M ■&■ .a* <5;,,J '.st*^*-- W >;%?: ,.■■.. '1 UNITED STATES OF AMERICA * ME WASHINGTON, D. C. GPO 16—67244-1 *.." J^-'wAl A N INAUGURAL DISSERTATION ON THE G O U T: SUBMITTED TO THE EXAMINATION OF The Rev. WILLIAM SMITH, S. T. P. Provost; The TRUSTEES, and MEDICAL PROFESSORS OF THE > COLLEGE of PHILADELPHIA, FOR THE DEGREE OF DOCTOR OF MEDICINE, On the 43d day of June, A. D. 1791. By GEORGE PFEIFFER of PHILADELPHIA* FELLOW OF THE PHILADELPHIA MEDICAL SOCIBTY. As man, perhaps, the moment of his breath, Receives the lurking principle of death; The young difeafe, that muft fubdue at length, Grows vrith his gfowt&, and ftrengthens with his ftrength. Pope. be then my earned care, and conftant ai#, S---"-^lY/.; To eafe his varied ills, and prop his tott'rlng 4ame. / ^ ^ '«f /, ■ ^^ PHILADELPHIA: * ^i^LJL • - PRINTED BY T. DOBSON, AT THE STONE-HOUSE, No. 41, SECOND-STREET. M,DCC,XCI, D-t%a r>^L. **-'! -, 4 S ' can all thefe gentlemen have advanced on this head lead ?—For my own part, I canriot but think, to corroborate our opinion. For when a man, tc overthrow eftablifhed facts, makes ufe c'J eiiipiiy affertions and railing, it is with me an aiiLoft indu- bitable proof of their reality. In -avour of our doctrine, the great Sydenham tells us, that young perfons are feldom or never afflicted with this dif- eafe, except from hereditary diatheiis; and that he himfelf never faw any, unlefs they had been be- gotten by gouty parents. Van Swieten fays, that he has feen many peo- ptej who had no reafon to blame any caufe what- ever but an hereditary taint; who although they lived according to the greateft chaftity and fobrietv, yet had been attacked by this difeafe even early in life—Among other inftances, he makes mention of a lkilful phyfician, who, knowing that the gout was hereditary in his family, always, from his early years, apprehended an attack from B this C » ] this latent enemy :—nor was he deceived, for he fell at length under its power. Dr Cullen, in his Firft Lines, alfo fays, that the gout is generally an hereditary difeafe ; and fur? ther, that the fails fupporting this doctrine are very numerous* The learned Dr Warner, in his elaborate trea- tife ort this difeafe, tells us, **' It appears from facts daily verified, that there are people much afflicted with the gout, in the early part of their life, who have not known intemperance, high living, or inac- tivity ; but have unfortunately derived it fromtheir parents, in the particular frame of their conftitu- tions." "Notwithftanding, (fays Kirkland, in his Enqui- ry,) what may have been faid to the contrary, I join in the general opinion, that the gout is often heredi- tary ; becaufe I have known children born of gouty parents afflicted with it—becaufe I have feen it inherited by the natural fon of a gentleman in the ftation of a labourer ; and becaufe thofe per- fons, whofe anceftors have been troubled with this affection, are more fubject to it than others." The following fact I received from a refpectable ftudent of medicine, who told me that he had read it in fome of Dr Cullen's manufcript lectures.-—I think it was nearly in the thefe words: " There is a certain charitable houfe in the city of Edin- burgh, in which, together with many children of poor origin, the natural offspring of gouty lords and gentlemen are maintained. It is obferved, that C « ] that moft of the latter become afflicted with this dreadful difeafe, while the former never experi- ence the flighteft fymptom of it." Now, thefe chil- dren are neither fedluxurioufly, nor fpanngry, but, no dOubt, live on good wholefome diet; and cer- tainty are not fuffered to be idle or inactive. Amongft other cafes, Dr Rufh, in his lectures, mentions that of a whole family who fufrered by rhis difeafe. The grand-father, if I miftake not, laboured under it—Moft of his children, if not all, had it after him-*-His fon married, and communicated it to- his- children—The greateft number of thefe were females, who lived neither an inactive nor in- temperate life ; but, on the contrary, ufed all ra- tional means to avoid the difeafe. In fpite, however, of their utmoft endeavours, they all died martyrs to the gout. It 1$ likewife not an idle and groundlefs hypothcfis, impofed on us by falfe and felf-interefted1 theorifts, but has been noted by ac* curate and faithful obfervers of nature, that chil- dren begotten before their parent has had the gout, have never known1 a fymptom of it: while, on the other hand, children of the fame parent, begotten after the difeafe has made its appearance in him, and especially foon after he has been labouring un- der a paroxyfm of it; thefe children, I fay, have been feverely afflicted with it. . . Definition [ w- ] Definition andHi/iory of the Tonic Species. THIS fpecies generally confifts in a violent pain and inflammation of the joints, particularly the fmaller ones, as thofeof the great toe, &c. fre- quently attended with fever; and, for the moft part, preceded by an unufual affection of the ftomach. It does not, however, always exhibit thefe phe- nomena; for inftead of the joints, it fometimes feizes on the lungs, brain, &c. Sometimes alfo, while it affects one part with excefs of action, as the joints or lungs, it affects others with deficiency of action, as the ftomach and inteftines; nay, I be- lieve, it feldom or never appears in the alimentary canal, except in the atonic ftate. A paroxyfm of the regular tonic gout, is generally preceded by a ceafing of the fweat natural to the feet; an unufual coldnefs in the feet and legs; a feeming defcent of flatulencies through the fleffiy parts of the thigh; a frequent numbnefs, alternating with a fenfation of prickling over the whole of the lower extremities; convulfive motions of the mufcles of the legs, and an unufual, turgefcence of the veins. Some de- gree of torpor and languor is at the fame time felt over the whole body, together with a diminution of the appetite, flatulency in the ftomach and bowels, &c. Thefe fymptoms generally continue only for a few days, after which the paroxyfm commences, moft commonly at two or three o'clock in the morning, when the patient is waked by a E. y 3 a.violent pain refembling that of a diflocated bone, and ufually affecting the ball of the great toe; though fometimes the calf of the leg, heel, or fome other part of the foot. Thefe fymptoms are immediately fucceeded by a chillinefs, fhivering, and fever, which, together with a topical inflammation of the part, generally continues as long as the pain itfelf. From its firft onfet, the pain gradually increafes, and comes to its height in about twelve hours; after which it as gradually remits, and in about twelve hours more almoft entirely ceafes, leaving the patient in a breathing fweat, who now foon falls into a fweet and refrefliing fleep. Upon wak- ing, he obferves, inftead of a fwelling of the veins of the part, which alone appeared before, the part itfelf to be confiderably minified and red. For feveral days after this, which I would call the great fit, there is a flight return every even- ing of the abovementioned fymptoms, which con- tinue with more or lefs violence till mornihg: after fome time, however, they entirely abate, and leave the patient generally in a remarkably good ftate of health: when the fit is going off, a vio- lent itching feizes the foot, efpecially between the toes. The progrefs of the difeafe is marked by the in- tervals, which were at firft from three to four years, gradually fhortening, till at length the patient is al- moft inceffantly tormented wit^i it, except for a few months in the fummer. It [ 1*4 1 It is alfo marked by the parts whteh k