that men ſhould ſometimes err in referring that to art which is the effect of cauſes purely natural. I might inſtance diſeaſes, not a few, in which either falſe ob⯑ſervation, or obſtinacy of opinion, or wrong deduction, or indolence, or ſuperſtition has introduced ſuch confuſion and incongruity, [28]that it is extremely difficult for a phyſician, who puts too much faith in what he has read, to form a proper deciſion from what he ſees; for he finds it almoſt impoſſible to ſhake off the authoritative opinions of others, although the evidence of his own ſenſes would lead him to a fairer and more obvious concluſion: whoever but even ſuperficially conſiders the treatment of rheumatiſm, will obſerve one ſtrong example of the truth of the general remark which I have juſt now made; for he will find phlebotomy, and bliſters, and purges, and fomentations, and bark, and opium, and mercury, and antimony, and guaiacum, and volatile alkali, and turpentine, and a variety of other remedies applied indiſcriminately in any ſtage of the diſeaſe, and which too have all of them in their turns, at one time or other, appeared to be uſeful; but he will not, if he has not loſt his reaſoning faculties, eaſily believe that from ſuch a diſcordant collection of remedies, it is a matter of indifference which he ſhall chuſe to employ, notwith⯑ſtanding he might be told by this or that author, that each and all of them would cer⯑tainly cure the diſeaſe.

[29]What I ſhall deliver concerning the cure of rheumatiſm, will be taken as, I think, every curative indication ought to be, from comparing the circumſtances as they gene⯑rally ſucceed each other, with thoſe which in the natural ſtate of the body are known to conſtitute health; and without being influ⯑enced either by the plauſibility of a theory, where facts ſeem not to accord with it, or by the authority of great names, which ſome⯑times we know can ſtamp a value upon in⯑conſiſtency, I will juſt ſtate the progreſs of the diſeaſe, and follow it as well as I am able, with the appropriate means of relief.

When a patient firſt complains of ſtiffneſs and ſoreneſs, and theſe are accompanied by the common ſebrile ſymptoms, we know not exactly what diſeaſe is about to ſucceed: for it may turn out to be ague, or any other ſpecies of fever ſtrictly ſo called, it may poſſibly be one of the exanthematous diſeaſes, or it may be any one of ſeveral other diſorders, juſt as likely as it may be rheumatiſm:—but we know ſuch an at⯑tack to be a deviation from the natural ſtate of the body; and, therefore, immediately employ thoſe means which a proper conſide⯑ration [30]of the concurrent ſymptoms ſeems to require.—The patient is, perhaps, accordingly adviſed to go to bed, and to uſe thoſe remedies which are calculated to promote an evacua⯑tion from the bowels, and produce an increaſ⯑ed perſpiration—but the choice of theſe reme⯑dies is certainly not a matter of indifference; a diſeaſe of conſiderable activity, as we judge from the previous and then exiſting circum⯑ſtances, is now approaching, and, therefore, in our endeavour to regulate the diſordered ſtate of the animal economy, we ſhould be careful leſt our attempt ſhould be the cauſe of much greater confuſion. In ſuch caſes I ſhould ſuppoſe phyſicians would rather ſim⯑ply employ the neutral ſalts, than purge with calomel, or jalap, or colocynth, or any of the reſinous articles of the Materia Medica, notwithſtanding it might appear to the patient, and to his friends, as a thing of very little moment how the evacuation was procured, or whether a cooling or a ſtimulating medi⯑cine had produced it: and for the ſame rea⯑ſon would bath the legs in warm water, and uſe antimony, and ipecacuanha, and ſaline mixtures, and all the milder kinds of diluent [31]and diaphoretic remedies, in preference to guaiacum or contrayerva, or ſpice, or alko⯑hol, or volatile alkali; for if by relaxing the excretories, perſpiration can by the common and the natural power of the ſyſtem be more copiouſly produced, there is no need of quickening the circulation, and conſequently of ſtimulating any ſet of veſſels to produce the ſame effect, when an increaſed action of the ſyſtem is not only not deſirable but is even hurtful.

But I muſt ſuppoſe, for the ſake of ar⯑gument, that the diſeaſe does not in a day or two yield to this method of treat⯑ment, but (as is then always the caſe) ſhews itſelf by more evident ſymptoms actually to be rheumatiſm: we may then, if we pleaſe, certainly proceed with ſtrict propriety to phlebotomy as another powerful means of diminiſhing the activity of the ſyſtem, we may urge our relaxant plant with greater energy, we may ſupply our diluents plenti⯑fully, we may uſe fomentations, or the warm bath, we may apply leeches, and we may give opiates: by this time, perhaps, the diſ⯑eaſe may have been mitigated, and as the ſyſtem may probably have been much weak⯑ened, [32]by the neceſſary evacuations, ſomething more cordial as well as tonic may now be allowed along with the relaxant remedies; but we ſhould be well convinced that the rheumatiſm has very much ſubſided before we hazard the uſe of wine, or ſteel, or bark ſingly.—Irregular pains will now, perhaps, occupy different parts, although the febrile ſymptoms ſhall have ceaſed altogether; and, therefore, in this latter ſtage of the diſeaſe we may apply cupping glaſſes, and bliſters, and ſtimulating plaſters, and liniments; and we may uſe calomel, or volatile alkali, or turpentine, or guaiacum, or any other re⯑medy of that claſs, which we may then more particularly approve.

This we may conſider as the general out⯑line of the cure of rheumatiſm, which it is ſufficiently eaſy for any of us to fill up ac⯑cording as the ſymptoms of the diſeaſe may vary, or as circumſtances may require.—I will further, however, endeavour to ſhew as briefly as I can, how the ſeveral claſſes of remedies into which I have thought it right to divide the Materia Medica can be applied, and of which I ſhall more eſpecially mention [33]thoſe medicines whoſe uſe has commonly ob⯑tained in this diſeaſe.

The claſs of aſtringents ſeems but of little uſe in the commencement of rheumatiſm; for where there is too much obſtruction al⯑ready, one would not hazard any remedy which might poſſibly diminiſh the area of veſſels—and although it might be ſaid that the obſtructed veſſels cannot admit of further conſtriction, from the impoſſibility of receiv⯑ing the aſtringent remedy into them, yet no one will doubt that it may find admiſſion into the neighbouring veſſels, and conſe⯑quently deny to the collateral branches that ready communication with the obſtructed part, by which it uſually experiences relief: and here I will obſerve, once for all, that I conſider every medicine as carried through the ſyſtem, and as capable of acting upon the containing veſſels; for although it may be aſked, how can we conceive it probable that a grain or two of an aſtringent medicine can be ſo divided as to affect every part of the body; I would anſwer, that perhaps on this very diviſibility of it depends its greater efficacy, and that if by the common teſts of [34]chemical experiments, we can certainly diſ⯑cover a ſingle grain of vitriolated iron mi⯑nutely diffuſed through every drop of ſeveral gallons of water, there is no good reaſon to reject the ſuppoſition that the ſame, or any other medicine, may be equally divided and diffuſed through the whole animal machine. I am well aware of opinions to the contrary; but it is unneceſſary to make any further di⯑greſſion upon a ſubject which is not immedi⯑ately before us. But although in the early ſtages of rheumatiſm, an aſtringent remedy cannot be employed with advantage, yet when the pain and ſwelling have ſubſided, and the ſtrength of the patient has neceſſarily been greatly diminiſhed by the continuance, as well as by the treatment of the diſeaſe, it may then be given with conſiderable benefit. It does not belong to this place to ſhew how aſtringents may ſecondarily produce a tonic effect: otherwiſe I might ſtate that a gentle aſtrictive power conſtantly applied to the ſimple fibre, muſt increaſe the coheſion of its parts, and conſequently render it ſtronger; and that whilſt this application is made (as I conceive it may be made univerſally, whether [35]by acids, or by metallic or vegetable matters) a greater energy is given to the whole ſyſtem, by which it is enabled to diſcharge its ſeveral functions more and more perfectly, until at laſt the regular and natural tone of it is com⯑pletely reſtored.

