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                    AN
       INAUGURAL DISSERTATION,
                   BEING
               AN ATTEMPT
                    TO
        PROVE THE IDENTITY
                    or
  GOUT  AND  RHEUMATISM.
                SUBMITTED TO
            THE EXAMlNAriOX OF <THE
REV. JOHN ANDREWS, D.  D. PROVOST
                (pro tempore),
                    THE
     TRUSTEES, AND MEDICAL FACULTY
                  OF THE
       UNIVERSITY OF PENNSYLVANIA,
          ON THE 21ST DAT OF APRIL, 1806,
                  FOR THE
 DEGREE OF DOCTOR OF MEDICINE.
BY CHARLES J^gCKE,
    OF VIRGINIA.    ' .*-''"••*•  - V--
The science of Medicine should be kept as clear of miracles as possible.
                              PROFESSOR BARTON.
          Simplicitas rarissima, in jfvo nostro.
         PHILADELPHIA,
PRINTED BY THOMAS AND GEORGE PALMER,
          116, HIGH-STREET.
1806. 
 
                           TO
                                                     i
          JOSEPH  EGGLESTON, ESQ.

                    OF VIRGINIA.

BEAR SIR,
      EVERY sentiment of gratitude and affection which can be
inspired by acts of disinterested friendship I shall ever feel towards
you.  I regard you as a second parent, to whose anxious attention
to my welfare I owe every advantage of my hfe.  No care, no effort,
that might tend to my future good, has ever been neglected by you.
In return for your paternal care, I can offer nothing but an assu-
rance of an attachment truly filial.

  With unfeigned wishes for  your future health and happiness, I
subscribe myself
                        Your grateful friend and nephew,
                                    CHARLES COCKE. 
* 
TO
            BENJAMIN  RUSH,  M. D.

                    PROFESSOR OF THE

     INSTITUTES AND PRACTICE OF MEDICINE

                         IN THE

           UNIVERSITY OF PENNSYLVANIA.

SIR,
      NEITHER ambition nor  self-interest induced me to affix
your name to this essay; for, important as is the sanction of your
name, it cannot cover the many  imperfections of thjs hasty pro-
duction.   It was a desire to manifest  my high respect for your
talents as a physician, my esteem for your private character, and
my gratitude for the  many favours  conferred on me, that have
prompted me to this dedication.
  That you may long live to disseminate the important principles of
medicine discovered by yourself, is the wish of none more ardently
than of
                            Your sincere friend and pupil,
                                       THE AUTHOR. 
 
INTRODUCTION.
       WHEN I commenced this essay, I expected to
confine myself to the  immediate subject of it.  That
this has not been the case, will be at once discovered by
the-reader at all conversant with medical matters.   He
will perceive that  the general subject of nosology is of-
ten touched upon, and that attempts  are even  made
to refute some of its principles.  These  things,  being
somewhat of a  collateral nature, it  must be acknow-
ledged  are not  quite  irrelative  to the subject of  this  ,
dissertation:  for it is  on the deep-seated prejudices in
favour of nosology that the objections to the sameness
of gout and  rheumatism are founded;  to think then of
removing the latter, while the former retained its full in-
fluence, would be a vain expectation.   From this con-
sideration,  therefore, I have thought fit occasionally to .
discuss the merits of the nosological  arrangement of
diseases.  And  here I must hope to be rightly under-
stood.   I have not attempted to enter fully into  the me-
rits and defects of nosology ; to treat this subject as its
importance deserves would require more time and  oh- 
                         x
servation than I can possibly have had, and greater abi-
lities  than I have  the vanity to claim.   Every thing,
then, touching on nosology must be understood as hav-
ing a partial application.   It is intended  to prove the
sameness of gout and rheumatism, not to refute the ge-
neral doctrine of nosology. 
AN
INAUGURAL  DISSERTATION,  &c.
       AS the establishment of every opinion in medicine should
rest on matters of fact, and not speculation, I shall on every occasion
prefer to give the support of the former to the principles that I shall
attempt to defend.  This, therefore, must be my apology for the nu-
merous quotations contained in this essay.
   Those who have been fond of discriminating between gout and
rheumatism, from the diversity of their causes, have blindly consi-
dered intemperance in eating and drinking as the only remote cause
of gout.   As well might they assert that a cargo of putrid coffee was
the -only source of yellow fever, because it has sometimes produced
it.  Intemperance is only one of a hundred causes of gout.
   " Dr. Harle*," says his biographer, " could never from his infancy
taste any kind of fermented or spiritous liquors.   If he had eaten a
piece of cake, or any thing else, in which there was the least mixture
of any such liquors, he was sure to be disordered by it, Water, there-
fore, was  his constant,  and  almost his only liquor,   But, notwith-
standing his temperance, his sedentary  course of life brought upon
him both the gout and  the gravel, which he justly called the rack
and torture of life."   And again, there is a fact more conclusive, be-
* Dr. Harle, of Newcastle. 
12
cause it is less limited.  In the above case, it may be objected that
there was a strong hereditary predisposition to the disease, which
did not require the co-operation of the all-powerful cause of intemper-
ance in drinking.   This would be their best apology, but even this
could go no farther  than to  prove  the power of  intemperance; it
could not give a specific action.   But in the case presently to be
mentioned, no such subterfuge will do; for, instead of the case  of a
single individual, we  have that of a whole nation.   Prosper Alpinus,
who resided some years in Egypt, gives an account that the Egyp-
tians lived entirely upon vegetable food, and generally drank water,
yet no people were more subject to gout.
   Thus then  we see that intemperance is by no means  the sole
cause of gout.  We are, however, very far from  wishing to re-
ject it entirely as a cause of this disease ; among these it should hold
the highest rank.  It is the most common^ as it is the most power-
ful.  The excessive use of fermented liquors is absolutely necessary
to that form of the disease which affects the ligaments and muscles.
This may serve to explain the fact,  that gout so seldom  appears in
the extremities of women, who  have it in other forms more fre-
quently than men in the ratio of ten to one*.  It appears in them
in the form of head-ache, dyspepsia, hysteria, &c.   I might here go t%»J
to explain the cause why  women  are more subject to gout  than
men, and, why it should assume a  particular appearance in them :
but this would be foreign to our purpose.
   Let us now see how far we are supported by facts  in the assertion
that the causes of gout and rheumatism are the same.
   Here we feel ourselves supported by the evidences of our oppo-
nents.   First, we will quote the authority of the illustrious Cullen,
as he holdsthe first rank among nosological writers.  This great man
has Bauer unquestionably acknowledged, that the same cause which
produces  gout can bring on other diseases.   These are his words:
« There are many instances of persons who  had for curing the gout

