No. 4.] LONDON, SATURDAY, APRIL 30, 1825.

LECTURESON THE

PRINCIPLES AND PRACTICE

OF PHYSIC,

BY DR. ARMSTRONG.

Theatre of Anatomy, Webb Strest.

LECTURE 23.

THE subject of this Lecture will bethe

Treatment of Gout and Rheumatism.The treatment of gout may be di-

vided into two parts, that which isbest adapted to relieve the fit, andthat which is best adapted to preventa return of the fit. I must premise,however, that gont does not requirealways the same treatment; you mustnot, in fact, prescribe for mere symp-toms, but for particular conditions ineach case ; and you will recollect, thatas the affection called gout is diffe-rent in its internal pathology in diffe-rent individuals, so it requires a cor-respondent variety of treatment. Thevalue of all general principles is, thatwe cin make them bear upon parti-cular cases ; so that a man who pos-sesses such principles will cc-nnect

effects with their true causes, andprescribe accordinsiy.

If we must allude in some degreeto the arbitrary and erroneous ar-

rangement which prevails on this sub-ject, gout is regasiar and irregular.Wliatis called the regular gout, oc-curs with evidence of disorder in someportion of the mucous membrane ofthe primæ vim, and the external sym-pathetic inflammation is generally inthe great toe. That inflammation isacute in some cases and subacute in

others, and then it is accompanied byfever proportioned to the degree ofthe external inflammation and inter-nal irritation. In other cases, the in-flammation assumes a chronic charac-ter, and the patient has no fever atall. Now if you find this affectionoccurring under the regular charac-ter, supposing it to be an acute orsubacute form of external inflamma-tion, in a young or middle aged sub-ject, the following plan will answer,in many cases, the best purpose :-

1. Absolate rest in the recumbentposture, confirmed as long as theremay be any sign of external inflam-mation and fever. Whilst the inflam-mation and fever continue, rest in therecnmbent posture is a most powerfulanxiliary.

2. The use of aperient medicines.Give about a grain, or a grain and a

half, of calomel, with fonr or sixgrains of rhubarb at night, and a

draught, if necessary, on the follow-ing morning, tepid, and composed ofabout an ounce of infusion of senna,with one drachm ot the scnpfiate otmagnesia, and a few grains of cal-cined magnesia; but if the tonguebe at all red at the tip, a little colddrawn castor oil will generally be amore suitable laxative af’cer the ca-lomel.

3. Exhibit every night abont a

drachm of the wine of the colchicumseeds, but be sure to withdraw italtagetler as soon as sickness shallsupervene. Sometimes it is necessaryto prescribe this dose twice a day.

4. Order a bland diet whilst anydegree of fever shall continue. Theseare the means which will most fre-

quently suffice to remove what iscalled regular gout, when it is of anacute or subacute form, without in-ternal inflammation.But it happens in some of these

cases, which in common language aredenominated the irregular gout, that

98

you have symptoms of actual inflam-mation in some internal structure,particularly in the mucous membrane4of the stomach, or of the small bowels,’which may be relieved by local blood-letting, by the application of leechesever the integuments of the affectedparts, so long as the pain remain,with a red tipped tongue, a quickpulse, and a feverish heat of the sur-face. Indeed I have often thus ap-plied leeches in gout advantageously,when symptoms of subacute inflamma-- tion of the internal mucous membranesexisted, and in more urgent caseshave bled the patient, or rather ordered bloodletting from the arm, withinticli benefit. But always considerthe age and the habits of individuals.If the patient be young, or middleaged and robnst, unbroken in his con-stitution, you may bleed with greatpropriety and advantage, either fromthe arm or by leeches, as the inflam-mation may require. If there be no

signs of internal inflammation, bleedingwill of course be unnecessary. Again,if the individual have had many attacks of gout, and have been a fretliver, local bloodletting will generall3suffice, where internal mucous inflanimation shall arise. In regard to ex-ternal applications, you will find thainone are necessary, if you treat th(

patient properly and remove the con.comitant disorder of the stomach.bowels, or liver, whether that disor4der be local simple excitement, or ; a

degree of inflammation of the mucoussurface. The great discoverer of th(circulation of the blood, HERVEYseems to have put his foot into cole"water when attacked by the gout, ancI knew a physician who did the samenot only with immediate relief, butwithout any remote mischief from thtpractice.