Emollients from affecting the ſimple fibre, in a manner directly the reverſe of aſtrin⯑gents, I need not ſay ought to be uſed when the tenſion is great, and heat and pain con⯑ſequently very urgent; for under contrary circumſtances every one thinks the mollify⯑ing power of oil, or mucilage, or water, either applied ſeparately or in the form of liniments, poultices, or fomentations, not only unneceſſary but ſometimes hurtful.

I have before taken occaſion to obſerve, that every thing which ſtimulates the ſyſtem in ſome ſtages of the acute rheumatiſm muſt be improper; the claſs of ſtimulants therefore, which increaſes the action of the living ſolid, can only be employed under particular cir⯑cumſtances of this diſeaſe, notwithſtanding the frequent and indiſcriminate uſe which is made of ſome of the remedies which are therein contained. If anatomiſts are right [36]in ſaying that there is a ſecerning extremity of an artery, whoſe ſecretion may be aug⯑mented in proportion as the circulation is increaſed, and if I am right alſo in fixing the [...]eat of rheumatiſm, as I have already done, in thoſe ſmaller veſſels which conſtitute the firſt orders of the lymphatic ſyſtem, ſurely no remedy can be proper which tends to pro⯑mote the ſecretion of a larger quantity of a fluid, which is at preſent in too great abun⯑dance, and whoſe abſorption muſt undoubt⯑edly add to the exiſting difficulties; for here I ſuppoſe ſtrong abſorptive efforts always to take place, ſince in rheumatiſm the extremi⯑ties of the lymphatics are active and vigor⯑ous, and the body not otherwiſe in a ſtate of diſeaſe, than as it may be induced by the obſtruction and diſtention in the lymphatic veſſels—far different from that ſtate where the energy of the animal machine has been deſtroyed by previous diſeaſe, where the fluid is permitted as it were to eſcape from the ar⯑tery through its ſecerning extremity, where it is collected in every cavity, where it is dif⯑fuſed every where throughout the cellular membrane, and where the abſorbents are as it ſhould almoſt ſeem in a ſtate of flaccidity, [37]and have not force ſufficient either to expand their orifices, or power to imbibe the extra⯑vaſated humidity.

As theſe obſervations will abundantly ſuf⯑fice to elucidate the idea which I have enter⯑tained both of the abuſe of ſtimulants in rheumatic caſes, and of the time alſo when they may occaſionally be given with advan⯑tage, I will only obſerve, that the nearer the ſtate of the diſeaſe is to that which we com⯑monly call chronic, and of courſe the leſs connected it may be with pain, and heat, and tumor, the more rationally will this claſs of remedies be applied. Although the guaia⯑cum is chiefly uſed, yet any of the reſins, or the balſams, may properly enough be em⯑ployed with ſimilar intentions—for when the ſyſtem is languid, the circulation feeble, the pains irregular, and the lymphatic wea⯑kened by diſtention, we want ſomething to promote a ſteady uniform action—for as de⯑bility will equally operate in occaſioning congeſtion in the lymphatics as in other places; ſo any thing which increaſes the activity of the living ſolid may remove it, and by producing an uniformity of action [38]afterwards prevent its recurrence. I know very well that my opinion reſpecting the uſe of ſtimulants in acute rheumatiſm, will be attacked by the argument of volatile alkali (which we all allow to be one of the moſt active medicines of this claſs) being very fre⯑quently given with conſiderable ſucceſs, and promoting an eaſy and a copious diaphoreſis; but that I may not ſhrink from the opinion, and deſert it as ill-founded, I beg leave to urge in favour of it, that in nine caſes out of ten, the ſtimulant power of ammonia is deſtroyed, before it can poſſibly act upon the ſyſtem in general. Every one who knows any thing about chemical affinities will agree with me when I aſſert, that the mucus of the ſtomach will immediately unite with it into a kind of ſaponaceous maſs, and as ſuch directly render its ſtimulant effect very doubtful; but if it be allowed that acrid, or acid matters ever exiſt in the ſtomach, the ammonia which was given under the impreſ⯑ſion of its ſtimulating power will be con⯑verted into a neutral ſalt, into a kind of ſpiri⯑tus mindereri, and act upon the ſyſtem with a truly relaxant power. I have no heſitation [39]in ſaying, that ſuch is my opinion alſo with reſpect to the two fixt alkalies, the kali and natron, which I conſider as ſtimulants in leſs degree, but which are convertible into very different medicines, by the means above⯑mentioned: if likewife, as is uſual, the pa⯑tient dilutes plentifully with ſimple watery fluids, the fact will be more obvious, and the relaxation much more compleat. Al⯑though I ſhall not, perhaps, be allowed by ſome to reckon calomel, and other mercu⯑rial preparations, as belonging to the claſs of ſtimulants; yet experience will bear me out in ſaying, that mercury is as hurtful in the acute, as it is uſeful in the chronic rheuma⯑tiſm: I do not mean to ſay, that an occa⯑ſional mercurial purge can do any particular miſchief in the moſt acute ſtage of the diſ⯑eaſe; but wiſh my obſervation, reſpecting this mineral, to be applied only to its regu⯑larly repeated doſe, which, I ſuppoſe, given after certain intervals, like any other ſtimu⯑lant medicine, and which, I believe, in acute caſes always aggravates the diſeaſe. All acrid matters taken from the vegetable king⯑dom as ſtimulants, muſt not for the ſame [40]reaſons be indiſcriminately employed; for the arum, cochlearia, naſturtium, raphanus, and ſuch like, cannot be proper, except in chronic caſes: in the ſame kind of general obſerva⯑tion I might include the aromata, which are ſometimes given, as well as thoſe other more ſtrictly medicinal articles contrayerva, ſerpen⯑taria, and caſcarilla: there are others ſuch as ſarſaparilla and ſaſſafras, which might alſo be included in the above remark; but the effects, which I ſhould otherwiſe expect from their ſtimulant power, are often obviated by the watery vehicle with which they are diluted, when given, as they uſually are, in the form of decoctions: I need not add that vinous liquors of every kind muſt, however they may be diluted, be conſidered as very highly improper in acute rheumatiſm, whether ad⯑miniſtered under the denomination of ſpirits, tinctures, wines or ales. The tepid ſprings of Buxton, and of Bath, when taken inter⯑nally, ſeem to me to produce that gently continued ſtimulant effect which I have con⯑ceived to be ſo very eſſential towards obtain⯑ing the cure of chronic rheumatiſm.—I know very well that caſes alſo of the acute kind [41]are relieved by both of thoſe waters (by thoſe of Buxton more eſpecially); but, I ſup⯑poſe, in thoſe inſtances that the good effects produced, have ariſen rather from the emolli⯑ent and relaxant power of the external appli⯑cation, than from their internal exhibition; I will not, however, pretend to deny that as diluents alſo, they may ſometimes be ſervice⯑able in acute rheumatiſm, and that, when uſed as baths, they likewiſe very conſtantly relieve the chronic ſtate of the diſeaſe.