  * This opinion is held and supported by  many authors, but particularly by pro-
fessors Rush and Barton.             y 
                              13
taken to a milk and vegetable diet for some time, and after being re-
lieved  by it,  had returned to a fuller  diet,- which not only brought
back the gout with more  violence than before, but occasioned vari-
ous other disorders in their bodies."  Here the only cause of disease
that I  can discover, is debility*, from low diet.  And 2d, the stimu-
lus of  high living (fuller diet) after this low diet.  Causes more sim-
ple in  their nature cannot be conceived of; yet we find them giving
rise to " various disorders."  If exactly  the same  causes produce
gout, with  many other diseases, we will venture to say that rheuma-
tism is one of these, for I believe no  two diseases are more nearly
allied.  We have proved.then, by the authority of Cullen,  that the
causes of gout and rheumatism may be the same.
   Dr. Quinceyt has an observation not inapplicable to the subject
before us*   " Why," says this author, " rheumatism and hysterical
affections are frequently  forerunners  of gout in the female sex is,
because these disorders are from the same peccant matter as  the
gout."  Though I can form no idea of his " peccant matter," yet I
can readily believe the fact, that the same cause produces all of them.
And, indeed, on this occasion it is of no consequence what, the nature
of the cause is supposed to be:  whether peccant matter, morbific
matter, crude humours, or specific action.   It is sufficient for  our
purpose to know it is the same in all.
   This remark  is interesting  in a twofold view.  First, because it
is an acknowledgment  (by  a very intelligent author) of the very
thing for which we are contending, namely, the unity of the causes
of gout and rheumatism.   Secondly,  it proves (what can be proved
by facts alone) that gout slowly supervening will pass over the lower
grades of disease, and at length arrive at that which all  authors
agree  in calling gout.   The  following facts will prove the same
thing.   In the works of Dr. Darwin,  we  find the case of the Rev.
R. W. who in his youth had lived pretty  freely, and of course had
his system  highly excited: but he was young and of a good consti-
tution.  In this  state of things  he slept  one  night  in wet sheets.'
This,  as was to  be  expected, brought on a violent attack  of  the
* Debility with accumulated excitability.
f Treatise on Gout. 
                             14
rheumatism; the disease was soon removed, but it continued to re-
turn for three successive years: after that time however it did not
appear again.   His health  continued  pretty good for some time,
when, from the ordinary causes of his rheumatism (his system being
now greatly debilitated), he had an attack  of what his physician
called gout.
  Two  explanations may be given of  this case.   1st, The disease
changed from a lower to a higher grade, in  consequence of there
being greater debility in the latter case; or it may be understood by
the following analogy. It is a principle in medicine well established,
that all  stimuli  have a greater effect after their  use has been for a
while suspended*and the same thing is true as it regards the intro-
duction  of a.' disease, for here, though the debility is the same, yet
the occasional cause is  magnified, by being  for a time withheld,
which will amount to the same thing.  Thus, predisposing debility,
which at one time  ended in rheumatism,  at another, being acted
on by a  more powerful cause, terminated in gout.
  Again, Dawson tells us that inflammatory diseases, as rheumatism,
pleurisy, quinsy, &c. generally precede a regular and perfect fit of
the gout.
  All these things  show that rheumatism does end in gout.  And
is this more wonderful than that dysentery and pleurisy should end
in a yellow suffusion of the skin, or with black vomit ? That this last
often happens is notorious to every one, who has attended to the
symptoms of this disease during an epidemic bilious fever.  When,
however, these symptoms  which mark  so strongly a yellow fever
occur, no matter under what cover,  whether dysentery, pleurisy,
rheumatism, or gout, yet  the disease is constantly considered as a
case of yellow fever. Why then may we not regard gout and rheu-
matism as one form of disease, seeing that they  in like manner end
in each other?                                             .••
   We have said that rheumatism ends in gout; this, it is true, is not
always the case; any irregularity, however, in this respect cannot be
urged as an objection to the general principle.  Thus,  should gout
come on without having assumed the form of rheumatism, we are 
                                15
 not on that  account to consider their natures as distinct.  For no
 more takes  place here  than often happens in the ordinary produc-
 tion of disease, as has been explained by our illustrious professor of
 the institutes of medicine.  For instance, a disease may come on
 with all  its  causes* being regular and observable, or with one  or
 more of  them being imperceptible.
    We might here  delay, for the purpose of showing that every
 affection  of  the extremities called gouty, is  but  a case of rheuma-
 tism.  Its causes, seats, symptoms, effects, and cure, are the same.
 But this  would be a digression.
    In Dr. Warner's Treatise on the Gout, we meet with the following
 observation.   The  matter which makes the gout is  not only the
 cause of  many other disorders in the nerves, before it is formed into
 regular fits, but afterwards these fits occasion such a concussion in
 the whole nervous  system, as to expel with the gouty matter a great
 deal that is the parent of other  mischiefs.   Was this  nosologist
 aware of the broad construction that was capable  of being placed  on
 this remark ?  Was he aware that it was giving up entirely that ar-
 gument against the unity of disease which he with other systematic
 writers would derive from a diversity of causes ?  For  what does  he
 say ?  That  the same  cause in a less degree  than was sufficient to
 bring on the gout, produced various other disorders!.   From this it
 evidently appears, that he admitted different diseases to arise from
 the same cause.  If the same cause can produce different effects, I
 would, ask, in accounting for this diversity of effect, what need have
 we of calling in the aid of a plurality of causes ? Thus do we see the
' futility of naming diseases}: according to their causes, and thus too
 do we ever find the principles of nosology at war with each other.

    • The  professor, speaking of the phenom
 says^ morbid action sometimes leaps over pred
 links i^o death.
    f Head-ache, vertigo, palsy, apoplexy, &c.
    J The  reader is once for all informed, that wherever  the term diseases oc-
 curs, it is to be understood as meaning nothing but different forms of the same
 disease.
isposing and alYthe intermediate 
16
  This author speaks of opthalmia and erysipelas (among others)
as being brought on by this " gouty matter."  The fact is true and
important, though the theory intended to explain it is false: for I be-
lieve no person at this time will talk of " an opthalmic, or erysipele-
tous matter" as the proximate cause of these diseases.   The expla-
nation of this  fact cannot be given on the principles of a morbific
matter, &c.  yet how  easy is it,  when we consider the proximate
cause* of all disease as a unit ?
  One of the most common causes of these, as of many other forms
of disease, such as quinsy, pleurisy, nephritis, palsy, apoplexy, &c.
is the alternate exposure to heat and cold.  See the simplicity of
nature!  she does not needlessly multiply the  instruments of her
operations.  Why then should we attempt to tread a path (a crooked
one too) to which she has not pointed ? The above fact will explain
the cause of all these  forms of disease appearing almost exclusively
in the fall and spring.
  We find even Dr.  Cullen enumerating cold as one of the occa-
sional causes of gout.  We do not, however, find him distinguishing
between this gout, and that brought on by excess in venery,  by in-
temperance, or by indigestion. No; whatever might have been the
cause of the disease, he considers its nature (when it assumes par-
ticular appearances) as a unit.  Now we shall afterwards see noso-
logists entirely disregarding the appearances and symptoms of dis-
ease,  and trusting to the cause alone as a guide to its nature.  How
inconsistent! how absurd is this!
   It may be objected to thisf, however, that the application of  cold
alone is sufficient to produce rheumatism, whereas to bring on gout
it requires  the co-operation of some  other cause.   I  will  readily
grant that this is the case: that some other cause besides the appli-
cation of cold is necessary to the production of gout;  but this cause
is nothing peculiar in its nature to gout.  It is debility, the predis-
posing cause of all disease}.

