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History never feels so true as when told by those having experienced it themselves. By chance we found the diary of a doctor, living around the turn of the 17th century. Dr Michiel Korsten was born in 1666 in a small Flemish village and kept a diary from 1702 until his death in 1732 at age 66. You will look in vain for intellectual contents in his notes. In contrast, this “bourgeois” man described trifling events and small talk about the middle class and the clergy of the town where he lived. He appeared to have a special interest in clothes and wine and punctiliously noted expenses for his wigs, his jackets, or liquor. More interesting for the medical reader, are his writings about his personal health problems: “podagra” (gout), “sciatica” (degenerative spine disease), and kidney stones. Being a patient and a doctor at the same time, he described quite precisely the symptoms and the treatments he used.
SYNTAXIS ET POETICA
The diary starts with memories of his medical education. After having finished “Grammatica, Syntaxis et Poetica” at the school of the Jesuits in Liege, he first followed an additional course “Logica et Physica”. In 1690, at the age of 24 years, he started to study medicine at Leiden University in Holland. At that time Leiden housed one of the most famous faculties of medicine in Europe. Young Michiel Korsten stayed there at Mr Van Velthoven's home, a rich merchant from his own native village. For board and lodging he paid 200 guilders a year. The courses in medicine he attended were for the greater part private and were given at the professor's house. According to his diary he had to pay 40 guilders a year for chemistry, 20 guilders “to be tought about herbs”, 20 guilders for “anatomy and to watch separation of the parts of the body”, 20 guilders to attend surgical procedures, 20 guilders for the courses of principles “to listen and write down chemistry, surgery and herbs”, and 40 guilders a year for the practical lessons, in the famous Leiden teaching hospital. The diary tells that it was common practice among the students to assume a poor appearance in order to obtain a reduced price for the courses.
Only one year later, in May 1691, he left Leiden to continue his medical training at the University of Louvain. For board and lodging at a local pharmacist's he paid 320 guilders a year. Only seven months later he graduated as a doctor. According to his own calculations, his studies had costed 300 guilders, excluding the costs of boarding and lodging. After having finished his studies he didn't know where to settle. In 1696, he finally started as a general practitioner in Sint-Truiden, a Flemish town in the region where he was born. In 1706, he moved to Maaseik, a town in the same province, where he lived and practised until his death. There he was also engaged by the “Table of the Holy Spirit” as the poor-people-doctor, for which he received a yearly wage of 160 guilders.
PODAGRA ET SCIATICA
The first attack of gout occurred in 1714 when Dr Korsten was 48 years old. On 1 June he mentioned a “sharp pain of podagra since two days”. A few days later we read “podagra now appears in the big toe of my other foot and even goes up to my ankle”. The pain increased over the next few days and obliged him to walk with a cane. Fortunately, the attack receded over the next two weeks. Further descriptions of gout were found in 1715, yearly from 1718 until 1725, in 1728, and a last attack in 1730. The worst year was 1722, when he had six severe episodes of podagra. The attacks usually started in the big toe and often ascended to the ankle. Frequently, an episode in one foot was followed by an attack in the other one. Most episodes lasted four to eight days, but some of them several weeks. The intensity of the pain varied from “a start of podagra in my left foot without important pain” to “sharp, burning pain accompanied by fever and itching”, which incapacitated him, making him unable to walk and perform his job. In 1725 he had to stay at home for several days and later had to make holes in his shoes in order to be able to visit his patients. The attacks were usually localised in the feet, but twice he mentioned gout in his shoulder, which forced him to ask for help to get dressed for several days, and in 1726 he had gout in both knees.
Dr Korsten's problem of uric acid metabolism is probably illustrated by three attacks of kidney stones, one in 1718, a second in 1721, and a last one in 1723.
Apart from gout and kidney stones, he also had “sciatica”. He was able to distinguish clearly between the pain from podagra and the pain caused by degenerative back disease. In 1722, 1724, and again in 1725 he described “stubbing pain in my left hip, irradiating to my knee. I can't sit or stand long and at night I have to get up and walk around the room.” The episodes of “sciatica” lasted much longer than the attacks of gout and took several months to resolve.