If what I have ſaid reſpecting ſtimulants be founded in reaſon, very little argument will be neceſſary to prove, that the claſs of ſeda⯑tives muſt, in almoſt every ſtage of the diſ⯑eaſe, be proper. I would beg, however, to be underſtood, that I call thoſe remedies ſe⯑dative, which, without weakening the ſyſtem, diminiſh its activity, and which may from a ſtate of motion, bring it under certain cir⯑cumſtances entirely to reſt: all medicines, therefore, of the narcotic kind, will be in⯑cluded under that diſtinction which I intend by the claſs of ſedatives; for the great vari⯑ety of remedies, which are ſaid to produce a ſedative effect, produce it ſecondarily only [42]through the intervention of ſome primarily acting cauſe: thus will aſafoetida, or ammo⯑niacum, or amber, or caſtor, or muſk, which we every day ſee given in ſome ſpaſmodic affections, overcome irregularity, or inequa⯑lity of action, by means of their ſtimulant power, indirectly producing, with reſpect to the exiſting ſymptoms, a compleat ſedative ef⯑fect. Opium and cicuta are the ſedatives which I have more eſpecially employed in this diſeaſe, and ſuch as may boldly be given every three or four hours, when the circumſtances of tenſion and pain, and watchfulneſs, ſeem to require them—Aconitum, hyoſcyamus, digi⯑talis, and ſome others may, perhaps, like⯑wiſe be found occaſionally ſerviceable; but cuſtom has not yet ſufficiently familiariſed theſe even within the ſphere of medical practice. I think from the effects obſervable after a large doſe of camphor, that I am au⯑thorized in conſidering it alſo as a powerful ſedative—as ſuch I have very frequently given it, and as ſuch alſo, from the benefit generally obtained, I cannot but very ſtrongly recommend it.

Tonics which may be ſaid to maintain the [43]power of the ſyſtem, without increaſing its action, may certainly very often be given with great advantage; but when the body is already ſtrong, when the circulation is power⯑ful, the muſcles firm, and the ſecretions re⯑gular, they cannot, I believe, do any good whatever. For in acute rheumatiſm, where the ſyſtem in point of ſtrength deviates little or nothing from its natural ſtate, we uſually, amongſt other modes of relief, attempt the recovery of our patient by means alſo which have a tendency to diminiſh both its force and its activity; and, therefore, I ſhould ſuppoſe when in the courſe of this diſeaſe the body becomes exhauſted, the circulation weak, the muſcular power enfeebled, and the functions imperfectly diſcharged, that bark, and ſteel, and bitters, and ſuch like remedies, were then only admiſſible.

The benefit which may be traced from the uſe of relaxants, in the acute ſtage of this diſeaſe, will always attach a very conſidera⯑ble value to this claſs of remedies. If we examine the opinions of thoſe who are the beſt informed upon this ſubject, we ſhall at leaſt find the majority of them favouring and [44]recommending a relaxant plan; for bleeding, purging, and ſweating are, as it were, the three great cardinal pivots on which both the ancient and modern practice ſeems to turn. That the loſs of blood will diminiſh the acuteneſs of this diſeaſe, experience abun⯑dantly confirms; but if we keep in view the account which I have above given, of its nature, and of its ſeat, we ſhall then moſt clearly ſee, that the diminiſhed quantity of circulating fluids muſt neceſſarily occaſion a diminution in the quantity to be ſeparated by the ſecerning extremity of the artery, and conſequently afford proportionally leſs to the active and healthy operation of the orifices of the abſorbent veſſels: hence, if any part of the lymphatic ſyſtem be over⯑charged and diſtended, it hereby acquires time to accommodate itſelf to the obſtruct⯑ing cauſe; for as a depletion has been made in the blood veſſels, it is neither equally preſſed upon from behind by the acceſſion of freſh fluid, nor meets an equal obſtacle to the regular diſcharge of its burthen into the veins, but then more readily propels its contents, and contracts itſelf to its uſual dimenſions. [45]The advantages to be derived from purging in acute rheumatiſm do not merely depend upon the excrementitious matter evacuated, but upon the loſs of a large quantity of fluid poured from the different excretories into the inteſtinal canal during the operation; for the ſudden evacuation of any fluid, tends directly to diminiſh the quantity in the cir⯑culating veſſels, and muſt conſequently pro⯑duce a proportionate degree of general relaxa⯑tion. The remedies which will promote a determination, as it is called, to the ſurface, have always been held to be proper both in the acute and in the chronic rheumatiſm; but the choice of them is not, as I have before obſerved, a matter of ſmall moment; for there is a manifeſt difference, whether the diaphoreſis be produced by ſtimulant or by relaxant remedies. I need not again go over arguments to prove that the chronic rheuma⯑tiſm, which is more eſpecially confined to a part, owes its very exiſtence to the debility there produced by previous injury, either from diſtenſion or from rupture—in either of theſe caſes, a regularly exhibited ſtimulant, by giving a little more energy to the whole [46]ſyſtem, promotes a more uniform action of the diſeaſed part, and often completely effects a cure: but it is not neceſſary, I think, that actual ſweating ſhould be produced; for the cure depends, as I ſuppoſe, not upon ex⯑ceſs of action, but upon its uniformity: for the exceſs either with, but more particularly without ſweating, often aggravates the diſ⯑eaſe. In the acute rheumatiſm, however, where the ſyſtem is in general acting pow⯑fully, and where the part diſeaſed has really become ſo from cauſes of obſtruction, which are entirely independent of debility, the dia⯑phoreſis muſt be produced by very different means: and here the neutral mixture of acid and alkali would hold a moſt diſtinguiſhed place, were it given in large and proper doſes; but as the prejudices of mankind will not often allow them to get out of a beaten path, we are too frequently obliged either to exhibit this mildeſt and very efficacious re⯑laxant in a manner ſo inert as almoſt to diſ⯑grace its character as a medicine, or to call in the aid of other remedies, which are ac⯑tive in ſmaller doſes: for if it is intended to produce the full effect of a relaxant, I think [47]it ſhould be given as an ordinary drink, in the way in which we would direct barley⯑water, lemonade, imperial, or any other com⯑mon or medicated diluent. In this mode of adminiſtration it would operate upon the bowels alſo as a gentle laxative, and render the uſe of kali vitriolatum, kali tartariſatum, natron vitriolatum, and others of this claſs, which we uſually diſtinguiſh by the general name of neutral ſalts, almoſt altogether un⯑neceſſary; ſome of which however, by the bye, and perhaps all of them, if given in ſmaller doſes, than thoſe in which they are commonly exhibited as purgatives, would be little if at all inferior to the celebrated draught of Riverius.