    * Morbid action.           f That cold produces both.
    \ There is nothing specific in this cause; it is merely a higher grade of the
 same cause.  The reason why, of two patients exposed to the same degree of 
                                 17
   Having seen that the same causes produce gout and rheumatism,
 we shall proceed to another division of the subject:  namely, to show
 that  each of them is produced by very  different  causes*.   It has
 already appeared that intemperance is a cause of gout, and there
 are facts innumerable to prove that a  sedentary life, great exercise
 of the mind,  domestic cares,  vexation,  great bodily labour,  Sec.
 do often bring it on.   Even mineral substances,  as lead, have often
 produced gout.  I will introduce the following fact;  first, because it
 proves the truth of the above assertion, and secondly, because it will
 show the inconsistency of naming diseases from  their causes.  Dr.
 Dawson (whom I before had occasion to mention), in his Treatise on
 the Gout, relates many instances of lead  bringing  on the disease.
 In one case the disease made its first attack  on the  bowels (from
 which, however, it was soon translated to  the extremities), when he
 called it gout.   Now, consistent with those laws  of nosology which
 stamp the name of a disease from its  symptoms  and seats, the dis-
 ease  before us should, in its commencement, most unquestionably
 have been  called colica pictonum, diarrhoea, or dysenteryt, and at
 length (as has been done)  get the name of gout.   What would be
 the consequence ?  That the identical cause which produced cholera,
 diarrhoea, &c.  a little after brought on gout.   Where, then, is the

 cold,  the one shall have gout, the other rheumatism, is evidently this: he that
 gets the gout has been debilitated before; this, combined with the debility from
 cold (with the accumulation of excitability which will  attend it), must produce
. a higher grade of disease than this last can of itself possibly produce : but the
 patient, who  becomes affected with rheumatism, laboured  under no debility
 prior  to this ;  his grade of disease, then, is such only as  the cold of itself can
 give rise to.
   * We are not unmindful here of the position  taken by us elsewhere, " that
 stimulus is the only remote cause of disease."  If this were granted, our point
 would be carried at once; for if nosologists admit the cause of all disease to be
 the same, they certainly  would cease to divide them  from a difference of cause.
 In this case then we chuse to take them upon their  own  ground, viz. that the
 causes of disease are different.
   t For it certainly had the seat and all the symptoms of these.
                                 C 
                              18
merit in saying, that diseases are different because  their causes are
so, since different diseases have the same cause ?
  But, besides this, every one who has read a single practical  au-
thor, must know that lead produces rheumatism: the very thing we
wish for;  for it is another instance of gout and rheumatism having
exactly the same cause.
  I conceive that those who rest the controversy on the principle
of diversity of cause producing diversity of effect, will have the libe-
rality to admit that a unity of effect must flow from a unity of cause*.
Let us apply this.  In the  first  place, is any nosologist ready to
acknowledge that  intermittent fever,  goitre,  and hepatitis,  are
the same  disease ?  I apprehend there is not.   Yet the two last of
these are said, by a  most ingenious  author  of our day,  to be
derived  from exactly the same  causes.   But further, the inhabitants
of Iceland, who were  exposed to precisely the same causes of dis-
ease,  were variously affected;  some with intermittent fever,  some
with goitre, and others with hepatitis.  The following case, which
in the course of the winter has come under  my own observation,
will serve very well to illustrate  this position.   A lady of this city
exposed herself by standing for a short time on a wet floor, with thin
shoes.  At first she felt  no inconvenience from it; in the course of
the night however she awoke with a most violent, pain in her side,
attended with a difficulty of breathing.  In the morning a physician
was called,  who very  properly prescribed for pleurisy (for it was
fever with the local affection-^which constitutes pleurisy).  By the
depleting plan the disease was in a few days removed, and the pa-
tient became convalescent.   This favourable  state of things, how-
ever, did  not long continue; for the patient soon began to complain
of Uneasiness and pain in the lower extremities, and a considerable
swelling of the parts was observable, so much so, as to induce some,
   * Who ever thinks of finding names for all the different grades of disease
produced by opium, or any other poison! Whether it appear in the form of
 spasm of the stomach, vertigo, convulsion, or all these combined, is it not yet
 the same disease, varying only in force, and that too from the magnitude of
 the cause ? 
                               19
 tvho witnessed it, to pronounce it a case of dropsy*.  The pains
 were fluctuating—in short, it bore every mark of a case  of acute
 rheumatism.   Here, then, we  have the same  cause in the same
 person, producing pleurisy and producing rheumatism*.
   Let  us examine this case.  The cause here is  a unit; that the
 effects then should vary, the matter to be acted on must be different
 If 1 ow we are able to show that this difference of matter is not ne-
 cessary to explain the phenomena of the case before us, I  conceive
 we shall be justified in asserting, that the effect also is a unit;  that
 is to say, this disease was the same when it attacked the pleura, as
 when  it affected the limbs.  In the  first  place, then, why is this
 affection determined at one moment to the lungs, at another to the
 extremities ?  I answer, it  is from the presence of  the same cause,
 and not from the presence of specific  causes in these parts.  This
 cause is local debility.  How this debility should produce disease in
 a part,  will be fully explained by the following proposition.  Sup-
 pose I immerse one hand into a frigorific mixture,  and expose both
 hands immediately after to the same degree of heat?that hand which
 had been the subject of this experiment will become painful, inflamed,
 and will swell, whije the other will remain quite unaffected by the heat.
 Here heat is the exciting cause ;  what is the predisposing ?  Nothing
 peculiar in its nature surely; for who will  believe that cold has the
 power of introducing something specific into the part which shall
 dispose it to take on disease ? Simple debility then, and not  any  spe-
 cific effect of cold,  is the predisposing cause.
   It is  now shown  that debility does exist in the part; will it be
 asked, why this should invite the disease thither ? Because that part
 is in consequence of its loss of power least able to withstand the
fence of impressions made on it; just as the weak in battle, cateria
paribus,  suffer most.