effects * for, at firft, we commonly fee one foot only affected, then both feet alternately; then the hands, wrifts, elbows, knees, lungs, brain, &c* It might have been mentioned before, that after the firft paroxyfms, the joints recover their former ftrength, fupplenefs, &c. but after the difeafe has frequently recurred, they remain Weak, and ftiff; and at length loofe all capability of motion. Con- cretions of a chalky nature, are likewife often ob- served to take place on the outfide of the joints, immediately under the fldn. It may alfo not be improper to mention that in this advanced ftate of the difeafe, the paroxyfms frequently alternate with nephritic affections. But, what feems moft extra- ordinary is, that the bones themfehres, fometimes become diftorted and fbft, likethofe of ricketty children. Many cafes of this kind are recorded by authors; fome of which, may be found in (f i. VanSwieten; 2. Morand; 3, Gagliardr; 4. Fetit; 5. Du Verney, &c. &c.) Du Verney relates an extraordinary cafe of a man, who about the twenty-fourth year of his age, was attacked with what were judged to be gouty pains, about his heels, knees, and the upper joints of his thighs. In a year after, his whole body was tor- * All {he phenomena taken notice of in this definition, have been ob- ferved by Sydenham or Cullen. f 1. Comment, vol. 13. 2. Hiftoire de la maladie finguliere, & de i'examen du cadavre d'une femme. 3. Anatom. ofs. pat. 70, & feq, 4. Traite des maladies des os. torn ii. 5. Traite des maladies des os. torn ii. t 15 3 tormented with fuch Violent pains, that he was 0- bliged to lie almoft continually in bed. About this time the bones began tofoften; and at length became fo flexible as to bend like wax. His body likewife ftirunk to a very fmall fize. It is remarkable, that in many cafes of this na- ture, mentioned by authors, the urine depofited a very plentiful fediment, which, upon examination, was found to be of the fame nature with the chalky concretions of the joints, and the calculi of the bladder. Dr Wifter, in his lectures on ehemiftry, relates the cafe of a child, whofe bones were foftened by the rickets, and whofe urine contained an aftoniflx- ing quantity of phofphoric acid. Now, when chemically analyzed, the bones of animals, at leaft when in an healthy condition, yield a large quantity of calcareous earth and phofphoric acid. From the abovementiorted cafe, therefore, the Doctor was inclined to conclude, (and I think very juftly,) that their firmnefs and folidity depend in a great meafure on the ptefence of this acid in them. And, in my opinion, we may as juftly add, that the calcareous earth alfo contributes very much to give them a confiftent degree of hardnefs. The matter of which the concretions we have juft mentioned are formed, is called by many au- thors the morbific matter, or caufe of the difeafe. This doctrine appears to me a very ftrange and er- roneous one ; for, in general, we fee nothing of this materies morbij till after the gout has been raging E *<" 3 raging many years. We therefore look upon it entirely as an effect, and not as the caufe; and think it quite rational to fuppofe, that, in procefs of time, the difeafe induces fuch a difpofition in the veffels of the parts particularly affected, as to caufe them to pour forth into the cavities of the joints, &c. that matter, which, in health, wa*s poured into the fubftance of the bones by their fe- cretory veffels, and gave them ftrettgth and firm- nefs. I have now given as full an account of the firft fpecies, as the nature of this work would admit of; but muft acknowledge, that feveral phenomena have been mentioned under this head not peculiar to either; as they muft, however, have come in fomewhere, I thought, they might as well be mentioned here as any where elfe. A very few words will fuffice for the Definition and Hijiory of the Atonic Species. Here there is, for the moft part, little or no inflammation and pain in the joints; fever generally light, or entirely wanting; and dyfpepfia, often at- tended with other marks of debility. The principal fymptoms are, lofs of appetite, naufea, vomiting, flatulency, acid eructations, and fevere pains in the epigaftric region. Frequently alfo, there occur pains and cramps in feveral parts of the trunk and upper extremities ; colic pains and coftivenefs alfo, for the moft part, attend, though E «7 1 though fometimes a diarrhoea. In thefe circunv- fiances the mind often fympathifes with the body ; fo that, to ufe the words of the immortal Syden- ham, " It is not eafy to determine which of the two is moft afflicted; for all the fymptoms of hypo- chondriafis not unfrequently attend. Palpitations', faintings, dyfpepfia, convulfions, &c. do likewife fometimes take place. When we are called to a perfon labouring under all, or moft of the abovementioned fymptoms, we may be almoft certain, that they are marks of the gout; by there occurring, at the fame time, flight pains, and, at leaft, a tendency to inflammation in the fmaller joints, efpecially of the lower extremi- ties: by their returning after certain periods of time ; by appearing in fuch habits as we might, a priori, fuppofe to be predifpofed to the gout; and by this difeafe having been hereditary in the pati- ent's family. It may not here be improper to obferve, that thefe two fpecies often run into each other; the tonic becoming atonic, and vice verfa; and that a mixture of both fometimes occurs. Of the Caufes of the Gout, THESE I ihall divide into the predifpofing, re- mote, occafional or exciting, and proximate. This is. a difficult part of our fubject. The three firft I fhall confider as appertaining to the difeafe C in £ i8 ] in general; and the fourth, as particularly diftin- guifhing the two fpecies of it. i ft. By the predifpofmg caufe, or predifpofition, I mean that ftate of the fyftem which is abfolutely neceffary to the production of the difeafe; and which, being wanting, the exciting caufes would al- ways be applied in vain. By this expreflion, how- ever, I do not wifh to intimate with Dr Brown, Cadogan, &c. that the action of the ufually excit- ing caufes, is always neceffary to its production. On the contrary, I firmly believe, that in the cafe of hereditary diathefis, it often occurs without the leaft evidence of any exciting caufes having been applied. The predifpofmg caufe then, I, with Dr Rufh, fuppofe to be debility; this debility is either acquired or hereditary. The acquired is alfo, for the moft part, of the indirect kind; the powers producing it being in general of a ftimulating na- ture. That general debility is the predifpofing caufe of the gout, may be inferred, ift, From the time of life at which it commonly appears: 2d. From the habits in which it generally occurs: 3d. From the inconteftible marks of debility, which almoft inva- riably precede every paroxyfm of it, as tremors, coldnefs, efpecially of the extremities, dyfpepfia, and weak pulfe. I infer it, 4th, From the reme- dies which, if given when a paroxyfm is about to commence, will frequently put it back. Thefe are the warm bath, laudanum, wine, &c. a pint, or even a quart of wine, may be often adminiftered, not E 19 ] not only with perfect fafety, but manifeft advantage, while a paroxyfm of even the tonic fpecies is in the forming ftate: but when the inflammation, and other fymptoms of exceflive irregular action, (for fo we fhall denominate it) have come on, nothing would be more improper or injurious, as we truft our plan of cure, which has been repeatedly prac- tifed with the beft fuccefs, will fully prove. Thefe confiderations on predifpofition will very aptly ap- ply to inflammatory difeafes in general; and few as they are, I deem them abundantly fufficient, en- tirely to overthrow Dr Brown's hypothefis, who fuppofes predifpofition to be nothing but an infe- rior degree of the difeafe itfelf. Thus, in the forming ftage of inflammatory difeafes, he tells us, that the action of the fyftem is confiderably above health; while it is notorious, that all their precur* fory fymptoms, without exception, tend to difprove this unwarranted affertion. Nay, fo univerfally are fymptoms of debility ob- ferved in the forming ftate of all difeafes, except fuch as arife immediately from wounds or poifons, that our learned profeffor of the theory and practice of medicine, (Dr Ruih) calls difeafe and debility fynonymous terms. Here we cannot but acknowledge a feeming in- accuracy of expreflion in making ufe merely of the word debility, to exprefs our idea of the pre- difpofmg caufe: for, fays an opponent, if it confifts in mere debility, why do we not fee it after ner- vous fevers, fyncope, &c? For furely, here we have [ 20 ] have enough of it in all confcience!