AS FOR THE CONTAINING CAUSE OF GOUT
Although a doctor today might admire Dr Korsten for his adequate diagnostic capabilities, the pathophysiology of “podagra” is not clear to him. In 1715 a priest told him in confidence that “a lady from the town had complained the doctor often was drunk and in an enervated state which caused some patients to choose another doctor” and “that he would be a good doctor if he had not this fault”. Consequently, the priest advised him strongly to reduce his drinking. However, although the doctor recognised he used alcohol too abundantly and although he seemed to appreciate the preaching, he did not effectuate the advice. The same year he ordered gin and French brandy, for one and two guilders respectively. In 1722 again, after having had several attacks of gout he bought three bottles of German Moselle wine and two bottles of French Burgundy. In 1730 he ordered at the same time drugs to treat his gout and 16 pints of gin (at that time one pint was 0.56 litre).
There is no indication that Dr Korsten recognised the association between excessive alcohol or food and his attacks of gout. His copious lifestyle is also illustrated by a mention of weight loss of 23 pounds after following a diet in 1723. Despite that effort, he still weighed 182 pounds. He himself attributed podagra to mechanical problems such as “walking in great heat” (May 1715), “tightness of my new shoes” (June 1718), “podagra started after hurting my foot when getting off my horse” and later “when getting out of my coach” (June 1720). We wonder if this ignorance was a shortcoming in his personal knowledge or if the link between alcohol and gout was not yet recognised at that time.
Already Hippocrates had observed “castrates and women before menopause never have podagra”, but mentioned “the Greek who drive horses are prone to this disease”. We are inclined to associate the possession of a horse with a richer lifestyle predisposing to more abundant use of alcohol. It was Boerhaave (1668–1738), a contemporary of Dr Korsten and teaching at Leiden University who wrote in aphorism number 1255 “generous drinks too abundant, a copious body and hereditarity” were associated with gout. Boerhaave was appointed in Leiden in 1705 and the aphorisms were published in 1708.1 Michiel Korsten left Leiden in 1691 and apparently postgraduate review courses were not yet customary at that time.
CUM BONO EFFECTU CONSEQUENTES
As for the treatment of gout, Dr Korsten was well aware of the recommendations of his time. Consistent with the “theory of humours”, we read in Tractatus de Podagra et Hydropia by Thomas Sydenham (1624–1689): “There are about three ways proposed, whereby we may eject the containing cause of the gout: bleeding, purging and sweating”.1 This is exactly what Dr Korsten did, to treat not only his gout but all his health problems. He prepared the sweating drink himself and meticulously noted the type and dose of herbs he used. He often added “Laudanum Opiatum”, apparently a more efficient pain reliever than sweating. Each course of sweating took five to eight days. During these treatment courses he drank water abundantly, which he ordered from a local fountain well, said to have healing properties. Remarkably, his notes on the drug treatment and their effects are written in Latin and so we read “etiam bene sudabam cum bono effectu consequentes (sweated a lot with good effect)”.
Sweating was usually combined with one or two days of purging by means of pills Dr Korsten had received from the local pharmacist's. The composition of these pills is not revealed in the diary and we can only speculate that they contained colchicine. The Greek already knew the potential of this drug in the treatment of gout in the 5th century bc. Later colchicine was used as a purging drug. Between 1600 and 1750, however, its use was out of fashion because Sydenham considered it a poison with lethal potential.1
When sweating and purging were insufficient, Dr Korsten tried to find relief in bleeding. In 1722 he twice went to a local surgeon and was treated by bleeding, first seven “ounces” (one ounce at that time was 31.25 gram) and soon afterwards nine. As the attacks of gout continued, he decided to go to Aachen, in the present Germany, to be treated by “cupping”, a different method of bloodletting (fig 1). The total course, including 11 “blood-cups” on different parts of the body, cost 20 guilders. This without any success, because when arriving home he immediately started a treatment course of sweating, which finally stopped the attack. In May 1726 he travelled a second time to Aachen, to take baths and to be treated by cupping. This time the costs were only 7 guilders because he travelled with acquaintances who did not charge him for the journey. Smaller attacks of gout did not need systemic treatment but were relieved effectively by local “sweating plasters”. Interestingly, he fought an episode of “sciatica” by “whipping my bottom with nettles”. A more civilised remedy was used when he suffered from kidney stones, which were successfully driven out by drinking oil of turpentine on three mornings .
THE END OF THE DIARY
From 1728 onward the descriptions of his health problems are less vivid and more and more he mentions a deterioration of his general condition. The diary ends in 1730 when he wrote “Slowly I am travelling to my grave, may God be merciful to my soul.” Two years later, in 1732, Michiel Korsten died.