In the claſs of relaxants, uſeful in acute rheumatiſm, I muſt very particularly reckon the antimonials. I need not ſay that all of them may be ſo managed, as to produce their proper effect; and that even in the chronic ſtate of the diſeaſe, they may be ſo combined with calomel, guaiacum, or other ſtimulants, as to form a remedy often very highly ſerviceable. Ipecacuanha, and per⯑haps ſome other remedies which in certain [48]doſes provoke nauſes, belong alſo to this claſs of relaxants: The pulvis ipecacuanhae com⯑poſitus (Dover's powder) has long been con⯑ſidered as a medicine of very great utility in acute rheumatiſm; and is one of thoſe hap⯑py compounds, where the relaxant effects derived from two of its ingredients, ſeem to be improved by the ſedative power of the opium.

Water, milk and water, milk-whey, but⯑ter-milk, barley-water, and ſuch others as may alter the ſtate of the fluids ſimply by diluting them, are very proper, both in the acute and in the chronic rheumatiſm; but indeed I do not know whether I ought to have ſtated any thing as diluent beſides water; for the others which I have enumerated, together with all the various mucilaginous decoctions, mixtures, and emulſions, which might be mentioned, ſeem more particularly to belong to the claſs of demulcents, which in rheumatiſm, as we do not ſuppoſe any acri⯑mony preſent in the ſyſtem, as its cauſe, we need not particularly conſider.

The remaining claſſes of remedies which merely promote the diſcharge of matters from the body which have become oppreſſive or [49]excrementitious, without affecting (or affect⯑ing but little) the general economy of the animal machine, are but in a ſmall degree applicable in the cure of rheumatiſm. Thus apophlegmatics or thoſe remedies which cleanſe the mouth and fauces, are not at all neceſſarily employed in this diſeaſe. Emetics indeed may indirectly promote the action of the abſorbents, and may or may not, as cir⯑cumſtances happen to combine, be uſeful in ſome caſes; and if they are given only in ſuch ſmall doſes as to create a conſtant nau⯑ſea, they may certainly produce a relaxant effect. The ſame obſervation may alſo be extended to purgatives, which beſides eva⯑cuating the inteſtinal canal may, as I have above obſerved, be followed by other very beneficial effects: but until we ſhall be con⯑vinced that there is ſome morbific matter to be expelled, which is the cauſe of rheuma⯑tiſm, or granting that, until we can bring ourſelves to ſuppoſe that by means of glan⯑dular ſecretion, ſuch a matter can be ſeparated from the general maſs of fluids, and more⯑over that the kidnies are the glands more di⯑rectly appropriated to that purpoſe, we ſhall [50]not, I think, completely truſt the cure of this diſeaſe to the very fallacious and uncertain action of diuretics.

SUCH, dear Sir, are the opinions which I have long entertained reſpecting rheumatiſm: I have been led towards them by no blind guides; for in this, as well as in moſt other things which bear any relation to our profeſ⯑ſion, I have endeavoured to follow reaſon and experience. I may indeed have miſ⯑taken my conductors, and been impoſed upon by the meretricious charms of fancy and hypotheſis; but unleſs you who are ſo well qualified to be my judge, convict me of error, I muſt ſtill continue to advance and to maintain them. Influenced therefore by the ſame ſentiments, and guided, as I believe, by the ſame directors, I will now proceed to conſider the principal phenomena attendant upon gout; and to point out, as conſiſtently as I am able, ſome of thoſe almoſt unintel⯑ligible circumſtances which have always ac⯑companied this diſeaſe.

[51]As I have endavoured, in the former part of this letter, to make it appear that neither gout nor rheumatiſm are at all con⯑nected with the doctrine of inflammation, it will be unneceſſary for me here to repeat the arguments, which I then adduced in ſupport of an opinion, which was intended to be diſtinct⯑ly and unequivocally underſtood. The ana⯑logy which thence I think exiſts between the two diſeaſes will become however much more obvious when we ſhall have conſidered that the ſeat of both is preciſely the ſame, that their progreſs is not much unlike, and their termination not very diſſimilar.

Flatulence, eructation, nauſea, coldneſs in the region of the ſtomach, dyſpepſia, borbo⯑rygmi, languor, vertigo, palpitation, dyſ⯑pnaea, quick ſmall and interrupted pulſe, ſlight rigors, with irregular and clammy ſweats, all or ſome of them uſually accom⯑pany the gout; and if pain be conſtant and exceſſive, either in the hands or feet, wriſts, elbows, ancles or knees, attended with the common febrile ſymptoms, and increaſing for ſeveral hours with heat, redneſs, and tumor, and, in the courſe of a few days, gradually [52]again ſubſiding with itching and ſweating of the part, the patient is ſaid to have had a re⯑gular ſit of the gout; but if the pain ſhould be equally violent, and inſtead of the extre⯑mities ſhould affect the head, or lungs, or ſtomach, or bowels, or kidnies, or bladder, the gout is denominated miſplaced; but if the pain ſhould be inconſtant, with reſpect to its duration, and attack one place, and then an⯑other, without producing any very conſider⯑able heat or tumor, it generally obtains the name of an irregular fit. To theſe may, I think, be referred all the varieties of gout which we meet with either in books or in practice; and theſe again, as we ſhall pre⯑ſently ſee, might, I believe, be more properly diſtinguiſhed, like rheumatiſm, into the acute and chronic.

The ſenſations which patients experience during a fit of the gout, are ſo different⯑ly deſcribed by them, that we cannot col⯑lect any thing very accurately from their deſcriptions, except one circumſtance, and in that they all agree, that the pain is exqui⯑ſite. In one it gnaws, in another it lacerates, in this it burns like red hot iron, in that it chills him like ice, this feels the bones ſcrewed [53]out of their ſockets, and that declares them to be bruiſed to a jelly. In ſhort, in this as in other diſeaſes where there is exceſs of pain, the ſenſes muſt neceſſarily be diſturbed; and as ſenſation has thus conſequently been rendered imperfect, we may very naturally expect a diverſity in their deſcriptions.