   *  And why not ? If there was fever, and an effusion of serum, (which was
 very probable), what was wanting to make it a case of dropsy ? Nothing.
   t  And we might say dropsy. We are here using the language of nosology,
 for with us all these are but forms of the same thing. 
                              20
  It appears, to me, that with those, who  have laboured to affix a
specific name and character to a disease, from the nature of its
cause,  it would have been  quite as  consistent to attempt the same
thing  with each symptom of disease: this would be nothing more
than an extension of their own principles.  Thus they should have
an appropriate name for head-ache, as it occurs in gout, in rheuma-
tism, in  intermittent and yellow fevers, &c for as (according to
them)  the diseases which produced the head-ache are different;
and as different causes  cannot produce the same effect, it  follows
that these head-aches are in their nature different.   This being the
case, how wonderful is  it to find nosologists prescribing the same
method of cure for all these affections of the head*  !
  An absurdity must follow one way or the other.   If they contend
that the causes are different, it will be ridiculous  to say,  that the
affection is the  same; and (since they assert that the cure of a disease
depends  on its nature)  if they do not admit a unity of affection, how
absurd will be a unity of cure !
  From all thatfhas been said above, we may deduce the following
inferences :
  The cause producing disease either does or  does not change  its
nature.  1st. If the cause has no tendency towards  altering the
nature of the disease ; then, of course, must all objections!, founded
on  such belief, be false and chimerical.  2nd. But if it be sufficient
to fix its nature, then must we have a plurality of gouts ;  for the
causes bringing on gout are  as various in  themselves as they are
different from  those of rheumatism.  I will close  this division  of
the subject with the following remarks.
   In former times all diseases were supposed to depend on a pecu-
liar humour.   Thus there was a rheumatic, gouty, and nephrotic
humour, &c.   This opinion is now entirely rejected, as not  being
founded on fact; but it is followed by one not less ridiculous. Instead
          /
    * Dr. Cfeyne, with many other authors, says, when gout has seized on the
head, &c it is to be treated as any other violent head-ache,  or as an inflamma-
tion of the brain  or its membranes.
    f To the unity of disease. 
                              21
of specific  humour,  the physicians of the present day*  cherish a
specific action in disease ;  this, too, as depending upon the variety of
cause which produces it.   Once for all, I repeat it, cause can give
force, and it can give local determination, but it cannot  give cha-
racter.   Disease, like combustion, is, under all circumstances, a
vinit.   " From the small artificial volcano of L^nery to the terrible
eruption of Vesuvius, there is  no other difference than  what con-
sists in the magnitude of the causef."
       II.  Of the Seats of Gout and Rheumatism.

  Agreeably to our arrangement, we are, in the next place, to
treat of the seats of these two forms  of disease.
  From the seats, as from the  causes of disease,  many arguments
have been deduced  to support the  principles of nosology; yet, on
these,  systematics have not placed much reliance, for we often
see them  (when it  suits their purpose to do so) entirely disregard-
ing the seat of a disease, and looking exclusively to the nature of its
cause, cure, &c.
  We shall divide this subject as we did the former.
   1st.  Endeavour to show that they often occupy the same seats.
  2d.  Demonstrate that no disease has always the same seats.
  We say, then,  that gout and  rheumatism are the same in their
seats.   1st. Does gout affect the  blood-vessels?  so does rheuma-
tism.  If it be objected  here,  that rheumatism  often  comes on
without fever, I answer, that, when  this is  the case, the disease is
local;  it shows that the cause is not sufficient to produce a general
affection.   I am  supported in this assertion by the evidence of the
learned Cullen ; he says, that where there is no pyrexia,  the pain is
generally  confined to one joint,  but  when any considerable pyrexia
is present, it commonly happens that the pain affects several joints
* There are certainly many exceptions.
t Chaptall 
                              22
at the same  time.  The presence of fever, then, only proves the
disease to be  more extensively diffused  through the system.  But
admit that it does more, admit that its presence or absence proves
the disease to be different, and the  consequence will be, that rheu-
matism, with many other diseases, differs from itself, for they exist
with and without fever.   This argument, then, would prove more
than those who should advance it would have it do.
  2d.  Does  gout  attack the  extremities of the  body?  so  does
rheumatism.
  3d. Does gout affect the joints with pain, inflammation, Sec. ?  so
also does  rheumatism.   Wallis,  who dwells much on their seats,
admits, that they both affect the  joints, but in a different  manner:
" For," says he, " the muscles,  their common membrane, and the
tendons are  affected  with  violent  pain in rheumatism;  but,  in
gout, the  tendinous, nervous ligaments, and even  the periosteum
are more violently affected."  I know not how far this assertion is
founded on fact, but I am disposed  to believe, that we should lose
nothing by admitting it  to  be true.  We will therefore go on the
supposition of its truth,  taking him on his own ground.   Nothing
can be more exactly in point, towards refuting this  objection,  than
the following analogy, and analogical  argument should not be re-
jected when unopposed  by facts, and when it *is the best that the
nature of the  case  admits of.  There is an affection of the fingers
of the hands, called paronychia, or whitloe ; surgeons make this
disease to have four situations in the integuments of the fingers, viz.
1st, between  the epidermis and true  skin ; 2d, between  the true
skin and theca of the finger; 3d, between the theca and periosteum;
lastly,  under the periosteum : they however do not suppose its na-
ture to be different, because it has this diversity of situation.   Its
force is unquestionably affected by it, but not its nature.   Now the
symptoms of pain  and inflammation which happen in the joints of
gouty patients, are no more the effect of specific action, than are those
symptoms which  constitute whitloe.  In both cases it is  morbid
action, of the  inflammatory kind, with a local determination.  We 
                              23
do  therefore assert,  that gouty  and rheumatic affections  of the
joints differ in no respect but in grade.
  On  this  subject of  the  joints  it is  also  objected, that  gout
affects the smaller joints, as the fingers, toes, 8cc while rheumatism
attacks the larger limbs.   The following case (were it necessary,
many others might be  adduced), recorded  by Van Sweiten,  is of
itself sufficient to refute this objection.  « A young girl of fashion
having exposed herself, when heated, to the night air and dews, on
the folio wing day felt  great  pain  in her  neck, which soon  after
spread over her whole body, sometimes (wandering after a strange
manner)  it seized her feet,  then her elbows, and the fingers of her
hands."
  Much has been said cbout the great toe,  as the particular seat of
the gout; as well might we place  yellow fever exclusively  in the
stomach,  or small-pox in the  skin.  I would ask, how by this  spe-
cific action can the following phenomenon be explained? The  cele-
brated Hoffman tells us, " that he  has sometimes observed from a
rather tight  ligature  suffered  to remain  for twenty-four hours on
the foot  after venesection,  on account of the  orifice being pretty
large,  a pain to seize the joints of  the feet, particularly the great
toe, in the same manner as  the gout, which continued troublesome
for  several days."  This very case occurred to Hoffman himself.
  Here no body will  imagine, that the great  toe was affected by
virtue  of any specific  action; how absurd then  is it to call in the aid
of such an action  to account for gout attacking this part  particu-
larly !
  4th. Is the brain ever the seat  of the gout ? Every body knows,
that hemicrania is a frequent symptom of rheumatism ; but further,
rheumatism has  actually affected the brain.  The daughter of Dr.
M**** had rheumatism, which alternated  three successive times
with mania.  I cannot  have the  least hesitation in believing,  tha
this was the same disease in different livery.
  Baron  Storck  mentions  a case of death from rheumatism, in
which one of the ventricles  of the brain was  found full of a  yel-
lowish  jelly. 
                              24
   5th.  The  parts about the  sacrum  are  alike affected  by  both.
Coiterus says, he had found the space betwixt the lower part of the
spinal marrow and its dura mater, to be " frequently filled with a
thin serum in arthritic, ischiadic, and podagric patients, and  some-
times with a viscid pituita."  This shows that gout does affect these
parts; and that this is often a seat of rheumatism, is notorious to
every one.                                              '
   As an objection to the  sameness of their seats, it  may be said
(and it is what we shall not deny) that rheumatism never affects the
nerves.   There is no greater difference here, than is observable be-
tween hysteria and  hypochondriasis;  the former appears in the
muscles and  nerves, while the  latter affects these with the blood-
vessels: nor  are they more different in llfis respect,  than a mild
bilious fever  and yellow fever, or an intermittent fever and yellow
"fever : while the former is confined to the blood-vessels  and bones*,
the latter lays hold of the stomach, blood-vessels,  liver, brain, and,
in short, almost the whole body ; yet every body is ready to admit,
that intermittent and yellow fever are the same disease, varying only
in force.
   6th. Does  gout affect the muscles ? Dr. Stoll describes a case of
episthotonos  from it.  Rheumatism certainly does fix on the  mus-
cles ; this is admitted by Dr. Cullen; and Baron  Storck, of Vienna,
relates the case of a rheumatic patient, in whom  there was " uni-
versal stiffness,  even to  tetanus."   In this respect, then, we see
gout and rheumatism meeting in a point, exactly.
   7th. They both affect the cartilages.   Dr. Rush mentions  an in-
stance of gout fixing on the lobe of the ear, and Van Sweiten relates
a similar one of rheumatism.
   From the  above view, it appears, that  their seats are the same.
If, then, the seats of disease be deemed sufficient to stamp a specific
nature on it,  we claim a unity of nature  for gout and rheumatism.