There are cases on record where-this practice has been productive ofbad effects. PORTAL mentions an in-stance in which a patient was attack-ed by a fatal inflammation of the lungs.If an individual in health plunged his:foot into cold water, and tf a chill ofthe whole surface followed, excite-jnent would eventually take place,and the blood would be circulatpdwith greater velocity than natnral,but all the internal organs being in asound state, none would become in-

2

flamed ; yet, on the contrary, if anindividual having a weak organ wereexposed to the same degree of cold,that organ would become inflamedduring the continuance of the excite.ment, on the principle already and re-peatedly explained. But inflamma-tion, from the mere sudden change oftemperature, might arise in some re-mote part through metastasis.You will remember the fact I be-

fore mentioned to you, namely, thatone individual, by changing the tem-perature of the parts alternately,could change the seat of gout fromthe wrist to the great toe. Upon thewhole, then, it requires great care inadopting that plan of treatment, first,because inflammation may occur inter.nally from excitement, and, secondly,from translation, connected with adeficiency of heat in one place, and anexcess in another. The best local ap.plication is warm water and a littlealcohol applied to the part, a mode oftepid ablution which produces greatrelief ; take care, however, not to ex-pose the leg naked at the same time.I have known inflammations of themucous membranes of the air passages,and of the mucous membrane of theintestines, occur from exposure of thelegs when the feet have been put intowarm water, especially in a coldchamber. Indeed I am in the habitof telling delicate males to cut off thefoot of a stocking and draw it over theleg, or of females, to cover the legsabove with a flannel petticoat, when-ever a lotion is applied to the feet insuch cases.

I have seen a work which was pub-lished by a Dr. Stiedman, at Wells, in1779, it is entitled "A successfulmethod of Treatment for the Gout,"and in the beginning of it he has

adopted for a motto, " Dolor est Me-dicina Doloris." He has recommend-ed that a blister should be appliednear the gouty toe, and he assertsthat when the blister rises, the painof the gout subsides. He says, " Thatnature seems operating to restore andestablish the health generally by creat-ing a particular sore:’ In short, thisspecnlative Doctor would have one

believe that the gout in the toe is anattempt of nature to make a sore, butthat she has not sufficient power toestablish it perfectly ; as if the gout

99

- .-were like lightning, going in flashesto the foot and other parts of thebody, and that the blister was theconductor to guide and fix it on the

extremity. An eminent surgeon, in

London, I understand, is in the habitof blistering in gout, and it is, se-

riously, a practice which deserves at..tention in chronic cases.. The poeticaldoctor, of whom I have just spoken,.appears to have been a- merry fellow,for he says that there are two kindsof clothing for the gout, an externaland an internal one, internal stimu-lants, and external ii-i itants, the latterof which, in protracted thickening andstiffness, have perhaps been too muchneglected in modern times.The second form of gout is that

which has been called irregular gout,which is most frequently connectedwith internal inflammation, or spasm.If, in such instances, you direct yourattention to the internal organs, youwill discover that the parts most lia-ble to iutlammation are the, mucousmembranes of the stomach, or of thesmall intestines ; the inflammation be-ing generally of a subacute kind, andtherefore requiring minute investiga-tion to ascertain its origin and pro-gress, particularly when seated in a

portion of the ilium. There is nothingpeculiar in the treatment of this formf inflammation, for it will yield tolocal bleeding by leeches, and a com-bination of the other simple meanswhich I formerly pointed out as theappropriate remedies, which will bealike successful here. I knew a phy-sician who practised with very greatsuccess for fifty years, and his princi-ple was, that the irregular gout was,generally, nothing more than an in-ternal inflammation. Sometimes, how-ever, spasms will be found to exist ingouty habits, from the remote causesformerly enumerated; if the stomachbe overloaded with crudities. or dis-tended with flatus, or irritated byacids, nothing relieves so soon as aglass of pure brandy. Yon may haveviolent colic produced from the samecauses, and if you were to give a littlebrandy with opium, the symptoms inmost instances would speedily be re.moved. Sometimes there are distinctevidences of congestion, the head beingheavy, the secretion of the liver de-fectivel the stomach distended, the

