The Understanding of Gout ca. 1800
Robert Hooper, A Compendious Medical Dictionary containing an explanation of the terms in Anatomy, physiology, surgery, practice of physic, material medica, chemistry, &c. &c., 2nd ed. (London 1801), s.v. Arthritis (illustration: Gichtkranker Und Tod ; National Library of Medicine A023129):
Arthritis (Arthritis, idis, f. from αρθρον, a joint). The gout. A disease arranged by Cullen in the class pyrexiae, and order phlegmasiae. It begins with an excruciating pain in the part, which swells and inflames, induces a high degree of fever, and always terminates by resolution or the deposition of a chalky matter.
William Buchan, Domestic Medicine: or, a Valuable Treatise on the Prevention and Cure of Diseases by Regimen and Simple Medicines, 19th ed. (London 1805), 357–54 (illustrations: Alfred Baring Garrod, The Nature and Treatment of Gout and Rheumatic Gout, (London 1859), 84 and following 601):
There is no disease which shews the imperfection of medicine, or sets the advantages of temperance and exercise in a stronger light, than the gout. Excess and idleness are the true sources from whence it originally sprung, and all who would avoid it must be active and temperate.
Though idleness and intemperance are the principal causes of the gout, yet many other things may contribute to bring on the disorder in those who are not, and to induce a paroxysm in those who are subject to it; as intense study; excess of venery; too free an use of acidulated liquors; night-watching; grief or uneasiness of mind; an obstruction or defect of any of the customary discharges, as the menses, sweating of the feet, perspiration, &c.
Symptoms. — A fit of the gout is generally preceded by indigestion, drowsiness, belching of wind, a slight head-ach, sickness, and sometimes vomiting. The patient complains of weariness and dejection of spirits, and has often a pain in the limbs, with a sensation as if wind or cold water were passing down the thigh. The appetite is often remarkably keen a day or two before the fit, and there is a slight pain in passing urine, and frequently an involuntary shedding of tears.
Sometimes these symptoms are much more violent, especially upon the near approach of the fit; and it has been observed, that as is the fever which ushers in the gout, so will the fit be; if the fever be short and sharp, the fit will be so likewise; if it be feeble, long, and lingering, the fit will be such also. But this observation can only hold with respect to very regular fits of the gout.
The regular gout generally makes its attack in the spring or beginning of winter, in the following manner: About two or three in the morning, the patient is seized with a pain in his great toe, sometimes in the heel, and at other times in the ancle or calf of the leg. This pain is accompanied with a sensation as if cold water were poured upon the part, which is succeeded by a shivering, with some degree of fever.
Afterwards the pain increases, and fixing among the small bones of the foot, the patient feels all the different kinds of torture, as if the part were stretched, burnt, squeezed, gnawed, or torn in pieces. The part at length becomes so exquisitely sensible, that the patient cannot bear to have it touched, or even suffer any person to walk across the room.
The patient is generally in exquisite torture for twenty four hours, from the time of the coming on of the fit: he then becomes easier, the part begins to swell, appears red, and is covered with a little moisture. Towards morning he drops asleep, and generally falls into a gentle breathing sweat This terminates the first paroxysm, a number of which constitutes a fit of the gout; which is longer or shorter according to the patient’s age, strength, the season of the year, and the disposition of the body to this disease.
The patient is always worse towards night, and easier in the morning. The paroxysms, however, generally grow milder every day, till at length the disease is carried off by perspiration, urine, and the other evacuations. In some patients this happens in a few days; in others, it requires weeks, and in some, months to finish the fit. Those whom age and frequent fits of the gout have greatly debilitated, seldom get free from it before the approach of summer, and sometimes not till it be pretty far advanced.
Regimen. — As there are no medicines yet known that will cure the gout, we shall confine our observations chiefly to regimen, both in and out of the fit.