  * An intermittent fever, which prevailed some years ago in Virginia, affected
the bones so violently, that from thence it got the name of " break-bone fever" 
                              25
  But we are next to examine into the propriety of naming disease
from its seats.
  We have said, that most authors have laboured to draw a line of
distinction between diseases, from the diversity of their  seats: and
in no instance have they relied with more confidence on the strength
of this argument, than in their labours to disprove the unity of gout
and rheumatism.  They have thought that this alone was sufficient
to establish a difference in their nature. This is one error springing
out of another.   They had seen gout frequently (generally)  attack-
ing the great toe—-rheumatism never. From this circumstance they
were led to believe that  the great toe was the throne  of the gout.
This then was their polar star, but finding that both of these diseases
at different times took very different stands, they were obliged t»
enlarge their geography of disease. Dr. Cullen admits an irregular,
a misplaced, and a retrocedent gout, and  in this he is followed by
many other authors.   With just the same propriety might we  dis-
tribute yellow  fever  into different classes, as it affects the blood-
vessels, stomach, liver, head, 8cc.  and thereby  have an irregular,
retrocedent, and misplaced yellow  fever.
   If it be asked to give the reason, why gout and rheumatism should
particularly attack the joints ? I answer, it is because there is a lo*
cal debility, which  invites the disease thither, and that there is no-
thing specific determining particularly to these parts*.   I say there
is local debility ; for  consult the writings of any  author, who  has
attempted to explain this fact, and you will find nothing mentioned
but such  causes as, we well know,  do produce such debjlity  ; these
are, the great exposure of the  parts to heat and cold, the small-
ness  of their blood-vessels, remote  situation from the heart,  and
their exercise disproportioned to that of other parts.
   The history of the following case, from  Dr. Darwin, will show, in
strong colours, the inconsistency of naming disease from its situation.
A certain lady  was most violently affected  with hemicrania, brought
on by a decayed tooth.  The extraction of the tooth, with  other re-
* All this has been elsewhere explained
                 O 
                            26
medies soon removed this affection; in a few weeks, however, the
patient suffered a paralytic stroke,  and was entirely relieved of the
pain in the head, which had now returned.  These were  certainly
different forms of the same affection.  For why may not the same
disease at one time appear in the form of tooth-ache,  and at another
take on the shape of hemicrania or palsy, as that gout should as-
sume the appearance of pleurisy, cholic, dysentery, &c?  lean see
no difference, Ihough systematics declare, that  gout is the same
under all these circumstances, yet  they will not agree to call the
disease before us by a  single name, « Odontalgia."  Why not ? It
has a single cause (.for no new one is mentioned), and in its  seats,
it is as much a unit as  the gout  is.   How contradictory, in this
respect, are the principles of nosology !
  Upon the whole,- then, since different  diseases occupy the same
seats, and the same disease  different seats; where is the propriety
of distinguishing between them from  this circumstance?  There is
none.   As well might we attempt to distribute the clouds into dif-
ferent classes,, as they take  different situations in the heavens, as
name a disease from the seat it occupies !
  Wind is but a commotion of the atmosphere ;  it is the  same  in
its nature whether it blow from the north or south, east qr west; it
is true it has different names,  but by these a difference of situation
not of nature is understood.
    III. Of the Symptoms of Gout and Rheumatism.