—Granted, we have ; but let it be remembered, that debility may be very properly divided into two kinds, viz. acute and chronic; and further, into fuch as affects the living or moving folids only, and fuch as alfo affects the fimple folids or ftamina. Under the former I would clafs fuch difeafes of defective action, as are, comparatively fpeaking, of but fhort duration, and appear foon after the caufes of them have been firft applied. To the latter belong the gout, and all other chronic difeafes; that is, fuch as do not appear immediately, but require a long conti- nued application of their caufes to produce them. To prove that even the firmeft of all the fimple fo- lids, viz. the bones may, and often do become much debilitated, we have only to refer to the works of Van Swieten, Petit, Du Verney, &c. Of the Remote Caufes. BY thefe, I mean all thofe powers, which, when long continued, produce the ftate of predifpofition. They are intemperance, indolence, intenfe ftudy, in fhort, irregularities of every kind. Intemperance in eating and drinking, are of themfelves fufficient to induce the gout; but muft (I had almoft faid) inevitably do it when connected with a fedentary or indolent mode of life: for then, notwithstanding Dr Brown's opinion, a ple- thora will be produced, which every body knows, muft induce debility. By plethora, I mean a pre- fer- C ai ] ternatural fulnefs and over diftenfion of the veffels by the fluids of the body. What muft we again think of that man, who, with unparalleled boldnefs, fteps forward to overthrow, by mere affertions, a doctrine founded on and confirmed by every day's experience ? Nothing in my opinion is more eafy to be con- ceived, than the gradual formation of a plethora by indolence, and luxurious living; for by indo- lence the action of the fyftem in general, and efpe- cially the fecretions, and excretions, are greatly diminifhed; while by the luxurious living, conftant- ly and particularly ftimulating the ftomach, an inor- dinate appetite is generally created, often attended with a quick and powerful digeftion. Here then, contrary to the Doctor's opinion, we have a large quantity of nutritious fluid generated and convey- ed into the fyftem. But all the fluids are too long, and in too great abundance retained there: now this retention conftitutes neither more nor lefs than plethora. The immoderate ufe of wine, and other fpiritu- ous liquors, is not only productive of the difeafe in queftion, but alfo of dropfies, obftructicns of the liver, and of other vifcera, madnefs, palfy, apo- plexy, epilepfy ; in fhort, almoft every difeafe, both acute and chronic, to which the human bodv is liable*. But, * For ample information on this fubje&, I beg leave to refer to an effay by Dr Rufh, intitled, "An Inquiry into the Effects of Spi- rituous Liquors upon the Human Tody, and their Influence upon :!•- Happincfs of Society." [ 22 ] But, further ; fo great is the power of thefe li- quors in producing the gout, that in thofe coun- tries where the ufe of them is unknown, this dif- eafe is alfo unheard of; witnefs India, and Lap- land. See Van Swieten's Commentaries, vol. 13. and Linnaeus, Flor. Lapon. p. i55f- Intenfe ftudy may act in two ways ; firft, by the inactivity generally connected with it; andfecondly, by a power of its own. We believe that both rea- fon and experience are on our fide, when we fay, that thinking is a ftimulus; and that when mode- rately employed, it invigorates both the mind and body; but that when carried to excefs, like other ftimuli, it induces indirect debility. Of the Occafional or Exciting Caufes. WHEN there is in the fyftem that peculiar kind of debility, or ftate predifpofmg to the gout, which is f Dr Cadogan, in his treatife on the gout, has the following note: " I have made what inquiries I could upon this capital article (viz. wine), from living witneffes; for I don't always pin my faith upon books, know- ingit to be no uncommon thing for authors, inftead of framing their fyftem from obfervation and experience, to wreft and explain both to fupport their opinions. I have been affured by a phyfician, who pradtifed above thirty years in Turkey, that from the Danube to the Euphrates, he had never feen a gouty Turk. I have alfo been informed by fome of our minifters, who had refided many years in Conftantinople, that the gout, and other difeafes of the fame clafswere not uncommon at court; but the courtiers, it feems, were not as good Mahometans as thofe who lived in the country ; for they drank wine, drams, liquors of all forts, without re- straint. " I have alfo been credibly informed, that the Gentoos, or Mahrattas, a people of India, living in the moil temperate fimplicity, chiefly upon rice, have no fuch thing as the gout, or indeed any other chronic difeafe among them." E 23 ] is either hereditary, or induced by the remote caufes, as before mentioned, then a fit of intemper- ance, excefs in venery, night watching, exceflive evacuations, &c. will often almoft immediately bring on a paroxyfm of it* by fuddenly inducing great debility, and a morbid increafe of excitability. But, fays a Brunonian, moft of your exciting caufes are direct ftimuli:—To be fure, an excefs of them will induce debility; but then it will be of the indirect kind, in which there is never an increafe, but always a diminution of excitability. What proof is there for this affertion? Dr Brown tells us fo.— It is true, he does; hut his ipfe dixit by no means makes it fo. Let us, however, for ourfelves examine the Doc- tor's accuracy on this fubject. By excitability, we mean that property in the animal ceconomy, on which all powers act. In proportion as the action of thefe is more or lefs fenfibly felt, we fay, that the excitability is more or lefs accumulated: their effect, is termed excitement. The Doctor has divided the excitement and excitability into a fcale of 80 de- grees. Now this, like many other parts of his doctrine, appears to me very incongruous; for, according to him, there cannot poflibly be a tran- fition from (we will fay) direct debility to in- flammatory diathefis, except by a direct and uniform afcenfion through the point of health; nor to indi- rect debility, unlefs by a paflage through both thefe ftates. * The reader will pleafe to remember, that all this may be done by he- reditary difpofition alone, independent of any evident external exciting eaufes.