Concerning the Gout

A PROBLEM Concerning the GOUT. IN A Letter to Sir JOHN GORDON.

Y OU have, by the very Magic of your most ingenious Discourse, (with which you honored me the other day) wrought a Cure very foreign to your Profession; you have rectifi'd the habit of my Mind, and expel'd a noxious Error from my Judgment. But give me leave to tell you, If you accustom yourself to such Methods, if you are at such Expence of Learning and Rhetoric, to undermine a sandy Notion, to break a brittle Fancy in pieces, you will make the number of your Opponents exceed that of your Converts; either by stirring up some fumes of Pride in such as I am, to observe our crude Conceits worthy of your Censure; or by raising an Itch of Contradiction, only to enjoy the pleasure of your Confutation. And now, to make my submission complete, I will present you with the Scheme of my Conceptions on that Subject, that so having rid my Thoughts of the burden of them, they may creditably expire under the Honor of your Correction.

I have been acquainted with the GOUT near twenty years, during which time the troublesome (but, as I have used to treat him, not very chargeable) Guest hath constantly paid me a Visit once in the year, and sometime twice; therefore I may be allowed to give an Account of it more than notionally and theoretically. And though I do not in the least pretend to any Knowledge or Judgment in the Noble Science of Physic; yet having in my younger years been conversant in the most delightful Study of Anatomy, I came to understand the Inside of myself, and a little to know, and with some astonishment to admire that orderly and stupendous Contexture of all parts of the Body, which no Hand, but that of an Omnipotent Creator, could effect; which every man carries about him, but few know, and none can understand, but such as have been accustomed to Dissection, and especially of living Bodies; and is in some measure represented by a Clock, the Order and Office of which is very admirable; but when you open the Doors, and behold the Motions (so like to Animal) the Harmony and Subserviency of each Wheel and Part to the other, all wonder of the Out-side ceaseth, and is disregarded. Besides, my Age warrants me to claim the Title of a Physician, in my own defense, that I may avoid the Epithet of a Fool; and I am obliged to pretend to some Proficiency, that I may escape the Censure of talking like an Apothecary.

Upon the whole, I do observe, That the Causes of that Distemper are as much mistaken, and as little understood, as the Cure. Wherefore I am in my Opinion very heterodox, and do think, That whosoever is so fortunate as to be affected with the Gout, (especially if the Indications of it do commence in his declining Age), he ought to use no means to repel it, or be rid of it, but patiently to endure the Fit, as a lucky, though sharp Composition for more fatal Maladies: as I have heard or read of a Custom used in the Low-Countries, That when a Man after Fifty falls into the Gout, his Friends come about him, they make a Feast, and rejoice at this hopeful prolongation of his Life, and a probable addition of Twenty or Thirty years to it. And by the way, I cannot but observe to you, That when Asa King of Judah was diseased in his Feet (which is by all interpreted to be the Gout ) it is noted of him, That he did not seek to the Lord, but to his Physicians; he did not patiently endure the Fit, but tamper'd with Plaisters and Pultises.

In some Persons the Gout is Hereditary, and in some it is Original; and though it be ordinary to impute the Assaults of it to Excess in Diet, and other inordinate Pleasures; yet having in my Observations remark'd how many Men and Women of the strictest Temperance, and singularly abstemious, have been in the most miserable manner afflicted with it, while others, setting no Limits to their Appetite, have for many Years indulged themselves in Excess, yet never suffered in any Symptoms of it; I cannot be persuaded that it proceeds naturally, or necessarily from such Causes.

It may justly and reasonably be called, Malae Causae bonus Effectus; and though possibly it were good for a man not to have that Disorder in the Humours, which doth occasion that Distemper; yet it is better to have that irregularity dispel'd by a Fit of the Gout, than to be fixed by a Disease in any of the Noble Parts, or transformed into an acute Fever; it may be well for a man to be of so athletic a Constitution, as to have no Disposition to the Gout; but it is certainly better for him that once hath had it, not to miss the Annual Return of it; nay I am almost induced to say, that the Gout is so fas from being a Disease, that it is rather a Cure, a Cure administered by Nature, without the aid of a Physician, and infallibly effectual, if not interrupted by cross and churlish Applications.