   Gout and rheumatism resemble each other in no respect more
than in  their symptoms;  in this they are as closely connected, as
any two forms of disease can be.
  To show how far the same symptoms are common to both, we
will here mention a few of the most prominent of them.
   1 st. From what was said under the preceding head,  it appears,
that fever may be justly considered as  a common symptom. 
                               27
   2d. They are both particularly disposed to affect  the  limbs with
 pain, inflammation, and swelling.
   3d. A fluctuating pain, removing suddenly from one part to ano-
 ther, is a symptom common to both.
   4th. Each of them observes stated periodical returns.   That this
 assertion is correct as it relates to gout,  is so evident,  as  not  to re-
 quire proof.  That it is true as it concerns rheumatism, will appear
 from the following circumstance:—Van Sweiten relates the case of
 a woman, who, having exposed herself to  the night air  and dew,
 became affected with  rheumatism ;  of this  attack, however, she
 was soon cured, but  ever after, at the same time  of the  year, she
 had a regular return  of the disease.  The immortal Sydenham had
 an eye to the same thing; he says, " it frequently  happens,  when
 the  patient has been  unskilfully treated,  that he is severely afflicted
 during life with flying  pains,  which are at some times violent, and
 at others more  gentle."  To this  account  it may not be amiss to
 subjoin the following remark  of the  same illustrious author, as it
 will afford another instance of the  affinity of these  forms of disease.
 " When," says he, "  the gout seizes a person far advanced in years,
 for the first time,  it  never has  such  stated periods, nor  proves  so
 violent, as when it attacks a younger person."  This observation
 may be applied with equal propriety to rheumatism. We have said
 elsewhere, that debility is the predisposing cause of all disease ; this,
 compared with the fact above-mentioned, would seem to be an in-
 consistency: for here, though  the  debility is greater, the disease is
 less  violent.  An explanation,  therefore,  becomes proper.  Three
 things are necessary to  the production of disease,  1st,  debility; 2d,
 accumulated excitability; and 3d, an irritant or exciting  cause.
 The greater the debility present, the more  liable  is the system  to
 disease, but not the  more violent  that disease ; it is the degree  of
 accumulation of the excitability that gives force.  Now with the de-
 bility which is incident to old age,  there is an exhaustion of the ex-
 citability of the system, whereas, with that debility which takes  place
 in youth,  there is an accumulation of excitability.  In the former
case, both excitement and excitability are exhausted, the  system is 
28
therefore unable to re-act, or rather,  the  disease has nothing to
act on.
  5th. The following relation, by Dr. Rush, shows a most marked
resemblance between  these diseases.  This observer (than whom
there is none more acute) of the operations of nature in the produc-
tion of disease, informs us, that the gout sometimes passes by the
blood-vessels, ligaments, and muscles, and invades at once the liver,
bowels, and brain.  Again, he says,  the morbid action induced by
Ihe usual causes of rheumatism,  affect, though less frequently,
the lungs, the trachea, the head, the  bowels, and even the heart, as
well as the gout.  These observations are supported  by the autho-
rity of many authors beside. It may not be amiss here to hint at the
sameness of the symptoms which mark these diseases when thus
translated.
  Rheumatism <like gout), translated to  the stomach, produces
pain, nausea and vomiting; to the intestines, diarrhoea and dysen-
tery ; to the heart, dyspnoea: to the lungs, a true peripneumony j
to the head,  heaviness, confusion and giddiness.
  6th. Dr. Rush has seen cases of opthalmia* from gout, and I have
witnessed one in which rheumatism  most evidently alternated with
opthalmia.
  7th. The  following fact will serve to show the  great analogy be*
tween their symptoms.  Henry Young was admitted into the Penn-
sylvania hospital during the winter, with acute rheumatism; he was
treated with  the common remedies for  rheumatism ; an  abscess
formed on his breast, after which all pain left his limbs,  and his
stomach became much affected with  pain and acidity.
  From the above, it appears, that the great characteristic symp-
toms of gout and rheumatism are the same. If then a sameness of
symptoms can make a sameness of disease,  we may venture to pro-
nounce, that gout and rheumatism are  the same.
   II. But I  am much disposed  to question the  merit  of naming
disease from its symptoms, seeing that a disease which even noso-
• Medical Inquiries, Vol. V. page 186. 
                             29
logists themselves agree is a unit, is often marked by a very great
diversity of symptoms.  Thus, gout,  for instance, will at different
times assume very different appearances. We have various accounts
of its producing coma, vertigo, apoplexy, palsy, loss of memory, and
madness in the brain ; hysteria, hypochondriasis, and syncope in the
nerves, pneumonia in the lungs,  diarrhcea, &c. in the bowers.  Dr.
Rush has seen petechias, gangrene, and black vomit ; and lastly, ft
it appears in the form of tic doloreaux or aura dolorifica.  I cannot
conceive of a greater multiplicity of characters than is here.  To
admit this, and yet, from matter  so changeable and contradictory in
its nature,  to attempt to fonn fixed and unchangeable principles, is
contrary to reason and common sense.
   I think, whoever will call to mind all the symptoms that consti-
tute the above diseases, mid recollect that they are  here enumerated
as making a part of gout, will not hesitate to declare, that such cases
of gout (if we regard the symptoms) are more unlike the ordinary
appearance of this disease, than this last is unlike a case of rheuma-«
tism.  How inconsistent, then, of these three appearances of disease
to give one name to the two least like each other !
   III. How very changeable and uncertain the symptoms of disease
are, and of course how ill calculated to give birth to any fixed princi-
ples in  medicine, the following facts and observations will serve to
show.
   The great Sydenham, speaking of what he calls scorbutic rheu-
matism, has the following words : " Neither are we ignorant, that
as many symptoms, resembling the scurvy, afflict gouty persons af-
ter the fit of gout is over;  and this is to be understood, not only  of
the gout, but also of a beginning dropsy."
   Again, Van Swieten relates a  case of what he  named  rheuma-
tism, in a young girl, " who in autumn complained of a pain about
the top of the os ilium; the following day, stooping suddenly to take
something  from the ground, the pain  instantly increased to a vio-
lent degree, and presently dispersed itself over the whole right side,
leg, and arm, nay, over the  right side  of the head.  Upon  being
blooded she had an immediate flux of the menses."  This case pre- 
30
 sents a strong objection to the nosological arrangement of disease ;
 for, governed by the symptoms, this affection should be called rheu-
 matism, but if we regard its cause and effect, we must consider it as
 a case of " retained or suppressed menses."  How systematics can
 get over this palpable contradiction in their doctrine,  or how recon-
 cile it,  I am at a loss to determine.   They cannot do  it.   In such a
 dilemma, they are obliged to  throw some of the circumstances of
 the case behind the curtain, and  select such only as will suit their
 purpose.   Thus, in the case before us, no notice is taken  either of
 the cause* or issue of the disease,  the  symptoms  were thought
 sufficient; because, had this author attended to other circumstances,
 he  would have found them at war with each other—symptoms mak-
 ing it one, cause and effect another disease.
  On the other hand,  we often find systematics entirely disregard-
 ing the symptoms of a disease, in their attempts  to  fix its nature.
 An observation to be met with in Cullen, will show how little confi-
 dence he occasionally placed on the symptoms of disease ; it is this :
 though the  disease (gout) may  sometimes assume  different ap-
 pearances, yet as he  supposes it to depend always upon  a certain
 diathesis  or disposition of the system, so every appearance that is
 perceived to depend upon that same disposition, he considers  as a
 case of gout.  This remark is an indirect but positive acknowledg-
 ment of the impropriety of distinguishing disease by its symptoms ;
 for here,  no matter what the symptoms are, it is declared to be a
 case of gout.
  The following circumstance will show how very flexile  the prin-
 ciples of nosology are.  If a patient  be attacked with a disease of

