The nature and treatment of gout

Preface

It is now many years since an extensive work on the exclusive subject of Gout has been published ; and the great advances in chemistry and its collateral sciences might alone have justified the laying before the profession a new work on a disease, so intimately connected with a humoral — it may, perhaps, hereafter be written, a chemical — pathology, as gout will probably at length, on all hands, be admitted to be. But my residence at Buxton, the thermal waters of which place have so long been famous in cases of gout and rheumatism, has afforded me large opportunities of observing and treating these diseases ; and the following work claims to be the result of my experience in gout cases. It has been as carefully digested and put together, as circumstances have permitted it to be ; and I lay it before the profession in the hope, that it must contain some useful matter. The diagnosis between gout and rheumatism appears to me, as vi PREFACE.

will be gathered from the body of the work, to be a question of much practical importance, and a subject that has seemed to be too little attended to. I trust that the time will come, when the so-called disease, rheumatic-gout, will be as seldom heard of, as I believe it to be of rare occurrence, — that definite views of the effects of colchicum on gout and rheumatism, and the consequent importance of forming a just diagnosis between these diseases, may eventually be obtained, — and that strong opinions of the connection between gout and cachexia may be generally held.

If, by a large number of the members of my profession, I should be thought to have made of too great importance, a disease, which has engrossed so much of my time and thoughts, — and of which they themselves may, possibly, have seen but little, —I hope that they will consider it as a necessary consequence of the circumstances in which I have been placed, and which have justified and enabled me to lay this work before them.

W. H. R.

The Square, Buxton.

Chapter I. Introductory

'J1 HE relative importance of a disease depends on the number of persons affected by it, on the degree of suffering it involves, on the greater or less probability of its cure, and on its direct or indirect effect upon the duration of life. It will admit of little dispute, that the class of persons chiefly attacked by it, — the greater or less importance of then- position and their labours in the social system, — will have some weight in determining the degree of importance to be attached to a disease.

The number of persons who suffer from gout in this great country is known to be large, and is perhaps much larger than is commonly supposed ; the amount of suffering occasioned by it is very great; the liability to its recurrence, and the amount of its injury to the system, increase with every attack ; this liability, although it may probably be

INTRODUCTORY.

lessened in most cases, can seldom be removed ; and it takes largely from the expectation of life. It is chiefly the highest ranks of life, and the most thinking classes of the community, that are attacked by this disease ; the liability to its influence does not extend to the masses of the people ; but it is, with few exceptions, confined to those who have raised themselves, or been raised by the exertions of their fathers, above the level of their fellows. The higher the rank, the more pure and noble the blood, the greater the powers of mind, and the more those powers are used, the nearer the man is to the time of life when his intellect is the most vigorous, the more liable is he to become the victim of this disease. Gout cannot be justly regarded as a mere tax upon luxury, or a mere atonement for indolence. The liability to gout does not cease with the immediate sufferers, but is transmitted to their posterity.

Gout is produced by such a degree of interference with what have been well called the organic laws, as diverts the amount of nervous influence, which is necessary to the due performance of the functions of the capillaries, to other — it may or may not be nobler and higher — uses ; thus interfering with the free conversion of arterial into venous blood, impeding the rapid deposition of new materials and the equally rapid removal of the old, giving time for chemical changes in the contents of the capillaries, and for the formation of crystallisable materials, the irritation of which is probably the immediate

INTRODUCTORY.

cause of gout and its consequences. Whatever has the effect of interfering with the communication of the salutary and needful influence of the nervous system to certain capillary vessels may be a remote cause of gout.

Gout cannot, under any circumstances, be looked upon as an unimportant malady, nor as affording to the system a desirable and useful exit for crude and noxious matters, and thereby saving it from more serious and life-endangering diseases. It is a disease sai generis, and for which the seeds must be sown a long time before it can show itself ; which other diseases cannot produce, although they may excite or aggravate one of its paroxysms.

Gout is a disease which occurs in paroxysms; which, when not modified, are sometimes distinctly marked; the duration and course of which are definite, several of them constituting an attack or fit of the disease, having an interval of longer or shorter time between the fits, but leaving a greater liability to its recurrence, and at shorter intervals, after every succeeding fit.

Other diseases may excite, but they cannot produce, gout; which is not a secondary affection arising from some other morbid condition, but a primary disease, having its peculiar predisposing and proximate causes, which other diseases can only excite or aggravate, and with which they may have no connection whatever. Therefore, when gout supervenes upon other ailments, they are not to be regarded as having produced it, although

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INTRODUCTORY.

they may have acted as its exciting cause; nor when those ailments have been greatly relieved, or perhaps entirely removed, on the supervention of gout, is the gouty paroxysm to be looked upon as their result, but as having influenced them by diverting the determination of blood from the organs previously affected, and in the same proportion relieved their morbid state.

