J. M. (Jean Martin) Charcot.

Clinical lectures on the diseases of old age online

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E. — Fermented liquors. — From our point of view, we must make a
radical distinction between spirituous liquors (rum, brandy, whiskey, 'gin,'
etc.) — ^hquors which contain from forty to seventy parts of alcohol in one
hundred — and the simple fermented beverages (wine, beer, cider, etc.),
whose alcohohc strength varies from four to twenty per cent. At the first
glance it looks as though the more a liquor is charged with alcohol, the
more it predisposes to gout ; but such is not the fact, and you will be as-
tonished to learn that the use — even the abuse — of distilled liquor does
not seem to exercise the shghtest influence in this respect. Indeed, gout
is hardly ever met with among people who drink brandy. In Sweden^
where alcohoHsmus is so frequent — according to Magnus Huss — this disease
is out of the question ; and it is the same in Denmark, Russia, and Pokmdj
In Scotland and Ireland, gout is rare among the lower classes. In Edin-
burgh, with a large hospital practice, Bennett " and Christison met with
barely more than one or two cases of it. Now, in these countries, the only
alcoholic liquor which the people drink is whiskey.

In London, on the other hand, gout is a very common disease among
the working classes, and is frequently met with in the hospitals. Now, the
only fundamental difference that can possibly be established, in this re-
spect, between the northern and the central portions of the TJnited King-
dom, is the enormous consuniption of strong beer (ale, stout, and porter)
by the laborers who live in the metropoUs.'

' It kills the rich oftener than the poor, the wise man oftener than the fool.
'Clinioal Lectures, etc., by J. Hughes Bfimett. Second edition, p. 916. Edinr
burgh, 185».— L. H. H.

' See Appeiidix, inserted at the close of this lecture.



THE DISEASES OE OtD AGE. 89

TMs truly remarkable influence of these beverages lias "been recognized
by all English writers on the subject, commenciag -with Scudamore. He
tells us that "gout is much more frequent in London, among the masses,
since the use of porter has become habitual." The testimony of Watson,
Budd, and Todd also corroborates this. assertion : "Most of those who are
given to the use of beer, especially porter, sooner or later suffer from gout,"
says the last-named of these three authors.

An example bon-owed from Budd ' wiU illustrate the influence which *
this kind of Uquor exercises. There is, in London, a body of laborers who
work at the raising of ballast from the bottom of the Thames. This is
done during low tide, and consequently, the working hours fall sometimes
during the day-time, and at other times at night. The workmen, who are
exposed to aJl sorts of inclemencies, are also obliged to expend great mus-
cular effort ; and, in order to obtain the best return (please to notice here
the practical nature of the English), a large allowance of porter is given to
these men. Each one drinks two or three gallons a day ; and, apart from
this enormous consumption of fluid, their diet is that of the very lowest
classes in London.

Now, gout is an exceptionally frequent disease among these poor men,
who share this sorry privilege with the peers of the realm ; and although
their numbers are but very few, many of them aie each year admitted as
gouty subjects in the Seamen's Hospital. And yet, these are generally
unfortunate Lrish peasants, in whom an hereditary vice of constitution
could not be advanced as a cause.

Garrod, on his side, attained the same results. He states that the em-
ployes of large breweries are frequently attacked with the gout, and yet
nothing can be found in their antecedents to explain this morbid predis-
position, except it be the abuse of ale, and porter especially.

These two beverages, however, are not remarkable for their richness ia
alcohol ; according to Mulder, Scotch ale contains eight per cent, of alcohol,
and porter five per cent." This proportion is smaller than that in our French
wines, and does not exceed that of the German beers, which seldom pro-
duce such effects, in spite of the large amounts drunk in the breweries.

It is evident, consequently, that d priori reasoning cannot be applied to
the question we are discussing, and that the influence of fermented drinks
upon gout is far from corresponding to their percentage of alcohol. Cir-
cumstances of a different kind, which have escaped us to this day, probably
iuterpose themselves at this point ; and for every kind of liquor we must
have recourse to the data of direct experimentation.