It has been obſerved of gout, that it ſel⯑dom attacks any perſons but thoſe of adult age—and of theſe more particularly, perhaps only, ſuch as have indulged in thoſe kinds of exceſſes, which have done violence to the ſyſtem, by diſturbing or deſtroying its func⯑tions. And here, in the very foremoſt rank, muſt I place that moſt pernicious of all poſſi⯑ble habits, which conſiſts in the uſe of vinous and ſpirituous liquors: for not only gout, but dropſy, palſy, apoplexy, and inſanity, in a manner moſt evident and incontrovertible, are too frequently derived from the abuſe of them. I need not endeavour to make the picture more horrible, by filling it up with groupes of miſerable wretches, who deduce their diſeaſes from the ſame undoubted cauſe; otherwiſe I might ſtate it as a fact, that at leaſt the half of all their infirmities is ſo produced, and that there is not perhaps more [54]than one fourth of the catalogue unconnected with it. I might alſo extend my obſervation to the influence which this moſt fatal cuſtom has upon the morals of the world, were I not likely to be conſidered as ſtraying a little beyond the line of my profeſſion: I cannot however help mentioning, that in one of the hoſpitals, where I have the honour of having my ſervices accepted as the phyſician, that not one in ſix of thoſe unhappy females, who have been addicted to intemperance in drinking, is reclaimed, although more than two thirds of the whole number there ad⯑mitted are eventually reformed. But let not the argument, againſt the abuſe of liquors, be ſuppoſed only to be applied to thoſe in the loweſt ranks of ſociety, for it will be found juſt and applicable to all; as well to thoſe who are in a ſtation below mediocrity, as to thoſe who are very much removed above it: one may indeed diſpatch his buſi⯑neſs ſooner than the other, but both of them are found at laſt to have done it ſurely and effectually: but as it will naturally enough occur as a queſtion, what may really be the abuſe of wines or of ſpirits, I will not heſitate to declare, that whenever it diſturbs the [55]animal economy, it muſt be improper, and that the uſe of it at all will then conſtitute its abuſe. I know very well, that in a ſtate of health there are ſometimes certain condi⯑tions which require the uſe of wine or of ſpirit; but if thoſe conditions frequently oc⯑cur, the occupation which produced them ought rather to be changed, than that the neceſſity for the remedy ſhould, by its repe⯑tition, by degrees at laſt convert it into a poiſon: For the natural antidote of languor and fatigue is reſt, and if we ſubſtitute a re⯑medy, which by its ſtimulant powers com⯑pels the ſyſtem to do more than in its ordi⯑nary ſtate it is accuſtomed to perform, the conſtitution muſt at laſt break down, and diſ⯑eaſe of ſome kind or other muſt inevitably follow. The very conſtant cuſtom of drink⯑ing wine and ſpirits has now indeed ſo very much obtained, that one would almoſt think that they were equally neceſſary to life as food; and that they were as conducive to eaſy and complete digeſtion, as they are in reality in the end deſtructive of it. I may very poſſibly be told that there are numbers in the regular habit of taking all ſorts of li⯑quors, [56]and who are living to a good old age, without experiencing any bad effects from them—but I would aſk, in return, whether they actually experience any good effects; whether one, who may thus be ſaid to be fortunate, has not outlived an hundred in⯑ſtances to the contrary—and whether the ſin⯑gle example, which has thus happily reſiſted injury, ought to be admitted as a fair argu⯑ment to prove the innocence of a cuſtom, when it is in the power of every medical practitioner to point out numbers who are daily becoming martyrs to it.

During this habitual and pernicious prac⯑tice, which might produce any of thoſe diſ⯑eaſes which I have ſaid moſt commonly fol⯑low as the effects of it, the indulgence with reſpect to food determines it rather to be gout than any other. For the ſtomach, al⯑ready enfeebled by being accuſtomed to the moſt powerful ſtimulants, ſeems now to re⯑liſh or to bear only that ſort of aliment which is immoderately ſpiced and ſeaſoned, and which, if it yields any nutriment at all, muſt afford it in conſequence of a hurried and in⯑complete digeſtion, from which there muſt [57]neceſſarily be prepared a crude and vitiated chyle: and although probably in the natural and regular diſcharge of the functions of the body any little error may, by the powers of the ſyſtem itſelf, be corrected, yet where any organ has loſt its energy, and the means which deſtroyed it are ſtill continually ap⯑plied to it, we muſt not expect that nature can any longer reſiſt ſuch reiterated violence. But theſe indulgencies are often unavoidably connected with another circumſtance, which is almoſt equally injurious to the regular economy of the animal machine; the uſual hours of reſt are generally encroached upon by a debauch; and when an opportunity of retiring at laſt arrives, ſleep, which ought to renew his ſtrength for the various employ⯑ments of the ſucceeding day, if it comes at all, generally viſits him in all the horrors of apoplectic ſtertor, oppreſſive colliquation, ſickneſs, dreams, and incubus.

From the obſervations which I have already made, it will eaſily be ſeen that I conſider a preternatural degree of irritability to be ge⯑nerated in the ſyſtem as the effect of exceſſive ſtimulus; and that the digeſtive faculties be⯑ing [58]thereby alſo deranged, chyle in an im⯑perfect ſtate, is conſtantly forced upon the lacteals, and thence into the circulation, in a greater quantity than the ordinary offices of the intervening glands, and of the lungs are able to correct. An incongruous unaſ⯑ſimilated fluid muſt therefore every where be circulated, and expoſed to the action of the ſecerning extremities of the arteries. Here indeed it may be modified and rendered more fit to enter by the abſorbent ſyſtem, where it is further modified before it is ultimately conveyed into the circulation again; but the body may be in ſuch an extreme ſtate of ir⯑ritability that the lymphatics, upon receiving this imperfect fluid, may thence immediately be diſturbed, their functions interrupted, conſtriction produced, and pain, heat, red⯑neſs and tenſion follow. Gout therefore, ac⯑cording to this idea, may, as the common expreſſion has it, be flying all over the body, for every lymphatic throughout the ſyſtem may more or leſs be affected. If ſituated in a patient's extremities it is generally at⯑tended by the uſual ſymptoms, which in an active ſtate of the body conſtitute it a re⯑gular [59]fit; but if miſplaced, or ſeated in parts very eſſential to life, the ſame activity of ſyſtem immediately produces ſuch imminent diſtreſs, that death, too frequently unexpect⯑ed, ſuddenly deſtroys him. I need not ſay that this is the gout which may reaſonably enough be denominated acute, ſince it is quick in its acceſſion, and ſpeedy in its pro⯑greſs. The ſame common cauſes which were enumerated as tending to bring on an attack of rheumatiſm, may here alſo very likely co-operate, and ſix a man at once with a fit of the gout, which might other⯑wiſe have deferred its viſit to a more diſtant period—for the conſtitution ſometimes ſuf⯑fers long under a variety of ſymptoms pro⯑ceeding from indigeſtion and the want of a proper aſſimilation, until ſuch occaſional cauſes, concurring with the increaſing irrita⯑bility of the ſyſtem, at laſt render the diſeaſe more manifeſt.