— See page/'k &c. E 24 ] ftates. Thus a perfon killed by lightening, or a fot who drops down dead, while he is emptying his bottle, or a patient, whom, being at number----- of debility, inftead of invigorating, you render weaker than he was before, by too powerful a ftimulus: all thefe muft firft, by regular gradation, have paffed through the feveral intermediate ftates juft mentioned; an idea equally repugnant to com- mon fenfe and reafon. His fcale alfo teaches us, that where excitement begins excitability ends, and vice verfa. Of courfe then they increafe in a ratio exactly oppofite to each other. He tells us, that in difeafes of direct debility, the excitability is always greatly-accumulated; and that we muft begin their cure with fmall dofes of ftimuli, and gradually increafe them : typhus and tetanus are claffed under this head. Now, who does not know that in tetanus, inftead of commencing with gentle, we muft begin and go on with the combin- ed force of many, and thofe the moft powerful fti- muli, to effect a cure? And that in typhus, the ex- citability, inftead of being morbidly accumulated, is very often infenfible to the action of the greateft ftimuli ? So infenfible is it frequenly, that flies have been feen to crawl over that tender organ the eye, without creating any uneafinefs. On the other hand, in phthifis pulmonalis, which he claffes un- der the head of indirect debility, inftead of being di- miniihed, is not the excitability often furprifingly increafed? So much fo, that we muft begin with the moft gentle ftimuli, and gradually increafe them 5 E 25 ] them; and that the flighteft exercife, as rocking iri a cradle or coach, is neverthelefs highly ftimulating. And moreover, who elfe would fay, that the ex- citability is morbidly increafed in hypochondriafis ? Are not the ftomach and inteftines, in this difeafe, almoft infenfible to the action of emetics, and even of drafticpurgatives? And is not the fyftem in general in fo torpid a ftate as to be but little affect- ed by the moft powerful ftimulants of every kind? But what we think will entirely overthrow this hy- pothefis, is the confideration of inflammatory dif- eafes. Here we have the Doctor's increafed excite- ment. If, however, excitability is meafured by the degree of fenfibility to the action of ftimuli, who, befides him,will,after amoment's reflection,venture to fay that it is here diminifhed? Is not the fyftem, or difeafed part of it, affected by ftimuli, whofe action would not have been felt before ?* That the exciting caufes bring on a paroxyfm of the gout, and all inflammatory difeafes, not as the Brunonians would fuppofe, by gradually raifmg the excitement above the healthy point, but by inducing debility, we infer firft, from many of thefe caufes being directly debilitating powers, as exceffive eva- cuations, night-watching, fudden munition from rich to low diet, the cooling vegetables, as water- melons, cucumbers, &c. 2d. From the indubitable marks of debility to be obferved in their forming ftage, and after the exciting caufes havebeen applied. „ D 3d, * Thefe ftrictures apply efpecially to the fcale prefixed to Dr Brown's Elements of Medicine. E *6 ] 3d. and laftly, From the good effects refulting from the administration of wine, laudanum, and other fti- mulants, at this time. From thefe obfervations it might be fuppofed by fome, that the aid of the vis medicatrix natura, muft be called in to extricate us from this feeming difficulty :-—But no—we acknowledge not the power of this fuppofed goddefs ; and have only to obferve, that in this ftate of debility, and increafed excitability, the ordinary agents, as heat, light, the blood, fecreted juices, &c. which were before har- monious to the powers of the fyftem, being now very difproportionate thereto, are the imaginary deity that will foon bring on the paroxyfm, unlefs a certain degree of tone and vigour be fuddenly given to the fyftem. Of the Proximate Caufe of the Tonic Species. I HAVE already faid, and I truft fhall clearly prove, when treating on the cure, that this fpecies is an inflammatory affection; and as all complaints of this nature, wherefoever fituated, muft depend upon the fame caufe, I fhall here deliver what I fuppofe to be the proximate caufe of inflammatory difeafes in general. I have, however, anticipated myfelf on this fubject, having already faid, that it confifts in an excefs of irregular action in the arterial fyftem. This term (firft taught us by Dr Rufh) I make ufe of in preference to Dr Brown's appella- tion of increafed excitement; becaufe, inftead of the [.i7 i ■ the general vigour being greater than ufual, we, for the moft part, obferve the energy of every part of the fyftem, except the arterial, to be very confider- ably diminifhed; fo much fo, that almoft their whole force and power of action feem to be ab- forbed in that of the heart and arteries. This is particularly the cafe with the functions of the ftomach, inteftines, and mufcles of volun- tary motion. I adopt the opinion of exeeflive' action as the proximate caufe: ift. From obferving the following fymptoms; as increafed heat, rednefs, tenfion, and a violent throbbing of the arteries. 2d. Becaufe by it I conceive all the phenomena of inflammation can be belt explained. 3d. Becaufe the direct tendency of the remedies by wrhich the moft effectual relief is obtained, is to diminifh action. Perhaps I may be blamed by fome, for not af- figning fome occult caufe ; as a lentor, or acidity of the blood, fpafm, &c. for the fymptoms of inflam- mation. Such characters I fhall leave to the proper enjoy- ment of their own opinions; and only obferve, firft, that all doftrines of this kind, though they may have flourifhed for a time, have at length been invariably refuted, and confignedto oblivion. That of Boerhaave has been fhewn by Cullen to be incompatible with the exercife of the moft: important functions of the animal ceconomy. Nay, we are taught by the celebrated Mr Hewfon's ex- periments, that a ftate of the fluids, exactly oppo- fite lite to what Boerhaave fuppofed, takes place in inflammation, Boerhaave imagined the proximate caufe of in- flammatory difeafes to be a lentor, or vifcidity of the blood. Mr Hewfon, in his Enquiries, has fhewn that the blood, in inflammatory diathefis, is thinner than in health. Dr Cullen's doctrine of fpafm has likewife, I conceive, been ably refuted by Brown, and other eminent men. I might alfo bring forward many arguments in oppofition to this doctrine ; but, as they may all be found in Brown's Obfervations, andDickinfon on Fevers, I will not take up any time in detailing them. I can- not, however, refrain from mentioning one fact which, I think is, of itfelf, fufficient to over- throw Dr Cullen's doctrine. The Doctor builds. his hypothefis chiefly on the two following phenomena: ift. A preternatural contraction throughout the whole arterial fyftem. 