In the fit, if the patient be young and strong, his diet ought to be thin and cooling and his drink of a diluting nature; but where the constitution is weak, and the patient has been accustomed to live high, this is not a proper time to retrench. In this case he must keep nearly to his usual diet, and should take frequently a cup of strong negus, or a glass of generous wine. Wine-whey is a very proper drink in this case, as it promotes the perspiration without greatly heating the patient. It will answer this purpose better if a tea-spoonful of sal volatile oleosum, or spirits of hartshorn, be put into a cup of it twice a-day. It will likewise be proper to give at bedtime a tea-spoonful of the volatile tincture of guiaicum, in a large draught of warm wine-whey. This will greatly promote perspiration through the night.
As the most safe and efficacious method of discharging the gouty matter is by perspiration, this ought to be kept up by all means, especially in the affected part. For this purpose the leg and foot should be wrapped in soft flannel, fur, or wool. The last is most readily obtained, and seems to answer the purpose better than any thing else. The people of Lancashire look upon wool as a kind of specific in the gout. They wrap a great quantity of it about the leg and foot affected, and cover it with a skin of soft dressed leather. This they suffer to continue for eight or ten days, and sometimes for a fort, night or three weeks, or longer, if the pain does not cease.
I never knew any external application answer so well in the gout. I have often seen it applied when the swelling and inflammation were very great, with violent pain, and have found all these symptoms relieved by it in a few days. The wool which they use is generally greased, and carded or combed. They choose the softest which can be had, and seldom or never remove it till the fit be entirely gone off.
The patient ought likewise to be kept quiet and easy during the fit. Every thing that affects the mind disturbs the paroxysm, and tends to throw the gout upon the nobler parts. All external applications that repel the matter are to be avoided as death. They do not cure the disease, but remove it from a safer to a more dangerous part of the body, where it often proves fatal.
A fit of the gout is to be considered as Nature’s method of removing something that might prove destructive to the body, and all that we can do with safety, is to promote her intentions, and to assist her in expelling the enemy in her own way. Evacuations by bleeding, stool, &c. are likewise to be used with caution, they do not remove the cause of the disease, and sometimes by weakening the patient prolong the fit; but where the constitution is able to bear it, it will be of use to keep the body gently open by diet, or very mild laxative medicines.
Many things will indeed shorten a fit of the gout, and some will drive it off altogether; but nothing has yet been found which will do this with safety to the patient. In pain we eagerly grasp at any thing that promises immediate ease, and even hazard life itself for a temporary relief. This is the true reason why so many infallible remedies have been proposed for the gout, and why such numbers have lost their lives by the use of them.
Notwithstanding the acknowledged and frequently experienced danger of tampering with the gout, such is the effect of intense pain, that I never met with more than two patients who could bear their sufferings with rational composure, or, what is the same thing, without frantic attempts to alleviate them. When the seat of the complaint is in torture, a promise to afford relief, though made by the greatest impostor upon earth, is listened to; and present ease is sought for, at the risk of any future consequences.
It is not many years since some persons of the first rank in the kingdom fell victims to the deceptions of a foreign quack, who soothed their impatience of pain, amused them with the charm of fancied recovery, and rendered momentary ease the fatal prelude to inevitable death. It would be as prudent to stop the small-pox from rising, and to drive them into the blood, as to attempt to repel the gouty matter after it has been thrown upon the extremities. The latter is as much an effort of Nature to free herself from an offending cause as the former, and ought equally to be promoted.
When the pain, however, is very great, and the patient is restless, thirty or forty drops of laudanum, more or less, according to the violence of the symptoms, may be taken at bed-time. This will ease the pain, procure rest, promote perspiration, and forward the crisis of the disease.
After the fit is over, the patient ought to take a gentle dose or two of the bitter tincture of rhubarb, or some other warm stomachic purge. He should also drink a weak infusion of stomachic bitters in small wine or ale, as the Peruvian bark, with cinnamon, Virginian snakeroot, and orange-peel. The diet at this time should be light, but nourishing, and gentle exercise ought to be taken on horseback, or in a carriage.
Out of the fit, it is in the patient’s power to do many things towards preventing a return of the disorder, or rendering the fit, if it should return, less severe. This, however, is not to be attempted by medicine. I have frequently known the gout kept off for several years by the Peruvian bark and other astringent medicines; but in all the cases where I had occasion to see this tried, the persons died suddenly, and to all appearance for want of a regular fit of the gout. One would be apt, from hence, to conclude, that a fit of the gout, to some constitutions, in the decline of life, is rather salutary than hurtful.