I am of Opinion, That this may be a proper Definition of the Gout, Arthritis est Purgatio Nervorum. And I am inclined to suppose so, by Reasons drawn from my own Observation and Experience. First, Because a Dullness of the Brain, and Heaviness in the Head (which is the Root of the Nerves) is a certain, if not a constant, precedaneous Symptom of an approaching Fit; and then when the Gout is fixed in the Hand, or Foot, or other Joint, immediately that Cloud which darkened the Brain, is dispelled; and the Understanding, Memory, and Fancy, is sensibly cleared and quickened. Secondly, Another Symptom is Motio formicans, a little stirring in the Back, like the crawling of Emmets or Pismires; which seems to be a Goutish Humour passing along the Spinal Marrow, from whence the Nerves are disseminated. Thirdly, Because the Operation, or affliction of the Gout, is not exercised on the Fleshy and Musculous Parts of the Body, but is suddenly darted and conveyed through the Channels of the Nerves into some Joint, and yet doth not remain in the Nerves; which I conceive to be performed thus; A Nerve being composed of many filaments covered with a Membrane, is the proper Vehicle, and Instrument both of Motion, and Sensation, the latter whereof is performed by the Object being carried by a tremulous Motion up to the common Sense (as a stretched Lute-string trembles at the top, when touched at the bottom); the other by conveying the Animal Spirits between the Cavities of those Threads or Filaments, which compose the Nerve, (as a Bundle of Quills clapt together must leave Spaces and Vacuities, because they are round, and can touch one another but in Lineâ, by reason of their Convexity); now through these Cavities, I suppose, the malignant Ferment which Nature throws off, (and is the very Elixir of contagious Humours) channels along, and passes to the Joints, where if undisturbed by violent and unnecessary Applications, it gently evaporates by insensible Perspiration, after its due Crisis and Periods.

Fourthly, Because the Gout, like other acute Distempers, hath its gradual and regular Procession, its Increment, State, and Declension; and having gone through the Extremities of the Body, passes off (if not checked and control'd by Plaisters, Salves, and Poultises ) leaving the Joint or Member free from all Pain, but weak, and disabled from Motion, which is the proper employment of the Nerves and Muscles. Fifthly, Because the Cramp (which is a convulsive Motion and Distortion of the Nerves and Muscles ) is constantly an Usher, or an Attendant of the Gout.

In the Tenets of Religion, I desire to be always Orthodox; in the Disquisitions of Natural Philosophy, I take a pleasure to be Heretical: I subscribe to the Dictates of the Church; but I am not ashamed to be a Non-Conformist to the Theorems of Aristotle and Gallen. So being once got out of the common Road, give me leave to ramble a little, and to present you with some other Notions, which without arrogance I may call my own, since as no other man (to the best of my knowledge) ever published the same; so peradventure no man else will applaud, or abet: but for that I am no way concerned; what I write, is for my own pleasure, and your diversion, and I am not at all ambitious to be the Leader of a Sect, or Party.

I am of opinion, That the Gout and Stone are one and the same, conceived and begot by the same Causes, fostered and cherished by the same Accidents, and only differing in their Seat and Position: the one ravaging among the Joynts, and external parts of the Body; the other making its residence in the inward Recesses of the Veins, and urinary Passages. I take the Stomach to be the primum mobile, and principal Agent in these Occurrences, to whose Indisposition and male administration the dolorous Consequences both of the One and the Other are primarily to be attributed: so that the Errors in the first Concoction (whether arising from the natural debility of that Vessel, or fomented by the inordinate use, and the irregularities of Diet) are the Embryo, or Seed-plot, from whence the Maladies and Disorders which infest the Body, are derived. Hence Agues and Fevers receive the first Rudiments of their Formation, from the crude Relics of Indigestion. Here, by precipitated Concoction, the pure and genuine Chyle is perverted into acrimonious Humours, and Choler adust, which become the original of Catarrhs, Consumptions, and Hydropick Distempers. But if by the Strength of Nature, and the Pancratic Constitution of the Party, the Malignity be removed from the Vitals, and the Venom precluded from channelling in the Arteries; then the Ferment, or morbific Salt, is forced away, and either ejaculated into the Nerves, which causeth the Paroxysms of the Gout; or transmitted into the Kidneys, and causeth the condensing of Gravel, which carrieth the Contagion off with it, if seasonably expel'd; but if fixed, engendereth the Stone, and the fatal Torments that attend it. Nay, the very end and utmost Effort, both of Stone and Gout, conclude in a sandy and calculous Accretion; the one visible in the Bladder, the other apparent in chalky, topaceous Stones in the Joynts of the Hand and Feet: To which, let me add the Observation of Dr. Willis, (which I have read in his Works) that having by powerful Physic driven away the Gravel from a Patient, he became presently afflicted with the Gout; and having forced that to depart, the Stone immediately returned, and became his Bane.