2d. A flop- page of the pores. Now, inflammatory fevers, have fometimes been obferved to be attended with profufe fweats throughout their whole courfe. I obferve, fecondly, That, in my opinion, the doc- trines of occult caufes, have been feldom or never productive of benefit, but very often of great mifchief to fbciety. With what dreadful confe- quences muft not a practice founded on the fuppo- fition of an acid in the blood, as the caufe,have been attended ? Of this I will briefly relate one inftance. A celebrated phyfician (I believe at Leipfic), be- ing of this opinion, was feized with a pneumony ; and E *9 ] and inftead of making ufe of venaefection, he took large quantities of alkali to neutralife the fupera- bundant acid. The confequence was—he died a martyr to his own ill-founded opinion. And I am bold to fay, that any phyfician, who, inftead o{ ftudying, and being guided by the book of nature, is governed in his practice by the idle fpeculations of himfelf, or of other ingenious men, will, moft probably, do much harm both to himfelf and thofe intrufted to his care. Far—far be it from me, however, to fay that theory is ufelefs. Let us only be careful to make it fubfervient to experience, and found practice; and not make our practice fubfervient to it. Though the theories of Boerhaave and Cul- len were very different, yet their practice was nearly the fame. But fee the great, the fagacious Sydenham. Look at his theories. How abfurd were many of them ! His profound and true know* ledge, however, fecured him from being led aftray by them in his practice. He contemplated the phenomena of inflammato- ry difeafes, and was fure that bleeding, purging, &c. were the moft effectual remedies. He too, in, thefe cafes, fuppofed the human fyftem to be filled with morbific matter. But when he drew blood* and by that means cured his patients, he content- ed himfelf with faying, that the morbific matter muft certainly have flowed out at the orifice, and t^e good humours have remained behind! Of E 3° ] Of the Proximate Caufe of the Atonic Species. AS this fpecies is directly oppofite to the tonic, fo all the fymptoms of it evidently declare its proxi- mate caufe to be deficiency of action. But it may be aflced, if the inflammatory ftate, or re-a£tion depends upon debility, why does it not take place here? To this queftion I anfwer, that though they both have their origin in debility ; yet to pro- duce this action, it is neceffary that the fibres fhould poffefs a certain degree of tone or vigour. Now,' to me it appears, that, in habits fubject to the atonic gout, the conftitution of the fibres is fo feeble, either originally, as in women, from repeat- ed attacks of the diforder, or from old age, as to render them not eafily capable of fuch re-action— I fay not eafily, Ipecaufe it does neverthelefs fometimes occur. For example, we know that cold is a debilitating power. Now, if two perfons, the one of a ftrong athletic, the other of a weak nervous conftitution, fhould chance to fleep in the open cold air, I can very readily conceive, though it would undoubted- ly debilitate them both, that the former would be in danger of contracting a pleurify, the latter a ty- phus. Alfo, that if a ftrong man and feeble wo- man, both unaccuftomed to intoxication, fhould be made, as it is vulgarly called, dead drunk, by fpirituous liquors, the debauch might be fucceec.ed in one by'an inflammatory, in the other by a ner- vous [ 3* ] vous fever. Again, though the cold bath muft act in the fame manner on all human fyftems; yet it is a fact well known, that in fome it produces a glow on the furface and increafed action, whilft in others, it induces a diminution, and fometimes a total fuppreflion of action. Why ? Becaufe, in the latter, the conftitution of the fibres is too weak to admit of a re-action. I now come to the moft important part of my fubject, viz. The C U R E. I SHALL treat of the cure of each fpecies in diftinct chapters. And firft, Of the Tonic. The indications here are, in the firft place, to alleviate and fhorten the fit. 2d. To prevent a return of it. Our firft indication is anfwered by all thofe means which tend to diminifh exceflive ir- regular action in the arterial fyftem—Thefe are bleeding, vomiting, purging, refrigerants, cold, &c. Here we have again to combat the notions and authority of Dr Brown ; for, in every inftance, he purfued a plan of cure, diametrically oppofite to this, which we are about to inculcate. We pre- fume, that the Doctor fell into this error in con- fequence of his being ignorant, that ircft. if not all E 3* ] all difeafes have two ftages; and that of many difeafes there are two diftinct fpecies—witnefs the gout and rheumatifm*. Indeed, his claflification of difeafes indifcrimi- nately into fthenic andafthenic, or difeafes of vigor and debility, appears to me one of the moft lament- able of all his errors; for when he fhould ftarve, he muft inevitably often ftimulate, and vice verfa. But becaufe he has feen fome cafes of the conta- gious catarrh, apoplexy, gout, &c. attended with fymptoms of defective action, and cured by ftimu- lants, they muft be always what he calls difeafes of debility! Now, it is well known, that the apoplexy is as often cured by bleeding as by any other means. But even the influenza of the autumn of 1789, as it appeared in this city, and other parts of our ftate, was to me an inconteftible proof of the falfity of this doctrine. For though it was in every inftance called an afthenic difeafe by the Brunonians; and though they indifcriminately poured in ftimulants without meafure, neverthelefs, thofe phyficians who paid more regard to nature than to the opi- nions of Dr Brown, and who, trufting a little to their own fenfes, faw the fymptoms as they really appeared, were abundantly convinced of its abfur- dity:—For although, in fome cafes, there were fymptoms of defective action, which ftimuli re- lieved; yet, in many they obferved a full tenfe pulfe, with other marks of excefiive irregular ac- tion, * This difcovery has been llkewife given to us by our eminent profef- ;or, Dr Rufh, and has been fully afcertaiaed by him in the courfe of his practice. C 33 3 tion, where bleeding, and the antiphlogiftic plan in general was practifed with fuccefs. Oiir firft remedy, then, is Bleeding. A*rB for its recommendation we fiavci-he fanctrdn tf lifter, Hoflman, Pringk, Small, CuHen, and M* Bride; all of whom recommend k, efpecialryhl the firft paroxyfms, and in the young and vigorous. Dr Ru$i "has likewife witnefled its good effects; for he, but a few months ago, cured a patient la- bouring under a fevere fitlsy bleedings and the an- pMtagiftic plan in general. Blood has fometimes been drawn to the extent eftweuty ounces at a time in this difeafe. This was, however, certainly a very large evacuation, w"hen we confider that k was taken from gouty patients: for though it might, and I dare fay, did put a /top to the fit for the prefent, yet, we now know, that large "bleedings difpofe to more frc- q-oent returns of the difeafe. And, except in yOungy vigorous conftitutions, we find the moft permanent relief from topical bleeding. Small, by the advice of Sir John Pfmgle, ap- plied leeches to himfelf with great advantage: when leeches cannot be had, fcarifications with a lancet, or cupping, maybefubftituted in their place. The next remedy is E Vomiting, C 34 ] Vomiting. In favour of this evacuation, we have the tcftimony ofM'Bride,Small, &c. The name of Small muft be undoubtedly of the higheft authority in the gout, when we reflect that he himfelf was moft cruelly af- flicted with it. After having by various means, and for along time, vainly endeavoured to obtain relief, he, at length, to his great fatisfaction and comfort, made trial of vomiting, and found it attended with the beft effects. He was firft induced to make trial of an emetic by a frequent ficknefs at his ftomach: it brought away a great deal of bile, and relievedhim fo much, that afterwards, whenever the gout feized him, he took one± by which there was generally a great deal of bile difcharged, both by the mouth and anus, and the violence of the difeafe was almoft inftantaneoufly alleviated. I think it, however, pro- per to mention, that Mr Small was of a ftrong ath- letic conftitution; and as even in this fpecies, the ftomach is often affected with atonia, I would be very cautious in the adminiftration of emetics, and generally truft to naufeating dofes of ipecacuanha, tartar emetic, &c. For one great effect of vomiting is a determination to the fuperficies, which thefe