Though it may be dangerous to stop a fit of the gout by medicine, yet if the constitution can be so changed by diet and exercise, as to lessen or totally prevent its return, there certainly can be no danger in following such a course. It is well known that the whole habit may be so altered by a proper regimen, as quite to eradicate this disease; and those only who have sufficient resolution to persist in such a course have reason to expect a cure.
The course which we would recommend for preventing the gout, is as follows: In the first place, universal temperance. In the next place, sufficient exercise.* [*Some make a secret of curing the gout by muscular exercise. This secret, however, is as old as Celsus, who strongly recommends that mode of cure; and whoever will submit to it in the fullest extent, may expect to reap solid and permanent advantages.] By this we do not mean sauntering about in an indolent manner, but labour, sweat, and toil.
These only can render the humours wholesome, and keep them so. Going early to bed, and rising betimes, are also of great importance. It is likewise proper to avoid night studies, and intense thinking. The supper should be light and taken early. The use of milk, gradually increased, till it becomes the principal part of diet, is particularly recommended. All strong liquors, especially generous wines and sour punch, are to be avoided.
We would likewise recommend some doses of magnesia alba and rhubarb to be taken every spring and autumn; and afterwards a course of stomachic bitters, as tansey or water-trefoil tea, an infusion of gentian and camomile flowers, or a decoction of burdock-root, &c. Any of these, or an infusion of any wholesome bitter that is more agreeable to the patient, may be drank for two or three weeks in March and October twice a-day.
An issue or perpetual blister has a great tendency to prevent the gout. If these were more generally used in the decline of life, they would not only often prevent the gout, but also other chronic maladies. Such as can afford to go to Bath, will find great benefit from bathing and drinking the water. It both promotes digestion, and invigorates the habit.
Though there is little room for medicine during a regular fit of the gout, yet when it leaves the extremities, and falls on some of the internal parts, proper applications to recall and fix it become absolutely necessary. When the gout affects the head, the pain of the joints ceases, and the swelling disappears, while either severe head-ach, drowsiness, trembling, giddiness, convulsions, or delirium come on. When it seizes the lungs, great oppression, with cough and difficulty of breathing, ensue. If it attacks the stomach, extreme sickness, vomiting, anxiety, pain in the epigastric region, and total loss of strength, will succeed.
When the gout attacks the head or lungs, every method must be taken to fix it in the feet. They must be frequently bathed in warm water, and acrid cataplasms applied to the soles. Blistering-plasters ought likewise to be applied to the ancles or calves of the legs. Bleeding in the feet or ancles is also necessary, and warm stomachic purges, The patient ought to keep in bed for the most part, if there be any signs of inflammation, and should be very careful not to catch cold.
If it attacks the stomach, with a sense of cold, the most warm cordials are necessary; as strong wine boiled up with cinnamon or other spices; cinnamon-water; peppermint-water; and even brandy or rum.* [*Æther is found to be an efficacious remedy in this case.] The patient should keep his bed, and endeavour to promote a sweat by drinking warm liquors; and if he should be troubled with a nausea, or inclination to vomit, he may drink camomile-tea, or any thing that will make him vomit freely.
When the gout attacks the kidneys, and imitates gravel-pains, the patient ought to drink freely of a decoction of marsh-mallows, and to have the parts fomented with warm water. An emollient clyster ought likewise to be given, and afterwards an opiate. If the pain be very violent, twenty or thirty drops of laudanum may be taken in a cup of the decoction.
Persons who have had the gout should be very attentive to any complaints that may happen to them about the time when they have reason to expect a return of the fit The gout imitates many other disorders, and by being mistaken for them, and treated improperly, is often diverted from its regular course, to the great danger of the patient’s life.
Those who never had the gout, but who, from their constitution or manner of living, have reason to expect it, ought likewise to be very circumspect with regard to its first approach. If the disease, by wrong conduct or improper medicines, be diverted from its proper course, the miserable patient has a chance to be ever after tormented with head-achs, coughs, pains of the stomach and intestines; and to fall at last a victim to its attack upon some of the more noble parts.