I might, perhaps, with more propriety of arrangement, have added above to the ex⯑ceſſes which become the foundation of an irritable and depraved ſtate of the body, that any thing ſuperadded to thoſe irregularities [60]which in its conſequences diminiſhes the vigour of the ſyſtem, muſt neceſſarily in⯑creaſe that irritability and deprativity: thus it has always been maintained that immoderate venery, and intenſe ſtudy, as they are two principal cauſes of debility muſt very conſi⯑derably augment any previouſly exiſting diſ⯑poſition to a gouty affection: but, I think alſo, that independent of ſuch a previous diſ⯑poſition they may eventually produce the diſeaſe; for whatever debilitates the general frame muſt debilitate its functions, and by that means ultimately induce not only pre⯑ternatural irritability of the ſolids, but ſuch a depravity of the humours, that may or may not terminate, as occaſional cauſes may conſpire, in a fit of gout: I think too, that a conſtant anxiety of mind, accompanied with daily bodily fatigue (as, for example, muſt inevitably happen in the profeſſions of phyſic and of law) may for the ſame reaſons, even in early life, create ſuch a diſpoſition, as when the frame grows old, and the powers of the ſyſtem become weaker, may end, ac⯑cording to circumſtances, in actual gout: I know very well that ſome of my friends will [61]here ſmile, and ſay, that in ſpeaking of cauſes, I have purpoſely omitted to mention all the good living which profeſſional men have the credit of enjoying with the world in general; but be that as it may, there cer⯑tainly are to be found ſome inſtances in both of them, as well as in ſeveral other very active employments, where from cauſes not at all connected with any ſuch ſort of enjoy⯑ment, the gout torments a man who really does not ſeem to have deſerved it: and, I believe alſo, that a ſolitary inſtance may even now and then ariſe in perſons of advanced age and irritable fibre, where from merely an alteration in the ſtate of the lymphatic, by induration or oſſification, the hands and feet ſuddenly become ſwoln and painful, and aſſume every appearance of a regular fit: But the gout which ſeizes a patient under the ſeveral circumſtances which I have juſt been endeavouring to deſcribe, is ſeldom very violent in its attack, or very quick in its pro⯑greſs. As it appears in debilitated habits, and is irregular in its acceſſion, it has been uſually called atonic gout, but as it is gene⯑rally of long duration, I would rather wiſh [62]to follow the analogy, and give it the appel⯑lation of chronic; for the ſeat of it is the ſame with its kindred diſeaſe of rheumatiſm, and like it too it continues through the remainder of life at uncertain intervals to diſtreſs the miſerable ſufferer.

I have above mentioned, that the gout may be miſplaced, as it is commonly termed, and by ſeizing upon ſome of the nobler parts immediately deſtroy life; but I beg leave here to aſſert it as my opinion, that either in the acute or chronic ſtate of the diſeaſe, the patient may ſuddenly die without any attack of actual gout upon thoſe parts, without any miſplacement, without any retroceſſion. I believe it will be admitted by all that there is both in health and in diſeaſe, a particular conſent throughout the ſyſtem, and a ſort of ſympathy exiſting between diſtant parts, that when one is affected, another, without any direct communication, ſhall be affected alſo. The diſlocation of a joint ſhall be attended with ſyncope; and an inflammation of the kidnies with vomiting:—an overcharged ſtomach ſhall produce headach, cholera ſhall be accompanied with ſpaſms of the legs, and [63]a wound of the toe or ſinger be followed by a locked-jaw, or even univerſal tetanus; and why may we not ſuppoſe that in the exqui⯑ſite irritability of ſyſtem which always ac⯑companies gout, that from cauſes which muſt probably for ever remain inexplicable, the head, the lungs, the ſtomach, or the inteſ⯑tines, may alſo ſympathiſe with the diſtantly affected part in a ſimilar manner?

It I were not afraid of entering into a conteſt about a matter of mere opinion (for which I have but little leiſure, and leſs incli⯑nation) I ſhould almoſt be diſpoſed to diſpute the doctrine of hereditary gout: I will allow that it has attacked father and ſon, from one generation to another, through a long ſeries of years; but unleſs it can be ſhewn that the education of the child has been correctly proper, and unleſs it can be proved that the ſon has not lived as the father, I have a right to maintain that the gout might originate with the ſon, as well as with the father be⯑fore him: and if it can be proved (as it may in a thouſand inſtances) that a gouty family by change of fortune—from a ſtate of affluence to that of an inferior condition, [64]has ever loſt the diſeaſe, we may then very juſt⯑ly doubt the truth of the opinion. We hear every day from patients that their bilious diſorders are hereditary; but every phy⯑ſician knows that the ſecretion of the bile is diſturbed by cauſes evidently more reaſonable than the ſuppoſed inherent diſpoſition de⯑rived from their anceſtors: The dropſy, too, and ſtone, and other diſeaſes which might be enumerated, have been reckoned heredi⯑tary for no better reaſons: As well perhaps might the ague in the Hundreds of Eſſex be called hereditary, which ariſes from the very ſame general cauſe operating upon all; or the itch, which in ſome families ſeems to be handed down as an heir-loom from generation to generation.

There is another very generally received opinion, which I cannot admit to be founded in fact, notwithſtanding it may be ſtated upon the authority of almoſt every gouty perſon, that a paroxyſm of the gout is ſalutary to the ſyſtem, and relieves it from every other diſorder. No one of the medical profeſſion will doubt the veracity of Sydenham, who [65]tells us, that his repeated fits of the gout were at laſt accompanied with a diſeaſe equal⯑ly, or more deplorable, the ſtone, and each of us might alſo, from our own obſervation, enumerate others; but a leſs temperate man than this our Engliſh Hippocrates, ſtrangely ſuffers himſelf to become the dupe of a fan⯑ciful deluſion, and boldly ruſhes amidſt pre⯑cipices, until he ſuddenly tumbles down head-long: for he does not bluſh, by daily irre⯑gularity, to build upon that foundation which he has ſo aſſiduouſly been laying, and where ſtructures, very different to that which he had intended, ariſe along with it. But there cannot, in any view of the matter, be the leaſt excuſe for his intemperance; for by this time he may aſſure himſelf, if he has any reflexion, that he has unadviſedly embraced what he now knows to be an error, and that the pernicious conſequences of the cuſtom are as certain as the pleaſures attending its commiſſion are tranſient. One would ſup⯑poſe too that the gout, even if it really was the cure of every other diſorder, afforded not, in the miſery which it brings along with it, any very great cauſe of exultation; and would rather heartily pity a man, than wiſh him [66]joy of the remedy in which he thus prides himſelf, and which he ſometimes has the hap⯑pineſs of trying, at leaſt, nine months out of the year. But the plan of adminiſtering this remedy, although it be generally ſo exactly ſuited to his inclinations, does not ſo well ac⯑cord with his conſtitution: for wine and brandy, and ſuch like ſtimulants, which in⯑variably conſtitute the chief part of his regi⯑men, not only give the full effect to his fa⯑vourite diſeaſe, but undoubtedly very often produce other diſorders: vertigo, dyſpepſia, tremor, reſtleſſneſs, and all the indeſcribable marks of nervous and bilious affections, ſoon begin to ſhew themſelves, which being too frequently miſtaken for wandering and miſ⯑placed gout, call again, in the opinion of the miſguided ſufferer, for freſh quantities of theſe baneful cordials, which, inſtead of proving the antidote for thoſe diſeaſes, tend only the more to fix and to confirm them: jaundice, dropſy, maraſmus, haemorrhagy, hectic fever, and colli⯑quative ſweats, teach him, too late, that to obſtinacy in his error his life muſt ſoon be⯑come an inevitable ſacrifice. Cordials then fail him, his ſtomach nauſeates the ſcorching doſes, and none but the mildeſt means, which [67]he has hitherto reprobated and neglected, can only now a little while unkindly prolong that miſery which death is anxiouſly waiting to terminate.