naufeating dofes abundantly promote. Even Mr Small himfelf, in flight attacks, found great benefit from the ufe of them. The third remedy is Purging. E 35 3 Purging. It is true that Sydenham forbids it, but he con- demns evacuation in general: his authority is, how- ever, merely negative; for though he, without a doubt, obferved them in fome cafes to be injurious, yet we have many pofitive proofs of their good ef- fects; and we know that even one pofitive proof is fufficient to overthrow an hundred negative ones. Gentle laxatives, or clyfters, are recommended by M'Bride, Small, and many other authors of emi- nence: and as a means to fubdue inflammatory action, we fee not the leaft impropriety in a cau- tious ufe of them; nay, if the patient be coftive, they cannot be difpenfed with :—Dr Rufh, and other eminent practitioners of this city, have admi- niftered them with good fuccefs. Sulphur has lately become a fafhionable remedy in this complaint. It is either taken in fubftance, a tea fpoonful for a dofe, once or twice a-day, or elfe in what is caljied diffufion in water, after the fol- lowing manner:—To one pound of fulphur, finely powdered, and put into a ftone or earthen jar, add one gallon of water ; let it Hand for four or five days, ftirring it well two or three times a-day: at the end of the fourth day draw it off fine for ufe. Drink half a pint every morning, at leaft half an hour before breakfaft. Let the jar be flopped clofe when you are not ftirring the mixture. This E 3« 3 This medicine conftantly keeps the habit lax, ancj very powerfully promotes perfpiration and urine; confequently confiderable benefit may be expected from the ufe of it in this fpecies of the gout, efpeci- ally as it is fo fafe and fimple a medicine. The fourth-clafs of remedies are Refrigerants. These, particularly nitre, are univerfally allow- ed to allay inordinate heat, and diminifh the action of the fyftem. To enter into the inveftigatiorir an<$ cfifputes of the manner in which they produce thefe effects, the nature of my work will not admit; and indeed, it is fufficient for my purpofe to know that they do produce them. Further, as the good effects of nitre,, in inflam* matory difeafes, are fo well eftablifhed by the moft eminent of the profeffion, I can recommend it as an excellent remedy in this fpecies of the gout. The fifth remedy is The application of Cold. There has been as mucbdifpute and contrariety of opinion on the fubject of cold^as perhaps, on any other in medicine. Some phyficians make it a direct ftimulant and tonic—others think they can- account for its effects better, by fuppofing it now a tonic, and now a fedative : while others, again,. make I 37 ] naake all its operations the confluence of a defi- cient ftimulus or fedative. The confideration of thefe opinions would, of itfelf, fill a volume. Suffice it, therefore, to fay, that its good effects in the fmall-pox> meafles, fy- nocha, phrenitis, tonic rheumatifm, tonic gout, in fhort, in inflammatory difeafes in general, are too Well afeertained to admit of any difpute. DrRufh, in his lectures, tells us of a gentleman in this city, who cured himfelf of a fit, by dipping the affected limb into cold water. But what more clearly proves the efficacy of cold in this difeafe than any thing elfe with which I am acquainted* is the cafe of the abovementioned Mr Small. This practice appears to be well known and followed in the Weft-Indies, efpecially in Jamaica. For Mr Small having occafionto vifitthat ifland, was defired by Dr Nafmyth, an eminent phyfician there, to lay afide the application of flannel and oii-lkin, to which he had been accuftomed, and keep only a cotton ftocking to his foot; telling him at the fame time, that experience had taught them, to keep gouty limbs cool in that country*. For feveral paroxyfms after Dr Nafmyth's ad- vice,. Mr Small kept the affected limb cool, by which means the fits were always rendered fhort and flight. Having, however, at the inftance of fome learned,, but prejudiced friends, neglected to make ufe of the abovementioned remedies,, in a fucceed-. ing * Mr Small's Obfervations aa the Goat, may he feen in the 6th v»- lumo of the London Medical Obfervations and Enquiries. E 3» 3 ing fit he fuffered a conftant and moft tormenting confinement for feveral months; fo that in a fub- fequent attack, difregarding their cenfure, (which he had like to have done too late) he again had recourfe to emetics, leeches, and cool air, thereby flopping its courfe. So powerful indeed were the anodyne effects of cold in his cafe, that when he lay in bed at night during a paroxyfm, he could almoft entirely diveft himfelf of pain, by uncovering the affected limb. Small likewife makes mention of two other gentle- men afflicted with this difeafe, who experienced the fame falutary effects from cold air. Along with the above means, the patient muft, for the moft part, ftrictly obferve the antiphlogiftic regimen, which confifts in carefully abftaining from all food (efpe- cially animal) and drinks of a ftimulating nature. The diet fhould confift chiefly of mild vegetables, and weak drinks ; as water, flax-feed, mallows, baum, and mullen tea, or others as harmlefs; and at moft fhould not exceed fmall beer, except the patient be aged, has been accuftomed to very high living, or his ftomach is much troubled with dyf- pepfia, when a little good wine, beef tea, &c. may be allowed; common whey has alfo been found by experience to be a very good drink in this difeafe. Might fear be employed with advantage?—Yes, if judicioufly exercifed, I think it might; for many are the facts and obfervations tending to prove!;:. debilitating effects. But, that it is beyond all con- troverfy a debilitating power, we infer, from the incon- C 39 ] inconteftible marks of debility invariably induced by it; as lofs of appetite, loathing of food, fick- nefs at ftomach, vomiting, diarrhoea, dyfpepfia, colic, tremors, &c. Concerning topical applications I have very little to advance, only requefting caution in their ufe. For though bliftering, anointing with volatile and camphorated liniments, &c. have often aflifted in removing the inflammation of the part, they have'. as often transferred it to fome more important one. This, however, I can fay, that anointing the part affected with molaffes, and covering it with foft cabbage leaves, have frequently been pradtifed with great advantage. I have now made mention of all the means that I deem neceffary in behalf of cur firft indication ; but before pairing to the fecond, I feel myfelf con- ftrained to fay a few words on the ufe of opium in this difeafe. For, like cold, its virtues are by no means agreed upon among phyficians. By fome it is efteemed one of the greateft and pureft ftimulants in nature: others fay, that it contains within it- itfelf powers both fedative and ftimulating; while others again tell us, that it is altogether a direct and certain fedative. As every thing that has a tendency to irritate the fyftem muft be hurtful in inflammatory difeafes, fo the two firft fects (if I may be allowed the ex- preflion) eanieftly advife us to avoid the ufe of it in this clafs of difeafes, as highly pernici- ous ; while, on the contrary, thofe who advocate the E 4» 3 the laft opinion, recommend it to us as a valuable remedy. In the pleurify, and other fthenk difeafes, I be- lieve it is pretty generally employed in Germany; and I have heard a rcfpectable phyfician in this city declare, that he and fome other pradtkioners (whom he knew) employed k very freely in them. Thefe facts, however, by no means prove its effica- cy. We likewife know, that furgeons, when they