But, what if I should strain a Point higher, and entertain you with a Fancy just now come into my head? Because every Man (who is not taken away by a violent Death) is said to die of a Fever; why may it not be rationally conjectur'd, that the most Notorious, Ordinary, and Epidemical Distempers and Diseases, are but so many diversified Kinds, or Species of Fevers? And if so, then I may be allowed to Coyn a new Distinction, and divide that Universal Minister of Death into these several Classes, Febris Venalis, Febris Arterialis, Febris Stomachica, Febris Nephritica, and Febris Nervea. Under the first, I place Pleurisies, and other Distempers arising from redundancy, or an ill habit of the Blood. In the second, are comprehended Agues, violent and malignant Fevers, proceeding from Inflamations, and Corruption of the Fountain of Blood and Animal Spirits, the Heart. The third shows itself in Colics, Iliac Passions, Griping of the Guts, and other Torments caused by Wind, and fetching their Original from the Stomach. The sharp twinges of the Gravel, and excruciating Miseries of the Stone, are excercised on the Kidneys, Ureters, and Bladder, and may fairly pass under the Denomination of Febris Nephritica. And doubtless the Pains and Afflictions of the Gout, may properly be Febris Nervea, since its Swing and Operation is wholly in the Nerves, and is indicated and determined by periodical and feverish Fits; a true Fit of the Gout being always attended by a Febricula, or short Fever. Thus the Body of Man is assaulted by Enemies of its own Generation; one sort of Fever storms it, another blows it up, another undermines it; this batters it, and that pulls it to the ground; every Man desires to live long, but no Man would be Old; and even the Gout, which generally is the Concomitant of old Age, helps to increase the Miseries of it. I will conclude with a Fable of the Gout and the Spider, which was told me by a Country Gardener. The Gout and the Spider (having been old acquaintance) met in a Summers Evening; and after ordinary Salutations, began to congratulate each other's Felicity. The Gout extol'd his good Fortune, that was so luckily placed in a stately House near adjoining, where the owner of it caressed him with all manner of kindness, comforting him with Plaisters, refreshing him with Oil and Frictions, covering him with Scarlet and Flannen, and treating him with so much Civility, that he was not put to the toil of walking, but rested Day and Night in a warm Room. The Spider said, I have taken up my Quarters in a poor Man's Cottage, where though my Entertainment be but mean, yet I enjoy Safety and Tranquillity; I spread my Nets through the House, I have as many Webs in the Loom, as would serve all my Generation, and no Body disturbs me. Thus having mutually discanted on their Happiness, a curiosity pricked them to change Quarters for one Night, that each might be a Witness of the other's good Condition; so they parted, appointing to meet in the same place, and recount their Adventures. Accordingly the Gout marcheth to the Cottage, attacks the Owner, and fixeth his Residence in his Great Toe. The Spider ascends the Gentleman's Parlour, falls presently to work, and before day he had extended his Manufacture through all the Spaces of the Room. The next Night they met again, but in a most deplorable Condition; the Gout looked as if he were halfdrown'd and half-dead. The Spider, as if he were frightened out of his Wits. But wondering a while at one another's Fate, and recollecting themselves, the Gout told his Friend, That when he came to the Cottage, he (according to his Custom) seized on the Good man's Toe, expecting to rest quietly there; but to his Astonishment, the Man started up, run about with his naked Feet, and plunged himself into a Pond, and had almost drowned or choked him, so that he had hardly escaped with Life. My Fortune has been little better (replies the Spider); for having finished my Work, and spread my Nets up and down the Room, I betook me to rest; but early in the Morning the Chamber-Maid comes, and with her Broom and Whisk un-mercifully destroys and tears down what I had wrought; I, upon the Alarm retreated into a Hole, and with much difficulty made my escape hither. So after a little pausing, they took leave: The Gout returning to the Rich Man, and the Spider to the Poor.

But lest the flat Repetition of such frivolous, and incoherent Stuff may prove as troublesome as the Disease it treats of; or the wanton Excursions of my Pen prove equally Vexatious to the very Twinges of the Gout; In pure Pity, and good Manners, I desist, after I have with all possible Respect and Sincerity, avowed myself,

The REPLY.