skin pal6, -while the patient complainsof lassitude and languor. In theseconditions, you will find local bleed-ing, and small doses of calomel, fol-lowed by rhubarb, or Croton oil, havea. good effect, but warm sinapismsshould be applied a short time to thefeet. The fact is, -these supposed ir-regularities are not peculiar to gout,because they happen in individualswho never had the gout, but they arealmost always associated with somedisorder in the primæ viae, more espe-cially seated in its mucons tissue,.asI endeavoured to ilinstrate in a formerLecture.In the chronic form of gout, the

chief remedy is the regulation of thepatient’s diet and driraks. If there. beno fever, a light animal diet may_beallowed, with a little bread, for din-ner ; the morning and evening meatconsisting of a cup of black tea andbread, with very little milk or cream,and still less sugar. But if thereshould be any fever present, you musthave recourse to a bland diet, onewhich will neither irritate the mucousmembrane of the stomach or bowels,nor excite the heart’s action. Thenext mean for the removal of chronicgout, is the use of’apprients; and thosewhich I have found to succeed betterthan any other, is a combination ofrhubarb, and an alkali, with a littlecolchicum. The vapour bath, too, isa very good auxiliary, often tendingto shorten the attack of chronic goutvery remarkably. I knew one gentle-man who had tried almost every thing,and found nothing shorten the attackso much as the use of the vapourbath.As to the prevention of gout, I be-

lieve that a return of this affection isby no means necessary. Many personshave an idea, that because they havehad one attack of gout, they must ne-cessarily have another and another;hut if any man would early and dulyregulate his habits, physically,nnorally,and intellectually, I firmly believe,that in 19 cases out of 20, the goutwould never return. The regulationof the patient’s habits is by far themost important measure in the pre-vention of gout,and a return of which,I repeat, is not necessary. The wayto manage such individuals, is moreeasily said than done, on account of

100

the difficulty of the exercise of self-forbearance. There is a man in Paris’who is very successful in curing allthe disorders of dogs. Ladies bringtheir lap-dogs to him, in their car-riages, and say their pets are verynnwell, and they do not know what isthe matter with them. The man takesthe dogs home, and locks them np inan airy room, gives them some water,a little bread, and a dry bone to pick;besides, by way of exercise, he makesthem skip about, two or three timesa day, under a little horse-whip, dex-terously applied.

At the end of a fortnight he takesthem to their mistresses quite well,active, and hungry, and though, sayste, they are not certainly so fat asthey were, they are quite well, I canassure you, on my honour as a doctor.(A laugh.) The man has made a goodfortune. Now a management of thiskind would generally prevent a returnof the gout; but, to be serious-thereare several points to be attended to inthe prevention of this disorder.

1. The Diet. Regulate the kind, andalso the quantity, of food. The foodought to be simple in kind, and mo-derate in the quantity ; indeed morepersons err with respect to the quan-tity, than the kind of food. One thingought to be observed, namely, that- those individuals who dine out veryoften never can be cured of gout; foryou can never put the stomach, liver,and bowels into perfectly good order.Such an epicure tries to reason thecase with you thus : why may not Ieat a mutton chop or the wing of achicken in company as well as alone?But the fact is, that he eats of threeor four different kinds of dishes, anddrinks of three or four kinds of wine:the present temptation of enjoymentovercoming all consideration of thefuture pain and penalty. The masti-cation should be slow, and an intervalof four or five hours should exist be-tween each meal, that one may be di-gested before another be taken.

2. The Drink should be attended tcas particularly; all fermented andiacid drinks should be avoided, and thEquantity of drink too should be verymoderate. If a person take a largEquantity of slop, say three or fouilarge cups of tea, in the morning, anèthe tame in the evening, besides a

considerable portion offluid at dinnerthe stomach must become very mnchdistended and disturbed indeed, inmany cases. Moderate, then, thequantity of fluids. It is of great con-sequence also that the water whichthe patient drinks should be pure, andeven that in which his vegetable and,animal food is dressed. I have seenthe health of many persons very muchimproved by attending to the waterwhich they drank, and that which wasused in cooking. The bread shouldbe home-made, or Le Mann’s, which isthe best in London.