We shall now consider the action of wine. The first rank must here be

, conferred upon the spirituous wines (Port, Sherry, Madeira, Marsala), which

are so extensively used in England, in all classes of society. These contain

a considerable quantity of alcohol, varying from seventeen to twenty per

cent.

The lighter wines (Ehine, Moselle, Bordeaux, Champagne) are far
from exercising the same influence as the former class.

But we cannot say the same of Burgundy, which nevertheless, contains
scarcely more alcohol than the precediug.

" Bed Hermitage and Burgundy, the latter especially," Scudamore says,
" contain gout in every glass."



' Tweedie : Library of Medicine. Vol. v., Art. Gout. Also in Bennett's (J. Hughes)
Clinical Lectures, etc., p. 992. Edinburgh, 1868.— L. H. H.
« Mulder : De la Biere. Trad. Delondre, p. 337. Paris, 1861.



90 CLINICAL LBCTITEES ON

Even cider, that beverage seemingly so free from danger, also appears
to favor the development of gout. According to Garrod, it is soft (new)
cider, and that having undergone only partial fermentation, which possesses
this unpleasant property.

I think that, as the influence which certain beverages exercise in this
regard has been sufficiently well proved, we may now safely pass to the
consideration of another subject.

B. — Lead-poisoning. — Garrod states that out of fifty-one gouty patients
who were in his service at the hospital, no less than sixteen were painters
or plumbers by trade ; and subsequent researches only confirm this strange
result. Thus, saturnine impregnation has been ranked among the predis-
posing causes of gout.

This coincidence once pointed out, documents in its support flowed in
from all quarters. Among the authors anterior to Garrod, Musgrave may
be cited as one who noticed gout following lead-colic, Falconer as another
making the same observation, and Pany, who, in his collection of cases,
has shown that gout is frequent in those attacked with lead-paralysis.
Finally, Todd reports several cases of gout occurring under analogous cii>-
Cumstances.'

Since the publication of ^ Garrod's work, several English authors have
described cases of this kind ; we may especially cite BurroWs and Begbie."
But in England we must take into account those aUmental causes we have
just enumerated. In Prance, where lead-coHo is so common, how does it
happen that gout is so rare among the great mass of the population ?

Well, in cases of saturnismus there are a few patients with the gout in
whom lead-poisoning is the only cause that can possibly be adduced. We
have ourselves had an opportunity to observe a very remarkable case of this
kind, and Dr. Bucquoy has just reported an almost identical case in Charity
Hospital.

It now remains to determine the cause of this singular coincidence.
Garrod affirms that an impregnation of the system with lead leads to an
accumulation of uric acid in the blood, especially in advanced cases where
there is paralysis ; this fact has been established in non-gouty cases of
Saturnismus, which seem not to have been albuminurious ; for their urine
had been examined, and it had been determined that the proportion of uric
acid was sensibly diminished ; but in these analyses there was no question
of the presence of albumen. Garrod asks himself whether, in this case,
there was an over-production of uric acid, or a failure in excretion of this
product. He leans toward the latter hypothesis, and this is the experi-
ment on which he bases his view : after having for several days examined
the urine of a certain number of patients suffering from various diseases, in
order to establish the normal proportion of uiic acid, he commenced to
employ acetate of lead medicinally with them, and he, found that the ex-
cretion of uric acid diminished.

It is then by paralyzing the action of the kidney, at least so far as ctm-
cems the elimination of uric acid, that lead favors gouty manifestaMons ;
but can the disease arise from the influence of this cause alone ? In a few

' G. Musgrave : De arthritide symptomatica, c. x., art. 5, p. 65. GenovsB, ITS.").
€. H. Parry: Vol. i., p. 243. London, 1825. Todd: Practical Remarks on Gout,
p. 44. London, 1843.

^W. Falconer : Brit. Med. Jour., p. 464. 1861. Begbie: Edinburgh Med. Jour.,
p. 128. August, 1862, Charcot: Gazette Hebdom. , p. 433. 1863.



THE DISEASES OP OLD AGE. 91

exceptional cases perhaps it can ; but if there are any adjuvant causes, the
effects of lead will be exhibited last of all.

m. — Exciting causes. — Incapable themselves of producing gout, still
the conditions we are about to enumerate possess great potency in bring-
ing about the development of an attack.