THo' by your Letter you do me the Honor to represent me as molded in that of the most extensive Friendship; and submit to my Reflections your very ingenious and well-contrived thoughts of the Cause, previous and subsequent Phoenomena of your old and intimate Friend, the Gout: yet I will not be guilty of so much Vanity, as to endeavor any alteration in that Scheme which you have so neatly and ingeniously framed: Especially your Sentiments on that Head, being espoused and very well defended, not only by Juncken, and those Learned Physicians, who will have the Nutritious juices to be conveyed to all the parts of the Body by the Nerves; but also by that Ornament of Learning, Dr. Charleton, present President of the Royal College of Physicians; for whose Learning and acute Reasonings, I have that veneration, that I judge it almost a Crime to entertain different Sentiments from his, in such Speculations. But I must add, without the least flattery, That if any inducements could oblige me to become a Proselyte to the speculative part of your Opinions on this Subject, you yourself furnish me with stronger inducements than all my Books or Converse in the World could do. For when I consider the height of your Fancy, the clearness of your Reasonings, the solidness of your Judgment, the great connection I find betwixt all the Links of the Chain of your various and pleasing Thoughts on all Subjects; the charmingness and peculiar neatness of your Pen, I am almost persuaded to believe, that the Gout must be a critical evacuation of the Brain and Animal Spirits, by which Hetrogeneous, Acid, Acrious, Austere, and other troublesome Particles are thrown off from the Brain and Nerves, on the Articulations of the Limbs, which clouds the Fancy, and lames the Reasonings of most Men who are strangers to that Troublesome, though Advantageous Crise: And I must tell you, that, were I confident your old Friend would procure me those Advantages I admire in you, I would almost court his intimate familiarity; but, Ex quovis Ligno non fit Mercurius.

Those who will have the Cause of the Gout to be lodged immediately in the Blood and circulating Liquors, and not in the Brain, and Genus Nervosum, and will have the Crise performed by the mediation of the Mucilaginous and Oleaginous Glands of the Joynts, seem to plead fairer; and are exposed to sewer intricacies, and less difficulties than the Patrons of the other Hypothesis are; and give a clear and very intelligible account of the Genealogies of all the Antecedent, Concomitant, and Consequent Phoenomena of that troublesome Companion; and lest a Man of your Universal Knowledge should be a Stranger to so useful a part of Anatomy, I presume to recommend to your perusal a little Tract, called, Osteologia Nova, lately wrote by Dr. Havers, from whose ingenious Pen the Commonwealth of Learning may expect what may be useful to that Republic.

But not to trouble you further with Speculations of this kind (for in framing, extending, and improving of fine Thoughts, I willingly and justly resign in your favors the right hand of Fellowship) I find, not only by thoroughly considering the animal economy, but by many years practice and experience, that those different Hypotheses forces very little alteration on the rational method of Cure: And you must pardon me, if I take you in task as to what concerns the practical part of your Letter, if in good Scotch (I pretend not to write English ) I may so term it; that being a Province to which I am not altogether a stranger.

In the first place, I must tell you, It's my Opinion, had a Man of your Head made it his business to be so much conversant in the Practical part of Medicine, as you are in the Theorick, you might have easily, not only promoted yourself to the Dignity and Title of a second Aesculapius, but also, (I am confident) you had altogether altered your Sentiments as to the Cure or Removal of your old Friend. I could (were it necessary) adduce many Instances, and possibly of your Countrymen, of whom some are on this place, others returned to Ireland, whom in a little time, by the use of Internals and Topics, I freed from that troublesome distemper, and not returned as yet.

But in the next place, you may consider (not to discourse now of the various Particles and alterations the circulating Liquors receive from the Air, by Inspiration and otherwise; (for the nature of a Letter will not allow of such Excursions) that whether the Cause or Minera Morbi, lodge in the Blood, &c. or Genus Nervosum: Mostly, the Stomach and Guts, and the various alterations the materials of our Diet undergoes in these digestory Cavities; cannot vindicate themselves to us, for performing their Duty so faintly; nor can we, to ourselves, for oppressing and burthening them so much. So that if the Chyle be Acrious, Acid, Austere, or of other qualities, the Blood must participate of the nature of the materials of which it is made. Besides, if a great deal of Crudities, Humours, or call them as you will, nestle and stagnate in the Guts, Stomach, or other parts of the Abdomen, which vitiate the Chylification and Chyle, and rivulets it ill to the circulating humors, by the lactic Veins (and if not carried off by Vomiters and Purgers according to the present Circumstances of the Patient) in Limine, must give new matter to new recurring Paroxisms, till a long abstinence, and oft recurring Fits, emacitates the Patient, and consumes the fomies Morbi in the first Region; which a rational Physician can remove very soon, without the least or very little trouble to the Patient; if Improvement or Biass ( the Brats of Authority ) oblige the Physician to be a Spectator, the Patient is like to have a pleasant time of it.