,_  * I have no doubt that the stimulus of distention, from the retained menses,
 was the  cause of all these different symptoms ;  why, it should at first produce
 no effect on the vessels of the uterus, seems to be, because the force of the sti-
 mulus was disproportioned to the power of re-action in these vessels ; that is,
 they were prostrated.  This opinion is supported by the fact, that blood-letting
 enabled the vessels to throw of the superfluous Wood, which never happens un-
less  there is suffocated excitement in the system.  I say, then, the vessels of the
 uterus being unable to take on diseased action,  the rest of the system sympa-
 thized. 
                               31
 rather doubtful nature (bearing, however, some resemblance to what
 is called gout), the systematic immediately  enquires, « Have you
 ever had twitching pains  in your feet ?" If he answer, " Yes," it is
 sufficient; it instantly has " gout" stamped upon it.   Now a most
 ingenious author tells  us (and I believe very truly), that there are
 few persons who have not at some time or other experienced these
 painful twitches, yet the systematic  entirely disregards this  symp-
 tom, unless he can make it form a feature of gout.
    In  this, also, will the  inconsistency of nosology appear;  gout
 translated to the lungs is said to be a true peripneumony, and is to
 be treated accordingly ;  yet when it  fixes on the  extremities and
 joints (at which time it certainly has every characteristic of rheuma-
 tism), they do not call it rheumatism, but still continue the name of
 gout.


       IV.   Of the Effects of Gout and Rheumatism*.

    We are in the next place to consider  these diseases, as regards
 their effects.
    1st. The most obvious effect of both is inflammation and sweU
 ling of the part affected ; this, it is true, does not so often occur in
 gout as in  rheumatism; the cause of which,  I suppose, must be
 the greater disposition gout has to remove suddenly from place to
 place, in this way not remaining  long enough in any one part to
 produce this  effect,  which requires some time.
   2d.  The effusion of coagulating lymph is a common  effect.   The
 nature of these effusions is different in both, according to the parts
 in  which  they take place.  Thus, when they happen in the kid-
 neys or urinary bladder, the lymph is  changed, under certain cir-
 cumstances,  into urinary calculus; in the ligaments and joints this
 effused matter is converted by stagnation into chalk-stones.   We
 shall  not  attempt to account  for this effusion forming different
 substances, as it happens in different parts, as this, though  it were
uniformly the case,  could not militate  against the truth of the po- 
                             32
sition we are  aiming to  establish; we will, however, observe, that
the nature of the effused matter is not always the same in the same
parts.  Morgagni dissected the body of a rustic, ninety years of age,
who died of a tertian intermittent fever ; in the tunica  vaginalis  of
the right testicle,  he found two calculi, in that of the left a great
quantity of water.  Thus,  it appears, that the same parts, from the
same cause, contained, the one water, the other calculi.
   3d. Both gout and rheumatism sometimes end in suppuration.
   4th.  They both  produce visceral  congestions; rheumatism less
frequently than gout.
   5th. They both produce  an effusion of serum, which (when it hap-
pens in hollow cavities) forms dropsies.  Our  illustrious professor
of the principles of medicine mentions cases of gout and rheuma-
tism bringing on  dropsy ; and Baron Storck records the cases of
three rheumatic patients, in whom dropsical  effusions were disco-
vered after death; in two of them the effusion took place in the ca-
vity of the  thorax ; in the  third, the water was discharged into one
of the ventricles of the brain.  This is sufficient to prove that drop-
sical swellings are equally  the effect  of both.
   6th. We are told by Dr. Rush, that gout sometimes produces a
collection of air instead of water in the cavity of the abdomen ; and
a German  physician, Mediavea, says, he has seen rheumatism ter-
minate in hydrops tympanites.
   7th. Stiffness and dislocation of the joints follows both these forms
of disease,  as every one knows.
   8th. Gangrene is produced both by gout and by rheumatism. Dr.
 Rush has seen the muscles of the leg destroyed by a mortification
brought on by  an attack of the gout.  In the dissections  of  Mor-
 gagni we meet with a fact, which shows the same thing to have hap-
 pened from rheumatism; he  tells  us, that the muscles about the
 sacrum of a patient, who had died of the rheumatism, were found in
 a state of incipient gangrene.
    The chalky concretions above-mentioned  were formerly consid-
 ered as an almost infallible proof of the presence of gout.  Had the
 writers of those times extended their researches and observation a 
                                33
  little, they would have found that this calculous matter was not peculiar
  to gout;  it is observable in many other diseases, as will appear pre-
  sently.  Calculous concretions were found in  the body, and that in
  the joints too, of an old woman,  who died of apoplexy*.   I do not
  pretend to say, that these chalk-stones were the effect of apoplexy ;
  yet of this  (which is sufficient for our purpose) I am satisfied, that
  the patient did  not labour under gout; for had she been afflicted
  with so violent a disease,  it would not have passed unnoticed by this
  great man ; but the truth of this opinion will appear still more evi-
  dent from hence, that this case was brought forward by Morgagni
  himself, to show by what different affections  this chalky concretion
  was produced. Hildanus declares that an «infinite number" of these
  calculi were discharged from the lungs of a consumptive patient; be-
  sides this, dypsncea, cough, hoemoptoe, asthma,  and hectic fever,
  have been said to produce them.
   These concretions are also formed in different parts of the body,
  and in parts, too, which occasionally contain very different substances.
  Thus, Morgagni, having dissected  the body  of a virgin, who  died
  of fever, found water in the abdomen, serum and calculous concre-
 tions in the thorax.  Further, they have been discovered in the kid-
 neys, liver, intestines, and eye-Uds, and both Preusseus and other
 authors relate cases of their bemg formed and discharged from an
 ulcer near the sternum.  Morgagni, speaking of all these calculous
 matters, so variously produced,  and in such different places, has the
 following remark: " These are  for the most part like the matter
 which concretes in the joints  of arthritic patients, friable, light,
 like pumice-stone, chalky, and tophaceous."
   In various points of view, we see exactly the same  effects produ-
 ced, by what nosologists would call very opposite diseases (and it
 has been shown elsewhere, that different effects can result from the
 same causes).  How insufficient, then, must be the effects of disease
}0t towards giving it a fixed and unchangeable character!

                          *  Morgagni.
                               £ 
34
       V.  Of the  Cure of Gout and Rheumatism.