A. — Alcoholic beverages. — The ingestion of but a small quantity of cer-
tain wines (champagne and port, for example), in the case of gouty patients,
is enough to induce at one time a violent attack of gout, and at another
simply a swelling of the great toe. Hence, Garrod has well said : " In what-
ever individual a few glasses of vsdne are always sufficient to rapidly and
invariably provoke an inflammation in a joint, that inflammation is certainly
of a gouty character."

B. — Attacks of indigestion, and gastric derangements act in a similar
manner. '

G. — Wet cold and suppression of the perspiration are in the same cat-
egory.

D. — Excessive intellectual labor, to which we have already alluded as a
determining cause of gout, is included also in this enumeration.

E. — Traumatic causes, operations, fractures, etc., act in like manner,
and I have seen a wound simultaneously induce an attack of trismus and
one of gout.

E. — Debilitating causes — hemorrhage, bloodletting, and grave diseases —
also exercise their influence upon the production of an attack. It is all
the more interesting to notice this point, since people are fond of painting
gout as a disease of plethoric individuals ; but Todd has shown that it
readily attacks debilitated subjects.'

"We shall devote our next lectiire to the theory of gout.

' Recently I had under my charge a former officer in the Confederate Army, who,
durmg the rebellion in the United States, was made prisoner by the Union troops.
Confined in a damp and unhealthy prison, and having a very insufficient diet, he be-
came a subject of gout ; he remains so till this day, and yet he has no hereditary ante-
cedents that could predispose him to gout, and previous to that time he never had the
least indication of the disease.



92 CLINICAL LECTURES OK



APPENDIX TO LECTtJEE IX.

English Beebs.

The question of the influence exercised by ale and porter upon the de-
velopment of gout is one that frequently recurs in these lectures, and it
seems to me to be necessary to present, in this connection, some descrip-
tion of the processes employed in making these beverages, and the chief
properties that characterize them ; so I requested Dr. Ball to prepare for
me a short account bearing on these points, vfhich I here present to the
reader. The information therein is aU the more useful, since it can be
found in no medical work published up to this time.



It is beyond dispute that, from the remotest antiquity, people who
were not acquainted vdth the use of wine discovered the means of utilizing
germinated barley {malt) in order to procure alcoholic beverages." Long
before they left their forests the Germanic tribes possessed this art, and
thus we are not astonished to find beer naturalized in England from the
time of the Anglo-Saxon conquest. The laws of Ina, King of Wessex (a
country of the Western Saxons), which were promulgated in 728, already
make mention of ale and alehouses ; and from that epoch beer has never
ceased to be the natural beverage of the English.

But during the course of these many centuries public taste has varied
more than once, and the brewers have been obliged to follow the fashion,
except, indeed, when they have forestalled it. In the middle ages hops
were not employed in beer-making, the beverage seeming to have had an
insipid and sweetish taste ; and they endeavored to correct this fault by
the addition of infusions of bitter and aromatic herbs. It was in 1524 that
the Flemings caused hops to be introduced into EngUsh brewing ; but this
practice was not legally authorized until 1552. The name ale was then
given to the sweeter beverages prepared from malt {germinated grain), while
the term beer was reserved for those impregnated with the bitterness of
hops. In the seventeenth century, however,, every vestige of this distinc-
tion was swept away, and hops were universally employed in the English
breweries.

The origin of porter is of much more recent date. It was in 1730, acr
cording to Malone, that it commenced to be used for the first time. About

' Herodotus and Diodorus (of Sicily) tell us that the Egyptians knew how to make
beer. Pliny and Tacitus testify the same as regards the Germans. " Potui humor
ex hordeo aut f ruraento in quaiudam similitudinem viui oorruptus." — Tac: De situ,
moribus, ao populis Germ. , cap. xxiii.



THE DISEASES OF OLD AGE. 93

that time the woriingmen of London were in the habit of drinking, in the ale-
houses, a mixture of beer, ale, and small beer, -which they called three threads,
because for every pint he drew for a customer, the inn-keeper was obliged
to go to three different casks. In order to avoid this inconvenience, the
brewer Harwood thought he would make a beverage that would combine
the flavor of these three ; he succeeded admirably, and the success attained
by the new drink among the lower classes of the metropolis was such
that the name porter ' was given it, a name which it has retained till this
day.