In my Practice, wherever I find the Minera Morbi, I tamper not with it, but turns it off how soon I can: and if I occasion thereby any troublesome Disorder in the Fluids, I force them to their proper Stations, by suitable Paragoricks: by which Methods I never had any Disreputation, but my Patients great Advantage. When Indications oblige, I cause open a Vein, I give Swetters and Diureticks, by which I divert the designed Course of those troublesome fluid Salts: and seeing the Animal Spirits are but the product of the Blood, and cannot be expected to be of a more mild temper than their Progenitor: I alter the circulating Fluids as soon, and much as I can, by removing out of them what is hostile and troublesome, and lodging in them such Principles and Particles I judge them to want. And I judge, by such a Method, (supposing still the Patient to be rational and tractable) the Gout is not altogether so stubborn and rebellious as he is discoursed to be; at least, I found him (in such circumstances) obsequious enough to my Commands; so that I will not be so unjust to the poor Criminal as many are. For should I not procure a tractable and rational Patient, what he expects, I would rather complain of my Timorousness, my being imposed on by the Bugbears of great Authority, and negligence of suitable administrations, than on the stubbornness of a few vicid, saline humors, may be cut off as to their Minera, and thrown off by suitable Medicines in a very short time.

Sir, I find you are irreconcilable to Topical Applications, whether Pultisses, Plaisters, or all others of that kind: but when I have discoursed you a little as to the nature of those kind Applications, I hope I may moderate your Passion against them; and do some of them the Honor as to procure them your most serene and obliging Countenance.

I must confess to you, and acknowledge, that such of them as are emplastick, astringent, and so contract the Pores, and stops the insensible transpiration, deservedly merit very much your displeasure, on the Grounds and Reasons you intimate in your Letter. But such internal applications as open the Pores, dissolves Coagulations, (by blunting the acid coagulating Salts ) in the cutaneous Glans, and possibly alters very much the texture of the circulating Liquors, without any previous trouble to the Stomach) I hope I may presume, to usher those to your acquaintance: and I have that very great esteem for your Merit, that I would not make you uneasy, by giving your Esteem and Friendship to any, but those I can venture my reputation for what I promise in their Name. And if you command me to disclose to you the very Secrets of my Cabinet, your Commands will be obsequiously obeyed.

I do not much admire the Custom of Holland; nor do I believe a Rational and Sedulous Physician (if the Patient be tractable) will suffer the Gout to run all these Stages; for I know by many Experiences, it may be strangled when in embrio, or may be destroyed in the Bud, before it can blossom; or if it do, may be made fall before it ripen, sublata causa tolitur effectus: but if we suffer our digestions to be lesed, vitiate, and oppressed, the circulating Liquors to be loaded with troublesome Salts, or other particles; if we lodge and continue in the Center, and digesting Cavities of our Body, such a mass of incommoding Humours, which must of necessity produce many Distempers, according to the Texture of the Fluids and particular Mechanisms of the Solids of those concerned; then the Holland Custom takes place, and not only the Gout, but other Distempers, both Acute and Chronic, runs their particular Stages in great Triumph, which we owe to our own Inadvertency, or our Physicians neglect; for our Health and Sicknesses are Mechanical, depend on Mechanical Principles; and he who understands this Mechanism well, and adverts attentively to all its Motions, Measures, and Stops, can order the bodily Machine so, that Opinions handed down to us from Antiquity, as to the Nature of Diseases, and Methods of Cure, will very soon and easily be antiquated with the serious Observers of what concerns Health and Sickness.

I do not question Persons of both Sexes, who lived very temperately, as to the Solids and Liquids of their Diet, are originally (if I may so term it) obnoxious and predisposed for several particular Distempers, from which many (who are absolute Slaves to their Palates, and venture on all irregularities of that Nature, and are intimate to all sort of Debauches) are exempted; but this depends mostly on the primative Configurations, and Mechanisms of the Glans, Tubulae, and other secretory Organs of the Body, which are not framed at the same rate in all individuals; whether this difference of particular Mechanisms, or Organizations, proceed from Hereditary (if the word may pass) Principles, or from other superior or concurrent Causes, I will not give you or myself the trouble to determine.

This Letter will not allow me to give you my Reflections on your Ingenious Speculations about the Nature of Fevers, and your placing them in their several Ranks and Classes, lest I should give you the trouble to read a Pamphlet instead of a Letter, which by its length is become too bulcous already, and may rob you of too much of your time, which you always employ to better purpose; but if This please, that may be the Subject of a Second Entertainment. You did me the kindness to read me some Essays you have yet kept in their Retirement; but in my Opinion they very much deserve a better Fate; and I am confident, you will very much oblige the Learned part of Mankind, if you give them that dress, in which they may be in their hands. Sir, believe me, that none esteems yourself, and the products of your Pen more, than