are aboutt o perform, and after they have-performed any capital operation, as that for the ftone, ampu- tation, &c. always adminifter opium very liberally, to prevent inflammation; and that, in the fame cir- cumftances, they would not, on any account, give their patients wine, fpirits, or any thing elfe which they deem ftimulating. All this, however, to fay no more, is to me no proof at all; for it is as pof- fflhrle for furgeons to be actuated by prejudice, and governed by fyftem, as any other people; and, it is more than probable, they feldom or never gave wine, or other cordials a trial. But, for my own part, I confider this very practice, as an infirper- able confirmation of the cordial effects of opium, and of the doctrine advanced in this differtation.. For it is well known, that before lithotomy or am- putation is performed, the fubjects of thefe opera- tions are often in a weak ftate; and that after the operation, they frequently fink through mere debi- lity, or the confequence of it—inflammation. ' Now, in this ftate of debility, after the operation, rhey pour in their laudanum, which by invigorating the E 4* 3 the fyftem, prevents the inflammation that other- wife might have enfued, and thus reftores the pa- tient. It cannot be expected that in this treatife I fhould enter into all the arguments on this fubject; fuffice it for the prefent to fay, that the Englifh Hippocrates, Sydenham, in his practice found it to be a moft excellent cardiac; and that from the writings even of the immortal Cullen himfelf, many facts may be collected which prove it to be a ftimu- lant. DrRufh, and many other eminent phyficians of this city, have repeatedly witneffed its invigorating power, to the great comfort of their patients, and their own fatisfaction. But What confirms it to me more than all is, that I have myfelf repeatedly ob- ferved the fame* It may be afked here, how can the very fuccefs- ful practice of Dr Warner, who fuffered inexpref- fibly from the gout, be reconciled to the doctrine of opium's being a ftimulant ? He, in the latter part of his life, made ufe of a watery foliition of this fubftartce internally; and fo great was the benefit he derived from it, that he counted the hour in which he difcovered its efficacy as one of the moft fortunate he had ever known. The Doctor's gout, however, evidently appears to me to have beert of the atonic kind: ift. Becaufe he was far advanc- ed in life when he began to ufe it. 2d. Becaufe he had been for many years troubled with the diforder. And 3d. Becaufe he alfo recommends, as from expe- rience on himfelf, wine, and fait meat, which every F body [ 4* ] body knows are highly ftimulating. Upon the whole then, from what experience has yet taught us, I would advife my patients to ufe it very fpa- ringly in this difeafe, unlefs there are evident marks of a mixed or defective action in the fyftem. I now come to the fecond indication, and here medicine can do little or nothing; our chief depen- dence is to be placed, ift. On avoiding all the re- mote caufes, efpecially in the fpring and autumn, when the paroxyfms generally occur. 2d. Tem- perance. 3d. Exercife. As the paroxyfms may recur, in confequence of cither direct or indirect debility, fo I would advife my patients to five on a diet, by which they may be preferved as much as poffible from falling into either of thefe ftates. For this purpofe, they muft avoid animal food, nor fhould they live entirely on vegetables, but on a diet compofed of a mixture of both. Such a combination is efpecially to be found in milk : and as vegetable matters, contain- ing the greateft portion of nourifhment, the farina- ceous feeds may be joined with milk; as alfo pota- toes, turnips, &c. The drink fhould confift chiefly of water. The great Dr Cullen affures us, that by timely abftinence, and conftant bodily exercife, the gout may often be prevented from ever appearing at all; and we know, from very good authority, that even after it has frequently recurred,, it may be era- dicated by a proper obfervance of thefe two grand agents, Dr C 43 3 Dr Cadogan highly extols exercife ; Dr Chal- mers beftows great encomiums on it; and Mr Small, from experience, efpecially on himfelf, ventures to declare, that nine in ten of gouty cripples owe their lamenefs more to indolence, and fear of a litde pain from exercife, than to the genuine effects of the difeafe. He made it a conftant rule to ufe ac- tive exercife, as foon as the inflammatory ftate was paft; to which means he is firmly perfuaded it is owing, that he always, except during the pa- roxyfms, enjoyed the free ufe of his limbs, from the time the gout firft made its appearance in him, which was in the year 1753, to the time of writing his effay in 1780. It muff appeal- evident to every perfon, that walking is the moft proper exercife in this com- plaint: However, if the patient h not able to walk immediately after a paroxyfm, let him begin with the paflive or mixed kind, as failing, riding, fric- tions, &c. But let him be particularly careful never to fatigue himfelf; for inftead of preventing, he would, by fo doing, be in danger of haftening on a fit. It will, I believe, for the moft part, be found neceffary for our patients to live more or lefs after this manner, during the reft of their lives. For although we hear of fome who have had no recur- rence of this diforder, after continuing it only for a few years, yet in many the cafe is very different. Of this Dr Rufh, in his lectures, relates a re- markable cafe;—it was that of a gentleman not far advanced beyond tjie acme of life, who was in eafy [ 44 ] eafy circumftances, lived high, and had for fome years been afflicted with the gout : this gentle- man was fuddenly reduced, - and caft into prifon, while labouring under a paroxyfm of it; and here his diet was very low ; the confequence was, the fymptoms immediately abated, and the fit was very fhort. His affairs for feveral years after his imprifon- ment compelled him to live low, during all which time he had no return of his diforder: but fortune, that deceitful goddefs, having. once more fmiled upon him, he relapfed into his former mode of good living, and was again vifited by its, faithful companion, the gout. I do not prefume to fay, that this courfe will be proper in all conftitutions; on the contrary, I am perfuaded,that to many who, in a paroxyfm, would require bleeding, &c. it will be often proper, in the intervals, with exercife, to adminifter aromatics, tonics, &c. fo that every phyfician muft be guided by the fymptoms prefent, and not by the name of the difeafe. I fhall conclude this effay with faying a few words on The Cure of the Atonic Species. AND this alfo very naturally divides itfelf into two indications; firft, to relieve our patient in the fit. This indication is anfwered by a proper applica- tion of ftimuli, efpecially the diffufible, as opium, vola- E 45 3 volatile falts, gum guaiac. aether, mufk, wine, &c. internally, and finapifms, blifters, or other flimu- lating fubftances externally, to the feet, &c. The gum guaiac. has lately attracted the attention of all Europe, as a remedy in the gout. Its good effects in the chronic rheumatifm, have been well afcer- tained for a confiderable number of years; but I believe it was firft recommended to the public as a cure for the gout, by Mr Emergion of St Pierre, Martinique : to give a minute detail of his practice and obfervations, would take up too much time; I therefore would refer to his letter on the fubject, which may be feen in Dr Dawfon's book of cafes in the acute rheumatifm and gout. His method was to digeft two ounces of the gum with three