3. A third point to attend to is theexercise ; a certain portion of which,in the open air, is necessary, in orderto secure a healthy digestion.

4. The sleep is another circumstanceworthy of consideration. If a mansits up late, first the nervous systembecomes irritable, and secondly, thestomach, liver, and bowels performtheir functions irregularly, and in thatway, very often, gout is induced.

5. The management of mind ishighly important. All, perhaps, thata medical man can do here is, to tellthe patient that he must avoid allthose occasions which, from expertence, he knows to disturb his mind.This cannot always be done to the de-sired extent, but the business of truephilosophy is to communicate serenityof mind amidst " the hum, the shockof men," amidst the tumult and ttir-moil of the world.

6. The sixth circumstance to be at.tended to is, the air, which, if possible,should be refreslaed in his apartmentsby ventilation, and that never canbe done effectually but through theaid of an occasional fire. A temporaryresidence, now and then, in the coun-try, is of great benefit to all cockneysaffected by the gout.

7. A seventh thing is to regard thecorrection of acidity, as it often provesa source of great uneasiness to the

patient, and prevents the due per-

formance of the digestive functions.Medically, nothing answers better forthis purpose, than to give gr. v. ofrhubarb, and gr. x. or xv. of the car-bonate of potash, in a little aromaticwater, before or after dinner, bywhich acidity is prevented, providedno errors be committed in diets anddrinks ; if there be a torpid state of

101

the colon, give a pill daily, containingtwo parts of aloes and one of mastich,made in a pill with tincture of gentianand a drop of the oil of cloves.

8. The clothing is a material pointtoo, in the prevention, for gout isoften induced by the change whichtakes place in the surrounding tem-perature, which, through the skin, dis-turbs the stomach, liver, and bowels,and brings on an attack of gout. Mo-derately warm clothing, therefore, isnecessarv.

9. Bathing is a very powerful meanin the prevention of gout, especiallybathing in tepid salt water, graduallvreduced to a temperature of about 60°,provided the patient feel warm andcomfortable after its use. It rendersthe person far less susceptible ofchanges of the atmospherical tempe-rature. By a combination of thesemeans, many individuals tvhom I knowhave entirely escaped a return of thegout. Many erroneously suppose thatan attack of gout is healthy, becausethey feel better after it, and they doso just on the same principle as thedog did by starvation and wlripping.Let the stomach be kept in goodorder by simple and wholesome diet,and gout will be certainly avoided, anaffection which is immediately pro.-ductive of much suffering, and which,remotely, not only cripples patients,but shortens their lives.

Treatment of Rheumatism.

Rheumatism was before dividedinto three forms, the acute, subacute,and chronic. In the acute form, ifthe individual be young and robust,yon may draw blood with great be-nefit in the beginning, according tothe degree of inflammation and fever.Bleed the patient decisively, and youat once make all impression on thedisorder. If the inflammation shouldbe subacute, and the fever not high,local bleeding will only be necessary.2. The exhibition of aperients is ne-

cessary, and for the first day or two,nothing is so good for this purpose ascalomel, rhubarb, and the sulphateof magnesia, with senna. 3. Regu-late the temperature of the apartment,because if the temperature be not pro-perly attended to, patients may beliable to attacks of inflammation of

the pericardium. The best tempera-tare in which to keep the chamber isfrom 60 to 62°. When a patient ismuch weakened, you should be mostcareful about the temperature, espe-cially when he has occasion to get outof bed to the night stool ; it is muchbetter in such cases to use a bed-pan,particularly where the skin is moist,and the weather cold. I think thatmade by WEiss in the Strand is byfar the best bed-pan which I haveseen for the purpose. Bleeding, then,locally or generally, and the use ofaperients, are the two first measuresto be employed, and the third is theuse of colchicum. This may be given,at night in moderate doses, the sameprecautions being attended to whichI before mentioned ; in a word, yommust leave it off as soon as any sick-ness is produced. 4. The fourth meansis a blister, which seems to removethe inflammation hanging about thejoints under a more chronic form.When you have succeeded in re-

moving the violence of an attack ofrheumatism by bleeding, aperients,and colchicum, you must treat it morecautiously afterwards; you must notbe guided wholly by the appearanceof the blood, which will be buffed tothe last in rheumatism ; but you mustthen adopt mild measures day afterday, and attend to the diet, tem-perature, bowels" and sleep. This

simple plan, with the assistance oflaxatives and a little colchicum, willalmost invariably succeed. But do,not continue the colchicum long, other-wise it witi do harm by disturbing thestomach and breaking up the generalstrength.