It is generally unwise, and sometimes unsafe, to check the development of a gouty paroxysm. In this respect, gout resembles the exanthematous, and some other diseases. This is no proof that gout is a desirable result of morbid action, but that the system, having become gradually and increasingly deranged, can only be relieved by a paroxysm of the disease, or by disease of some central and vital organ ; this being the usual consequence, and always the risk to be incurred, when a paroxysm of gout is checked, or its development interfered with ; a risk which ought only to be incurred under peculiar circumstances, and then to be prepared for and lessened, as far as may be, by all the means that medicine affords.

Although the occurrence of the gouty paroxysm often relieves, or removes, previously existing derangements, it does not lessen their liability to return. Gout is not, as was once supposed, a direct means of diminishing the tendency to other diseases. On the contrary, by disturbing the equilibrium of the circulation, diminishing the tone of the capillaries, deranging the nervous system, and interfering with

INTRODUCTORY.

or impairing its influence on the secreting and excreting organs, gout becomes an important agent in increasing the morbid tendencies of the system, aiding other causes of disease, and lessening the probabilities of life. The immediate relief afforded to deranged states of organs, by a paroxysm of gout, must not be confounded with its ultimate consequences. Gout can only remove or diminish pre-existing derangements, by its derivating or evacuating action; and there could hardly be a more uncertain and severe counter-irritant, or a more hazardous evacuant, than a fit of gout.

The seat of gout, and probably the only structure that is ever affected by it, is the white fibrous tissue. Why the capillaries that permeate this tissue, should be so exclusively liable to this disease, can only be a subject of conjecture. It may be owing to the density and firmness of this tissue, and its comparatively little power of accommodating itself to any sudden or great increase of size of the parts it envelopes, or of the vessels that permeate it. The parts of this tissue that are the most distant from the heart, the most dependent, the most exposed to the effects of cold and wet, are those which are the most subject to this disease. Gout, almost always, first attacks the feet; and, next to the feet, the hands are most liable to suffer from the disease ; the fibrous tissue of the articulations being the seat of the attack. Perhaps the pressure to which the feet are subjected in the act of walking, and the still further pressure of the boot or shoe, increase

INTRODUCTORY.

their liability to gout ; and this may be the reason why the second joint of the great toe, as being more peculiarly pressed upon in walking, is the part usually first affected by the disease. Next to the smaller joints of the toes and fingers, the larger joints, and especially those that are distant from the trunk of the body, least protected by their own coverings or by clothing, and that have the most freedom of motion are those, cseteris paribus, that seem most subject to be the seats of gout. There is, however, no joint that is not liable to suffer from this disease. The articulations of the vertebrae are occasionally the seats of gout. It is, however, a general rule, with few exceptions, that the nearer a part is to the trunk of the body, and the farther from the surface, the less frequently is it found to be attacked by gout. It is only in cases of long standing, and extreme aggravation ; or when, from neglect, or ignorance, or peculiarity of constitution, the development of the disease in other parts has been interfered with, that the more deeply seated or the more central parts are involved in the disease; or that those parts of the fibrous tissue which are not attached to joints, and consequently not subjected to much motion, suffer from gout. But, under such circumstances, there is perhaps no part of the fibrous tissue that may not become the seat of gout; and it may attack the periosteal covering of any of the bones, the sheaths of the arteries or the nerves, or even the dura mater.

Gout is a disease of inflammatory character, the

I degree of inflammation varying from the slightest to the greatest amount of increased action. Gouty inflammation is of specific character, differing from common inflammation in its course and its effects.

These preliminary observations have seemed to be necessary to the account to be given of this disease; and the further consideration of it is divided into the separate heads of 1st. the remote causes, and the predisposing cause, 2nd. the exciting causes, 3rd. the nature of gout, 4th. the treatment of the paroxysms of the disease, 5th. the treatment after a paroxysm, and during the intervals between the paroxysms, and 6th. the means we possess of preventing altogether the access of the disease ; premising, that it has been found difficult, and sometimes impossible, to keep these different subjects distinct from one another, and to avoid discussing questions connected with one division of the subject under another part of it ; and that it has sometimes been found impossible to avoid repetitions, and indeed that in some instances repetitions have been purposely indulged in, either to preserve the continuity of the several chapters, or to impress matters that seemed to be of especial importance.