The progreſs of a fit of the gout, as I believe I have above mentioned, is quick or ſlow, according as it may be influenced by particular circumſtances; for if the ſyſtem be acting ſtrongly and vigorouſly, the limb (as in rheumatiſm) will ſwell, become red, and exceſſively painful, and, in the courſe of a few days, again ſubſide, and recover gra⯑dually its proper functions: but if the con⯑ſtitution has already been much impaired by repeated attacks, or has previouſly been debi⯑litated from other cauſes, the gout, though attended with ſymptoms ſufficiently painful, does not proceed with that rapidity which would characteriſe it as the acute gout, but ſlowly and irregularly, like a truly chronic diſeaſe, advances towards its termination: And here I muſt take occaſion to obſerve— that whether in its acute or chronic ſtate, this diſeaſe, like the rheumatiſm, muſt end either by the lymphatic recovering its proper of⯑fice, or by collateral channels vicariouſly diſ⯑charging its duty, or by the fluid being ef⯑fuſed [68]into the adjacent cellular texture in conſequence of its rupture—where, from the diſſipation of its thinner parts, it concretes into an indurated maſs, and is vulgarly called a chalk ſtone.

Upon the cure of a diſeaſe, which com⯑mon opinion almoſt ſuppoſes to be incurable, you muſt not expect me to deliver any thing very deciſive. The prejudices of the multi⯑tude are always oppoſed to the experience of the few; and therefore what you and others of the medical profeſſion may concur with me in conſidering as proper and cor⯑rect, the world in general will very probably diſregard as trifling and hypothetical. Whilſt I profeſs myſelf therefore to be one of thoſe who think that the gout may be often alle⯑viated by other means than patience and flannel, I do not expect to be implicitly be⯑lieved: and when the prepoſſeſſions of a patient have induced him to entertain the idea that nothing elſe can be done for him, I would rather give him up to his own remedies, which will often undoubtedly afford him very great aſſiſtance, than preſs any method upon him in which he had not a reaſonable confidence, and conſequently in which he [69]could not be expected unremittingly to per⯑ſerve.

During a fit of the gout it is in vain to at⯑tempt any thing more than a mitigation of the exiſting diſtreſs: it is only after the pa⯑roxyſm has ceaſed that the expectation of a complete cure can rationally be entertain⯑ed.

For the ſake of arrangement we will ſup⯑poſe a man juſt ſeized, for the firſt time, with a regular fit of the gout in his hand or foot, accompanied with the uſual ſymp⯑toms attendant upon pain and tumefaction: Although it may not be ſo very exactly mark⯑ed as to diſtinguiſh it at once from rheuma⯑tiſm, or from rheumatic gout, a name, by the bye, which ſeems to have been invented to cover the difficulty of nicer diſcrimination; yet if the circulation be found quick, the ſkin hot, the mouth dry or clammy, and the mind, as well as body, in a ſtate of reſtleſſ⯑neſs and agitation, there will be a ſufficient aſſemblage of ſymptoms to determine a phyſi⯑cian in his method of cure. I ſhould ſup⯑poſe that nothing very materially different from the plan which was laid down as uſeful in the active ſtate of acute rheumatiſm could [70]here be thought wrong, and that relaxant and diluent remedies, aided by moderate external heat, could not be improper: The general irritability of the ſyſtem will demand alſo a proportionate doſe of a ſedative medi⯑cine, and conſtipation muſt be prevented by the ſeaſonable uſe of purgatives. The pro⯑per adminiſtration of ſuch a method will com⯑monly produce an alleviation of all the ſymp⯑toms, and a little time, with the aſſiſtance of proper tonics, will uſually complete the cure. But by the frequent repetition of ſuch at⯑tacks, as the ſyſtem muſt now be conſiderably debilitated, we will ſuppoſe its uniformity greatly interrupted, and inſtead of the re⯑gular ſwelling, and the commonly continued degree of torture, the appearance of the tu⯑mefaction ſhall be ambiguous, and the pain variable and inconſtant. And here, in this irregular ſtate of the diſeaſe, with a body almoſt worn out, and a mind equally ſhat⯑tered and enervated, what concurrence of ſymptoms ſhall I deſcribe, from which we may reaſonably deduce any curative inten⯑tion? What Sydenham calls an unconnected and diſorderly ſet of phenomena, (farrago quoedam [...] incompoſita atque inordinata) [71]and which he applies ſo properly to hyſteri⯑cal affections, may give ſome idea of that contrariety of ſymptoms which very often appears in a fit of irregular and chronic gout. If indeed this very confuſion itſelf does not afford us the beſt indication of the nature of the diſeaſe, I am at leaſt ſure that ſome phy⯑ſicians, and thoſe of no mean account, are diſpoſed to think that a better characteriſtic of it is ſtill wanting, and therefore do not heſitate to call it gout, becauſe they cannot with certainty ſo develope the ſymptoms as to denominate it any other diſeaſe. The dyſpeptic condition of the ſtomach, the pa⯑ralytic tremors of the limbs, the convulſive twitchings of the muſcles, the relaxed joints, the frequent ſyncope, the interrupted reſpi⯑ration, the apoplectic vertigo, the oedematous extremities, the univerſal maraſmus, and the deſpondency of mind, are all of them, (and more indeed might be added to the ca⯑talogue) the genuine marks of the chronic ſtate of this diſeaſe; and as they muſt neceſ⯑ſarily call for their own appropriate remedies, no general method of cure can be eſtabliſh⯑ed as applicable to them all. I cannot there⯑fore attempt to introduce any certain and [72]ſpecific plan for the relief of the diſeaſe ſo accompanied, but will conſider the ſeveral circumſtances as they ariſe according to my own therapeutic claſſification.

The aſtringent order of medicines, inaſ⯑much as it may ſometimes indirectly anſwer the purpoſe of tonics, as I have above en⯑deavoured to explain when treating of rheu⯑matiſm, may occaſionally be uſed when the ſyſtem is labouring under the evident effects of debility, when the digeſtive organs tar⯑dily perform their functions, and the bodily ſtrength is ſtill waſting by colliquative per⯑ſpirations. I will not unneceſſarily extend this letter by mentioning particular remedies, as the choice of each muſt be directed by circumſtances not only depending upon the period of the diſeaſe and the conſtitution of the patient, but upon a variety of others which can only be known as they are com⯑bined with, and ariſe out of, the occaſion of adminiſtering them: and in this I am confi⯑dent, that every phyſician who practiſes upon a rational and comprehenſive ſcale will agree with me, whatever may be the opinion of thoſe who conſult their memorandum-book, [73]rather than their judgment, and look for a noſtrum ready prepared and manufactured, inſtead of examining the caſe, and then adopt⯑ing a formula from the plain dictates of a common underſtanding.

The emollient claſs may certainly be very well employed, whenever there may be ten⯑ſion and conſequent pain, whether the diſeaſe be of the acute or chronic kind—and any of thoſe external means which are calculated to ſoften the part without impeding perſpi⯑ration, or any other office of the ſkin, will be proper.