Chronic Rheumatism.

The main thing in chronic rheuma-tism is to regulate the diet, in the waywhich I have mentioned with respectto gout, namely, it should be simple inkind and moderate in quantity. A pa-tient affected by chronic rheumatismshould keep his bowels regularly butmildly open ; and if he cannot do thisby diet, and the attempt to obtain anevacuation at a certain hour, the com-pound rhubarb pill of the EdinburghPharmacopoeia, or the compound aloe-tic pill of the London Pharmacopœia,will be found proper aperients.

102

3. A third point is exercise; the

patient should take exercise in theopen air, for it tends not only to esta-

blish the health, but to remove the

pain and stiffness about the joints,when carried so far as to produce agentle and a general perspirafion:Where exercise tails to produce thiseffect, the vapour bath will be found anexcellent remedy, followed by frictionand motion of the affected joints.Blisters are sometimes useful. Acu-

punettiration has done much good inmany cases, and the French have re-cently made an improvement in thatprocess, by allowing the minute

needles to remaiu in the part for sometime, and certainly experience hasproved the superiority of this prac-tice.There is a remedy which is very

popular in some parts of the north ofEngland for the sciatica, which is acaustic issue placed beneath the headof the fibula, between that bone andthe ridge of the tibia; if an issue bemade there it will generally succeedin removing the sciatica as far as I

’have observed. Though now a popu-lar remedy, you will find that it is re-commended very strongly by Cotl1n-nias, and I can assert its utility in se-veral obstinate cases.Other means are very useful in

chronic rheumatism, as the warm saltwater bath ; if an individual be nearthe sea during the summer, and usethe warm salt water bath three times’in the week, and continue it for twoor three weeks, at the same time at-tending to the regulation of his dietand sleep, he may often succeed in

getting rid of the complaint. Sul-phureous waters used externally andinternally have sometimes a very goodeffect, as the Harrowgate waters. Ifthese means have been fairly triedthere will be seldom any necessity torecommend a change of climate ; butif they should fail, then send the pa-tient, if practicable, into a milder at-mosphere, which will be very useful.Patients and medical men, however,are apt to look for advantage to thingsat a distance, and to neglect the re-moval of those circumstances whichprevent or retard the recovery at

home ; therefore, try every means athome first, and be sure not to rely ona merely medical treatment, but at-

tend most strictly to the diet, the pro-per management of which will alonesometimes remove chronic rheama-

tism, aided by the cautious use of thecolchicum and the vapottr bath.

LECTURES

ON

PHRENOLOGY,BY

DR. SPURZHEIM.

LECTURE 3.

(THE Doctor repeated briefly whathe had said in his preceding lectureon the antiquity of the doctrine whichassigned to the mind a plurality offorms, and on the influence of theconstitution, or temperament, in de-termining the degrees of activity ofthese powers; he also remarked, thatexercise, and the mutual employmentof the mental faculties, had the great-est influence in increasing their ac-tivity.)LADIES AND GENTLEMEN,

j I shall now mention how we maydistinguish the nature of the differentfunctions by the external signs. Whenspeaking of size, Ladies and Gentle-men, you will recollect what I said ofthe different dimensions; you mustnot attend merely to an elongation ofthe cerebral parts, but regard also thebreadths ; the cerebral parts may belong and narrow, or short and broad;or they may be short and narrow, orlong and broad. Experience showsthat these differences of size exercisean influence on the manifestations ofthe mind ; and I certainly prefer ce-rebral parts which are thick to thosewhich are merely narrow and elon-gated. Moreover, in considering thesize, you must not confound protube-rances with development; you mustform a clear idea of what is called aprotuberance in phrenology. Protu.berances do exist, and we must seehow they exist: if a cerebral part bemore developed than the neighbour-