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Chapter II. Remote Causes And Predisposing Cause Of Gout

Hereditary influence is the principal remote cause of gout. There are probably few medical men of the present day, who have had the means of forming an opinion on this question from a large number of gout cases, who entertain a doubt of the very great power of hereditary influence in the production of this disease. The cases are comparatively few in which this is not found to be among the remote causes of the disease ; and the responsibility incurred by those, in whom gout occurs without the aid of hereditary influence, must be great, in the same proportion. To estimate this fully, it must be remembered, how difficult or impossible it is frequently found to be to ascertain the diseases of the parents, and still more so those of the grand-parents, of our patients; and on the other hand, that the constitution of the other parent, which must often be such as would be calculated to modify greatly any morbid influences derivable from either parent, seems to be so little effectual in the case of this disease. In some few cases, all the

TREDISPOSING CAUSE OF GOUT. Q

children of a family are found to suffer from gout, even when traceable to one parent only ; but this is not common, and is rarely found to be the case, unless the ravages of the disease have been considerable in the existing and previous generations. It generally happens — but this rule has many exceptions— that the children who most resemble the gouty parent are the most liable to suffer from the disease ; or, the attending circumstances being alike, haye the disease earlier in life, and to a greater degree. Females are more likely to escape than males, or not to be attacked till later in life, and then in a greatly modified form. The exceptions to this are generally cases in which the disease is complicated with hysteria, and very much modified by such complication. When we see physical characters handed down from generation to generation; when we see features, expression of countenance, complexion, voice, capacity of chest, breadth of shoulders, gait, and gestures, thus transmitted from parents to children ; when it is contended, and with much probability, that the child of parents accustomed to the luxurious indulgences of civilised life, cannot be kept in health upon the same amount or quality of food, as will afford adequate nourishment to the children of the poor ; it cannot be thought to be singular, although it must be allowed to be inexplicable, that a disease so strictly constitutional as gout, and for the manifestation of which a predisponent cause must have been long in operation, should have hereditary influence as one of the most important of its remote causes. There is a common opinion, that the alternate generations of families liable to gout very frequently escape an attack of the disease. That one or even two generations of such families do sometimes remain free from gout, is certainly true ; and that this immunity does not necessarily exhaust the hereditary influence, although it must greatly diminish its degree, appears to be true ; but that the grandchildren of gouty people are more likely to be gouty than their children, supposing the children to continue free from the disease, is unquestionably one of the many vulgar errors.

Sedentary habits are among the most influential of the remote causes of gout, and, in a very large proportion of cases, are found to have played an important part in producing the habit of body in which gout originates. By sedentary habits is to be understood, not simply the sitting during the greater part of a man's waking hours, but the doing so without interruption during many consecutive hours, and without reference to the digestive functions, and the condition of the nervous system. A man may sit during the same number of hours daily, with much less risk, if he acts up to the knowledge, that he should not do so during the latter stages of digestion, nor continue to do so when the powers of the nervous system are becoming exhausted, whether from the want of food, or of sleep, or of muscular exercise. To avoid the risk of suffering from sedentary habits, or to diminish, the risk as much as possible, it seems only necessary that the sittings should not be long continued at any given time, but should be interrupted, at as short intervals as may be, by muscular exercise, which should be varied, to avoid sameness, and to call into exercise the greatest number of muscles ; that the sittings should not be needlessly protracted beyond the third horn* after any meal, that a longer interval than five waking hours between the meals should be avoided, and that the first intimation that the system requires the refreshment of sleep should be attended to. Every observer well knows how little these particulars are attended to by sedentary people, and more particularly when such habits have been acquired by yielding to a fondness for mental occupations. But, whether sedentary habits have been thus acquired, or result from needful attention to the duties of life, or from indolence, these habits are powerful among the remote causes of gout, and powerful in proportion to the degree in which they are indulged, and as they are regulated or not.

That sedentary habits should be thus powerful as a remote cause of gout, admits of easy explanation. Whatever interferes with the action of the capillaries upon the blood, whether it consists in depriving them of a proportion of the nervous power which is necessary to that action, or in a degree of interference with the passage of blood through them, or in depriving them of occasional but important mechanical assistance, any such agent may

1:2 be a remote cause of gout. The effects of muscular exercise in assisting the passage of blood through the superficial veins, in accelerating the return of the blood to the heart, in stimulating the heart to quicker and fuller action, in exciting the general circulation, in circulating the blood more rapidly through the lungs, in adding to the amount of the changes produced on the blood by the respiration, in increasing the action of the cutaneous exhalants, thereby acting indirectly as an evacuant* are well known, and may be justly regarded as among the necessities of man's nature. To deprive the system of the influence of so powerful an agent, must be to risk its derangement. Although seldom, and perhaps never, sufficiently powerful if acting alone, to induce the habit of body which constitutes the predisposing cause of gout, by adding to the effect of other agents, the influence of sedentary habits in confirming gouty tendency must be admitted to be great.