Stimulants in the acute ſtate of gout, notwithſtanding their uſe has ſo very com⯑monly obtained, both in the practice of al⯑moſt every patient, and in the recommenda⯑tion of almoſt every phyſician, cannot ſurely be entitled to ſuch a general approbation from the actual experience of either. They have adopted the remedy becauſe it is pleaſant and cuſtomary, not becauſe it is good and ſer⯑viceable. For if they practiſe upon the old idea, that gout is a diſeaſe highly inflam⯑matory, one would ſuppoſe it impoſſible that Brandy and Madeira could be choſen as the proper remedies to diminiſh its activity; and [74]if the opinion which I have entertained of the nature of the diſeaſe be thought by them in anywiſe conſonant to reaſon, they will eaſily alſo agree with me in thinking, that the indiſcriminate uſe of ſtimulants cannot mitigate it: but in the chronic ſtate of this diſeaſe, where the debility is extreme, where dyſpepſia greatly oppreſſes the patient, and where there is a general tardineſs in the per⯑formance of the ordinary functions, I am very far from ſuppoſing that a regularly and properly adminiſtered ſtimulant, which pro⯑duces a conſtant, equal, and uniform action throughout the ſyſtem, can be wrong, when innumerable examples of the contrary are occurring every day: Upon this principle, I ſuppoſe, that bliſters and ſinapiſms, which are commonly applied to the extremities, may be uſeful; for ſo long as they contri⯑bute towards promoting a greater degree of energy in the habit, they may be of ad⯑vantage to it.

I think there can be very little doubt about the propriety of admitting the claſs of ſeda⯑tives into the method of cure for the gout, whether it be acute or chronic: for pain muſt in either caſe be mitigated; and as we know [75]that in the moſt active ſtate of the diſeaſe, opium and the reſt may be very well com⯑bined with thoſe medicines which are cal⯑culated to diminiſh the power and force of the ſyſtem, ſo may they alſo, with an equal degree of fitneſs, be joined with thoſe which correct its irregularity, and reſtore to it its firmneſs and its ſtability. In the common at⯑tack therefore upon the ſtomach, and indeed upon other parts where the idea of miſplaced gout has uſually called for the ſtrongeſt ſti⯑mulants in very immoderate quantities, I would rather truſt to a ſedative for imme⯑diate relief, either alone or in conjunction with other medicines, as circumſtances might then indicate and ſeem to require.

The weak and debilitated ſtate to which patients are ſometimes reduced by a long continued fit of the gout, and in which we generally find them during the tedious lin⯑gering attack of it in its chronic form, de⯑mands the uſe of tonics—and therefore the Peruvian bark, and bitters, and other ſtrength⯑ening remedies, will here maintain their place and character as very uſeful.

The relaxant claſs will always merit con⯑ſiderable attention in the firſt attack of the [76]acute gout. The vigor and activity which then prevail in the ſyſtem—the quickened circulation, the general heat and reſtleſſneſs, the thirſt, and other febrile ſymptoms, all require the immediate exhibition of relax⯑ants: and the neutralized ſaline remedies, an⯑timonials, and others which relax the ſyſ⯑tem without heating it, will be given with manifeſt advantage. I have no great doubt upon my mind, that under the above circum⯑ſtances, phlebotomy might very often be pro⯑ductive of conſiderable benefit to the patient, notwithſtanding its uſe appears not yet ſufficient⯑ly to have obtained in practice—for in all the doubtful caſes where it has not been exactly determined whether the diſeaſe was gout or rheumatiſm, and where phlebotomy has been employed as the cure, it has evidently re⯑lieved; and it would be ridiculous to allow, in matters of ambiguity, that the chance has always fallen on the right diſeaſe, and that bleeding, which we ſometimes judge proper in rheumatiſm, has invariably (and although we found it ſo very difficult to diſcriminate) been performed in one, and never in the other. I will not however preſs the opinion, [77]which both reaſon and analogy have thus induced me to ſupport, ſince no one will ſuppoſe that there are not many caſes of gout in which its uſe may be very hazard⯑ous, and many in which it would be abſo⯑lutely hurtful; for it is only in the very acute ſtage of this diſeaſe, where the body has not been previouſly reduced by general irregularity, but is ſtrong and vigorous, that I ſhould ever conſider the neceſſity of venae⯑ſection: in all caſes, otherwiſe circumſtanced, there cannot poſſibly be a doubt about its im⯑propriety.—The topical application of leeches, where the limb is greatly loaded and diſtend⯑ed, I have never found injurious; but on the contrary, I might perhaps ſay, that I have always found it beneficial.

Diluents and demulcents, whether we con⯑ſider them merely as vehicles for more effica⯑cious remedies, or as capable themſelves of correcting or altering the ſtate of the circu⯑lating fluids, cannot in any ſtage of the diſ⯑eaſe be improper.

As to the other claſſes of remedies which may or may not be requiſite, as the ſtate of the conſtitution may or may not be influenced by the diſeaſe under which it labours, I do [78]not think it of any importance to endeavour to call your particular attention towards them; for every one readily knows when there is any neceſſity for their exhibition.

The protuberances which often appear upon the extremities in conſequence of a ſevere fit of the gout, and which, I have before obſerved, have been denominated chalk-ſtones, as they ſometimes degenerate into ulcers very difficult of cure, will frequently require the aſſiſtance of ſur⯑gery. I have no opinion of the utility of the marine acid bath in ſuch caſes, notwithſtanding it has been much employed upon the Continent, and lately recommended here: for unleſs theſe protuberances can be proved to conſiſt of un⯑combined calcareous earth, as their name would import, but of which as detached from phoſ⯑phoric acid I believe there exiſts not a ſingle particle, the marine acid cannot eaſily affect them without equally deſtroying the interme⯑diate and connecting animal fibres.

When the paroxyſm has completely ceaſed, if the patient has the reſolution to enter upon a very ſtrict regimen, he may generally prevent its recurrence. I muſt be underſtood to ſpeak of ſuch caſes only where the gout has properly ſub⯑ſided, and where the parts being entire are again performing their functions perfectly: Herethen, [79]if he determines upon abſtinence from every thing which ſtimulates, and which in the end moſt aſſuredly produces a morbid irritability of the ſyſtem; if he is moderate in his pleaſures, his buſineſs and his exerciſe; if he ſtrictly denies himſelf every kind of ſpirituous, vinous, or other fermented liquor; if he ſteadily adheres to a milk and vegetable diet; if he obſerves early hours, ſupports a regular warmth of body, and keeps the paſſions of the mind equal and undiſturbed, he will, I have no doubt, not only deſerve a cure, but find it: and in the chronic ſtate like⯑wiſe of this diſeaſe it might be well for him to conſider, whether a general plan of forbearance and moderation might not better alleviate the miſeries which always accompany it, than the contrary habit, which too commonly prevails; and whether a diſeaſe, which when thus fixed affords us but little hope of eradicating it, may not however be rendered much more ſevere and intolerable by the many additional evils which muſt neceſſarily ariſe from intemperance.

After having thus brought my letter to its concluſion, I have only to hope that in the courſe of it I have not manifeſted an inde⯑corous preſumption in delivering particular [80]opinions, nor betrayed an unreaſonable confi⯑dence in maintaining them. What I have written has been ſuggeſted entirely by caſes which have fallen under my own care: and if any obſervations have been made which do not exactly accord with former theories, I can only ſay, that they are the reſult of reflexions which have been faithfully copied from prac⯑tice: I may be wrong, but I am not conſcious of my error. Let me therefore truſt, if better information than that which I have hitherto acquired ſhould detect my miſtakes, that it will be advanced with temper, and urged againſt me with liberality; for the cauſe of ſcience is beſt promoted by candid diſcuſſion and calm inveſtigation.