pints of taffia for feven or eight days; then to filter the liquor through cotton or paper, and take a table fpoonful for a dofe, every morning falling: after the publication of his letter many people made ufe the guaiacum. To fome it proved beneficial; others it manifeftly injured very much. In thofe inftances in which it proved injurious, I am inclined to attribute its failure to an improper and exceffive adminiftration of it; or elfe to its indifcriminate ufe in every ftate and cafe of the gout. Now, fuch a practice, at leaft if our doctrine be true, it is evident, cannot but be attended with bad effects: I am for my own part perfuaded, that it will rarely be found ufeful, except in the atonic fpecies of the difeafe, or in the intervals, when other ftimuli are indicated. That [ 46 ] That the guaiacum is improper in the inflam- matory ftate, I do not reft, on bare affertion. That accurate obferver, and excellent phyfician, Dr Cullen, has known it repeatedly to prove very hurtful in it. I muft, however add, that our pro- feffor of the Materia Medica, and many other practitioners, do not hefitate to employ the mix- ture of guaiacum, in thefe cafes, as it proves a certain cathartic. If the ftomach is affected with vomiting in this difeafe, columbo root or other bitters are very good. Porter has fometimes put a flop to it. A plaifter of venice-treacle to the ftomach is alfo a proper application. Sydenham appears to have been converfant chiefly with this fpecies; and it is certainly in this that he recommends his heating and bitter ftoma- chics ; as horfe-radifh, angelica, wormwood, eli- campane, venice-treacle, Peruvian bark, &c. It muft alfo be in this, that Dr Cheyne fo highly ex- tols the bark, and chalybeates ; and that Warner recommends wine, fait meat, &c. Here alfo, if at all, will Dr Brown's rum, whiiky, and brandy be found ufeful. For the fecond indication, exercife will be found indifpenfably neceffary—and indeed we cannot too warmly recommend it. Sydenham places great confidence in it, efpecially riding on horfeback ; for this admirably, and according to him, more than any other exercife, invigorates the digeftive organs. if E 47 3 . If the patient cannot ride, let him make free ufe of frictions ; and when able, he muft alfo often ex- ercife his lower extremities by walking, &c. Let him by all means remember, that all this muft be moderate ; for if exceffive, it will be worfe to him than indolence itfelf. 2d. Solid and ftimulating food is very ufeful, as wild fowl, fait meat, beef, &c. The meals muft be fparing, but may be often repeated; his drink may be porter, fherry, Madeira, port, &c. but the ftomach fome- times rejects all thefe; when Dr Cullen tells us, ar- dent fpirits and water muft be allowed. To fupport the tone of the ftomach, aromatics and bitters may now and then be given—Peruvian bark is very good; but I believe iron will be found more effectual for this purpofe than any other medicine. I fhall fay nothing of the numerous noftrums, that have been from time to time employed in this difeafe; I fhall even pafs by the Duke of Portland's famous powder, and juft mention that there are fe- veral cafes related in the EdinburghPhyficalEffays, Vol. III. in which hemlock, an infufion of tanfey, and lime water, were feparately adminiftered with feeming advantage. • If there is fufficient power in the fyftem, to pro- duce a glow on the furface after it, the cold bath may likewife be employed with advantage. It is highly neceffary for perfons fubject to the gout, efpecially to the atonic fpecies of it, to avoid wet feet and cold; which may be done, by wearing cork [ 48 ] cork foals to their fhoes, and repairing to a warm climate during the winter feafon. In the beginning of this treatife I have faid, that the gout counterfeits almoft every difeafe to which the human body is liable; and have now to add, that in every appearance it is to be treated as fymptoms indicate. I had nearly forgot to mention one article of the higheft importance in this difeafe, I mean peace of mind; for as vexation has often a great deal to do in its production, fo Sydenham, Cadogan, and many other eminent men, fet down its oppofite as one of their principal agents, in an attempt towards a cure. It might now perhaps be afked, why has fo little been faid on mifplaced and retrocedent gout? To anfwer this queftion, I would refer to the feventh page of this thefis; in which place I have faid, that the gout, wherefoever it appears, will be either in- flammatory or atonic, except in a few cafes, in which a mixed action takes place. I have likewife faid very little on the ufe of blifters; and indeed, conceived it unneceffary to fay more than I did. I will however juft add, that when the gouty diathefis is in the habit, but the difeafe, inftead of' fixing on the extremities, flies about from one part of the fyftem, to another, and perhaps lights on fome internal part of great importance, the appli- cation of blifters, and of other ftimulatin? fub- ftances to the lower extremities, may be advifed to invite the gout thither. In C 49 ] In the former part of this thefis I have faki* that a paroxyfm of either fpecies of the gout, when in the forming ftate, may be often obviated by a proper application of ftimuli; as wine, laudanum, &c; I likewife think, that electricity may be very advahtageoufly employed for the fame purpofe. In- deed fome venture to make ufe of it as a remedy in inflammatory action; and Cavallo, in his Effay on Medical Electricity, tells us, that the gout has been certainly cured by it in various inftances, and that inflammations of every fort are generally relieved by it. As it is however known to be a very pow- erful flimulus, I would ufe it with great caution where there was excefs of action. In the fifteenth volume of the Medical Com- mentaries of Edinburgh, we have the cafe of a Mr Brifaud, who at different times had for feveral years been afflicted with gouty pains in his feet. On a certain day, while labouring un- der thefe fymptoms, he went out to hunt, and had occafion to pafs through a fmall marfh, in which there was about a foot, or a foot and an half of water ; in this he was ftruck by a torporific eel, which produced a very violent commotion in both his knees : he, however, purfued his route ; the pain foon fubfided, and when the account from Which this iketch is extracted was penned, Which Was eight months after he had been ftruck by the fifh, he had not yet felt any return of it. It would therefore appear, that electricity, if prudently employed, may prove ufeful, not only G as E 5° 3 ^ui palliative remedy in alleviating gouty paim, tnu ..; in preventing a recurrence of the paroxyfms. ^jjkirning the affected part with moxa, when it can'be done conveniently, has been often practifed, efpecially in the Eaft-Indie's. And Herman Bufs- chof, a Dutch phyfician of the laft century, who refided at Batavia,in the Eaft'-Indies, fpeaks of it as a certain and infallible remedy. Succeeding phyfi- cians, however, have not been fo fuccefsful in its application, and Dr CuHen thinks very lightly of it. Thofe who wifti for particular information on this fuliject, may confultBuffchof's Treatife on the Gout. Ha-* ing concluded this differtation, I have only"' to bid a refpedtful and affectionate adieu to this rifing feminary :—That flie may long continue to fend forth her fons, eminent for learning and vir- tue—that her medical profeffors may long be an ornament to her, and fhine forth the brighteft lu- minaries of fcience—and that they may ever conti- nue to be the patrons and promoters of medical knowledge, is my fincereft wifh. THE END. 3L10 mi