Undue exercise of mind is usually allied to the last-mentioned of the remote causes of gout. It often contributes greatly to the production of the gouty habit. This is evidently owing to the

* If the hypothesis of Dr. Willis be correct, that the great use of perspiration is to render venous blood thicker than arterial blood, by depriving the latter of a portion of water as it passes through the capillaries, for the purpose of calling the wonderful principle of endosmosis into operation, which he conceives to be of great importance in promoting the absorption (passage ?) of the blood from the arteries into the veins, the importance of muscular exercise to our physical welfare will be still further demonstrated.

PREDISPOSING CAUSE OF GOUT.

expenditure on the mental operations of a greater or less proportion of the nervous energy, which is necessary to the adequate and natural performance of the several organic functions, rendering the action of the capillaries more sluggish, and causing the chemical changes that take place in those vessels, which changes are necessarily the effect of vital action, to be less perfectly or less regularly effected than is consistent with health.

It might be, that every man's system is capable of producing a certain amount of nervous power, — that amount varying in different individuals, and, no doubt, varying in the same individual at different times, and under different circumstances, — that amount being at any given time essentially definite and limited ; and it might be, that this power could be used indiscriminately for the very different purposes of ministering to mental acts, or the bodily functions, or any of the physical requirements of the system. But, whether this be so or not, it is quite certain that the more a man uses his mind beyond a certain point, the less actively are his bodily functions performed ; and if this, which must be called excessive, use of the mind's powers be continued, the bodily functions, from being performed sluggishly, come to be performed imperfectly, and, in fact, arrive at the point where health passes into disease. But, further, it might be, that, to expend the nervous power in any one way excessively, not only abstracts so much from the other modes in which this power was intended to be expended, but is attended with a real loss of a part of the nervous influence ; for it is quite certain, that by alternating one way of expending this power with another, by using it at one time in mental processes, at another in the functional offices of the body, as movement of the voluntary muscles, and then recurring to mental exercises, a larger amount of nervous energy may be manifested, and that too without injury, than can otherwise be displayed even at the expense of the body's well-being. This is probably tantamount to alternating exercise of the arms with that of the legs, or of one arm with that of the other, or of the muscles principally used in the act of walking with those used in the act of riding, by which a greater amount of power may be expended with less fatigue. It is now well known, that different parts of the nervous system have different offices assigned to them : that to one part is assigned the intellectual, to another the motor, to another the sentient, to another the respiratory, powers ; and it is evident, that these are so far independent of one another, as to be able to perform their offices without robbing the other parts of their powers. What is contended for is, that to use any of them unduly is to debilitate and interfere with the action of the other parts, in the same way as a man may produce the sense of fatigue in all his muscles by using some of them too much ; and, further, that by using all of these powers duly, every one of them becomes capable of — more and

PREDISPOSING CAUSE OF GOUT.

more — appealing to aid and strengthen one another mutually.*

In ignorance of these truths, or more probably in their despite, for they are truths which can hardly have failed to present themselves to the mind of any one, the temptation of letting the series of thoughts continue uninterruptedly for many successive hours, the feeling that it may be difficult to take up the chain at the same point again, and to go on adding new links to it with equal facility, and, more than all, the proneness to indulge inclination at the expense of judgment, are yielded to, and come to be less and less easily resisted, until the indulgence becomes habit, and the intellectual debauchee is perhaps only awakened to the magnitude of his error by seriously-impaired health.

There can be no doubt, that, for the accomplishment of the important changes which the blood undergoes in the capillaries — changes perhaps essentially chemical, but which are nevertheless effected under the influence of the nervous and vital power, and by its means — a large amount of nervous power must be required and expended ; and if an excessive

* This is a strong argument in favour of general education, and the systematic training of the masses of the people to habits of thinking, and giving them as far as may be a taste for exercising the mind in the fields of science and literature, on the principle of adding to their chances of health and longevity, as well as that of strengthening the probability of their being good citizens and useful members of society. There are fewresults of statistics so interesting as the finding the expectation of life to be so largely increased by education and habits of thought, and this, notwithstanding the injury to the bodily health that attends the undue use of mind.

amount of this power be so expended in any one way, whether in mental acts or otherwise, this must be at the expense of the other parts of the economy, and the functions of those parts must be inadequately performed in the same degree. But, in such a case, it is seldom that this occurs equally in all the other parts of the system. On the contrary, some one part or organ almost always suffers more than any of the others, and perhaps sutlers exclusively. Further, the effect is not, in most cases, manifested until after this unfair distribution of nervous power has been in operation a considerable length of time.