  We have now  reached the last, though not the least important
division of our subject.
  As it is a principle held by nosologists, that disease is a  unit,
when it arises from the same cause and is cured by the same reme-
dies, it will be sufficient, for our purpose, to  prove, that the  cure
of gout and rheumatism is the same, having already shown the iden-
tity of their causes.  I say, this  is a ground taken by nosologists;
the truth of this assertion is discoverable in the writings of almost
every systematic, especially in those of Cullen and Sydenham.  How
far the method of cure for a disease was supposed to  go (by this
last-mentioned author) towards establishing its nature, will  appear
from the following circumstance. The latter great man, having  given
the history of a case of " scorbutic rheumatism," observes, that he
was led from its symptoms (especially as it occurred in women, and
in men of weak constitutions), to refer it to  the hysteric class,  yet as
it did not yield to anti-hysteric remedies, he thought himself bound
to call it rheumatism.  Here then the decision, as to the nature of a
disease, turned entirely on the nature of its cure.
   The following remark by C. Aurelianus, might, with propriety,
 have been introduced elsewhere, but I have chosen to reserve it for
 this place, as here it will serve a double purpose ; to show, on the
 one hand, what great confidence nosologists placed in the cure of a
 disease, in their attempts to fix its nature; and on the other, how ne-
 gligent systematics are of the seats of disease, unless  it suit their
 purpose particularly to attend to them.   The remark is this: « But
 we must not contend about names, which seem only  to be  distin-
 guished according to the difference of situation, yet are understood
 to be of one property in the cure."
    To go through the whole catalogue of remedies, which, at differ-
  ent times, are proper to be exhibited in these forms of disease, would 
                               35
 Swell this essay far beyond its proper limits ; neither is it necessary:
 for should I now, after having laboured to prove that their nature is
 the same, hesitate for a moment to deny  that tkere is any class of
 remedies peculiarly adapted to either, I should be guilty of the high-
 est inconsistency.  As I consider gout and  rheumatism to  be the
 same disease, varying  only in its grade,  the only diversity of cure
 will be such as this different force of disease may require.
    As  I would prescribe for  the  symptoms of disease, without any
 regard to its name, and as  it  has been shown, that the symptoms of
 gout and rheumatism  are  often the same, it  follows, that  exactly
 the same method of cure is  to be observed in both.  The plan of
 treatment, which the principles I  hold would lead me to adopt, may
 be summed up in a few words.  In these, as  in all other forms of
 disease, I would  deplete when I believed there was  great  morbid
 action in the system, and stimulate when this action was weak.  In
 rheumatism, in gout, in yellow fever, in every other disease, I would
 bleed, in an active or depressed* pulse, and stimulate where the re-
 verse  was  the case, without the least regard to name, specific ac-
 tion, or matter.   The truth of this principle is unquestionably esta-
 blished  by the  following important fact: A lady in  this city had
 taken a large dose of opium,  for the purpose of destroying herself.
 Soon afterwards Dr. Rush was called in ;  he immediately attempted,
 by means of emetics, and by a feather thrust down the fauces, to bring
 on vomiting; but after many ineffectual  attempts to procure a dis-
 charge of the opium from the stomach, he resolved  no longer to re-
 gard the cause of the disease, but (governed by the principles of medi-
 cine which  he had adopted) to proceed to  its cure with reference to
 the symptoms alone; when he found the   pulse full  and  active, he
 advised depletion ; when it  languished, he gave stimulants.  Thus,
 without regard to any specific cause, name, or nature, and having a

    * There is a distinction made by some authors between a depressed and op-
pretsed pulse;  the latter is a pulse of debility, the former of prostration. By too
forcible impression the system does not re-act, 
                              36
view to nothing but the state of the system, did he check the rapid
progress of this affection towards death.
  Though I decline  entering particularly on the consideration  of
the remedies for gout and  rheumatism, yet to remove a seeming
objection to the  position taken by us, it  is proper that I  should
speak particularly of one of these remedies : the remedy to which I
allude  is blood-letting.  Most authors recommend this in recent
cases of gout, but it is no less a true than common observation, that
its use is often improper in this disease,  even when (governed by
the ordinary indications for  the  use  of the lancet) we  should be
strongly prompted to  pursue this plan* ; and, in this respect, does
the cure of gout differ from that of rheumatism,  for this delusion
never  occurs in  the  latter.  This objection, at first sight,  seems
plausible enough, but if it be examined into, it will be found with-
out merit.   Whenever this  state of gout occurs, I imagine it is  in
such persons as have, what Dr. Rush has very  happily  called the
" soap-bubble excitementf."  This excitement is generally, though
not always, the effect of intemperance; but,  neither this kind  of
excitement, nor this caution in the use of blood-letting,  is peculiar
to gouty patients: it is especially observable  in the  diseases  of
drunkards; hence we are  particularly cautioned  against the too
hasty use of blood-letting in pleurisy,  hepatitis, 8cc. as  they occur
in such patients.   From this it appears, that this phenomenon may
be explained without  referring it to any specific action in gout.   It
is the effect of a cause, which, with gout, gives rise to many other
forms of disease.
   With this li'tls exception, then, I  consider the general  plan of
Cure for the gout and rheumatism as the same.
   Having  already shown the very close analogy which obtains be-
tween these diseases, aS it regards their symptoms and  seats,  it  is

   * Dr. Barton  has seen venesection produce evident ill effects, when the state
of the system seemed to call aloud for its use.
   t It is obvious why  this kind of excitement should forbid the use of the
lancet. 
                             37
hardly necessary to say, that  the  local remedies likewise must be
the same.  While I am on the subject of local remedies, it may
not be ami$s to give  the following relation of a fact, from Baron
Storck,  both as it proves the  success of the same remedy in them,
and as it affords a case of rheumatism in which the analogy between
these diseases will most strikingly appear.  This  author tells us,
that he saw a  case  of rheumatism,  in which the disease was, at
first,  seated in the joints of the hands and feet; at length, however,
it  became  diffused through the whole  body,  affecting the eyes
and breast particularly.   He then  observes,  " Strong sinapisms
were applied to the hands and feet: in less than half an hour's time,
a  violent pain  settled  on the  knees, and wrists, and the  dan-
ger of suffocation wras immediately lessened."  What  a marked
resemblance  do we  observe  here !  the very same remedy produ-
ced, in  rheumatism, exactly the same effect that it did  in gout, to
wit, brought back the  disease from internal parts, to the external
ones  first affected.
   Having shown that  the cure of gout  and  rheumatism is the
same, we claim  for them all that this argument is  supposed to
prove ;  that is to say, if the cure of a disease have any hand in esta-
blishing its nature, we will venture to infer, that the subjects of this
essay are in their nature a perfect unit.
   We  have  now considered gout  and rheumatism  under every
view that can be taken of them ;  1st, regarding such things as re-
lated to their causes;  2d, to their  seats;  3d, to their symptoms;
4th, to their  effects;  and,  lastly,  to their cure.   After  all of
these, we have  thought ourselves justified in drawing the infer-
ence, the truth of which  it has been the object of this essay to es-
tablish.
   I have now brought this essay to  a conclusion.   No one can be
more sensible than  I am myself, of  its  very numerous  imperfec-
tions; for these, in  justice to my own feelings, I  must offer some
apology.  I shall say  nothing of my youth  and inexperience ; they 
38
are pleas worn out by use; I will only observe, that it was written in
a few days, and after the excitement of my mind and body had been
very much reduced by the studies of the previous winter, and the
soUcitude which  accompanies the examinations, previous to receiv-
ing the honours of the univefsity.
THE END. 
 
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