Perhaps, strictly speaking, when the organic laws are thus disobeyed in the first instance, an immediate penalty is generally levied and enforced. A man of temperate habits cannot commit a debauch of wine, a man who has been used to a moderate diet cannot partake to excess of the luxuries of the table, a man of regular life cannot enter into dissipation, without immediate warning that he is warring against the physical necessities of his system, and doing wrong to his body's well-being. His digestive organs will probably give signs of disordered action, his activity of mind will probably be diminished, and that equanimity be disturbed which is so closely connected with a healthy body. But, if such warning be neglected, and neglected notwithstanding its frequent repetition, such repetition occurring at first at short, but at gradually lengthening, intervals, at length ceases; and the individual may appear to have become habituated to the unnatural circumstances.

PREDISPOSING CAUSE OF GOUT.

And if, in such an extreme case as that now supposed, this gradual apparent usage of a system to such irregularities always happens in systems that possess an average amount of original power, it is necessarily still more the case, when the irregularities are less considerable, and perhaps confined to an undue devotion to sedentary pursuits, or the practice of sitting up rather late at night, or the using rather more food, or rather more stimulus, than the wants and waste of the system require. But, in all such cases, the opinion that the system has become reconciled by habit to the irregularity is delusive. Sooner or later, depending much perhaps on the original strength of the constitution, or on the physical education and its consequences — improving or leaving unimproved the original constitution — time, the sure test of right and wrong, shows the extent of the delusion. In many instances, the ultimate manifestation of evil consequences is sudden, and from the accidental operation of an exciting cause : the predisposition has become established, and has ended in the production of disease.

Gluttony and intemperance have always been acknowledged to be important remote causes of gout. The effect on the system, of dietetic errors, irregularities, and excesses, is great and cumulative. The derangement and exhaustion of nervous influence from the amount of vital power demanded for the digestion of an excessive quantity of food, the repletion of the vascular system and the surcharging of the blood with nutritive materials, the additional demand for nervous influence to vitalise and organise these materials, and finally reduce them to the forms in which they may be expelled from the system, are so many direct causes of disturbing the equilibrium of the nervous and vascular systems, and of inducing or augmenting morbid tendencies. And these effects are cumulative. If children are allowed to eat largely and improperly — to consume excessive quantities of food, and food that is so rich and various in kind as to pamper appetite — the effect on the moral and physical nature, on the habits of the after-life, on the constitution and health of the adult and the advanced life, is great and increasing. The moral influence must be bad, and the physical consequences almost equally so. The states of system which constitute the virtual predisponent causes of many of the diseases of the after-life are unquestionably often induced in these earlier years, and traceable to errors in the physical management of the infancy and early childhood. It is very well known that scrofula is commonly — too commonly — induced or aggravated by scanty food, badly-ventilated rooms, and filthy habits ; and it is equally to be relied upon, that other morbid states, more especially of course such as are more or less dependent on, or connected with cachexia, derive theirremote causes from errors in the diet and the hygienic management of the young. With especial reference to gout, this is a question of importance. It is believed, that the predisposition to this disease, although so generally manifesting itself in middle life, and so rarely

TREDISPOSING CAUSE OF GOUT. 19

in early life, may be created in the years of growth ; and that where there is hereditary predisposition, the dietetic and general management of the children may do much towards lessening such predisposition. It is thought that, even in these days, parents are little aware how much the future well-being of their children, as regards the probability of life and health, is thus in their own power — how much may be done to alter and modify existing predispositions, or to check the production of predispositions to diseases that they themselves had not suffered from, nor appeared to be liable to. In the one class of life, where poverty and labour take from the children adequately nutritious food, and good and careful nursing, cleanliness and ventilation are still within the reach of all who know their value, and strive for them; and though not substitutes for plenty of nourishing and wholesome food, and careful and active tendance, are at least important and influential means of counteracting the bad effects of the want of these ; and, in the other class, where cleanliness, and abundant clothing, and good nursing, and daily taking out into the open air, and airy, wellventilated nurseries and school-rooms, are not wanting, and are held at their due value, the good effects of these great means of rearing a healthy system are apt to be much counteracted by a habit of gross feeding, cloying and surfeiting the system with rich and appetising viands, impairing the digestive processes, producing in the first instance a state of repletion, then one of digestive irritation and dis-