To please the popular taste, they formerly gave this porter a very deep
color, by prolonged torrefaction of the grain. But it was soon perceived
that, by doing this, they destroyed the greater portion of the saccharine
matter contained in the malt, and that the richness of the liquor in regard
to fermentable principles was diminished thereby. Becourse was then had
to a number of artificial processes for coloring porter, which were prohib-
ited in 1816 by an act of parliament ; and the only ingredients which, to-
day, serve for the manufacture of beer, are water, malt, and hops.

It was then discovered, however, that complete torrefaction of malt,
though destroying the sugar it contained, gave rise to a very soluble color-
ing matter : and since then this substance, which came within the terms
of the law of 1816, was largely employed in making porter.

To-day this beverage is a mixture of several kinds of beer, kept a long
time after being commingled, so as to push fermentation to its utmost lim-
its and convert all the sugar into alcohol. But, since the malt is exceed-
ingly torrefied at the commencement, it contains but little glucose at the
very moment when the working begins, and consequently can never be as
rich in alcohol as the other varieties of beer. Its essential characteristic,
however, is a tendency to acetic fermentation, for, all the sugar being de-
stroyed, one more step suffices to convert the alcohol into vinegar. From
a theoretical standpoint, this change ought never to take place ; but prac-
tically the porter delivered for use is frequently acid, a fact of which I have
many a time assured myself.

The name entire is generally given to beers that have been mingled ;
while stout is applied to one that is prepared with more care and is des-
tined for more delicate consumers, though it participates in the general
characteristics that we have just described.

Under the name ale are classed all the other varieties of beer that do
not possess a deep color, and are not prepared from excessively roasted
malt ; hence, they are richer in saccharine matter and alcohol ; and as fer-
mentation has not progressed far enough to destroy all the sugar they con-
tain, they possess a very different flavor from that of porter, and present
no tendency to sour.

Thus, we may divide into two great classes the beer that is used in the
United Kingdom : the first class is rich in color, but poor in alcohol, de-
prived of sugar, and ready to undergo acetic fermentation ; they are also
impregnated with a principle obtained by the torrefaction of grain, and
which perhaps is not alien to their pathogenic properties. To this class
belong the beverages known under the generic name of porter, and whose
use so markedly predisposes to gout.

The second class, on the contrary, though poor in color, are rich in al-
cohol, and do not contain a trace of acetic acid.

It is understood, of course, that in this brief account we could not include



' " Probably because the "LouAotl poi-ters first used it." — Webster.



94 CLINICAL LECTURES OIT

all the variation to which caprice, chance, or local customs may have given
rise. In England, the beer of one county or shire does not resemble
that of its neighbor ; and each distinguished brewer has his secrets, which
especially stamp the products of his manufacture. It is enough, then, to
have presented the reader with a general view of the subject, without en-
tering into a Eoinute study of details.



THE DISEASES OF OLD AGE. 95



LECTURE X.

PATHOLOGY OF GOUT.

Bummwry. — Rational Theory of Gout — It can hardly be Formulated in the Present
State of Scientific Knowledge — CuUen — Discovery of Lithia Acid (Uric Acid) —
Influence of this Fact upon Modern Works— Garrod's Researches — He establishes
the Fact that Uric Acid exists in Excess in the Blood of Gouty Patients — Origin
of this Excrementitious Product — It is still but little known— Are Urea and Uric
Acid Immediate Products of DisassimOation ? — Experiments of Zalesky.

Empirical Researches — Effects of Fasting — Animal Diet — Exercise — Contradic-
tory Results in this Respect — Influence of Liquors : Experiments of Bocker.

Theory of a Gouty Attack (Fit)— The Articulations preferably affected— Fibrous
Tissue, Cartilage — Predilection of Gout for the Great Toe — Successive Invasion of
Joints — Tophi — Deposits of Urate of Soda in the Cartilages — Pain — General Re-
action — Visceral Phenomena — Insufficiency of our Knowledge in this Respect at
the Present Day.

Gentlemen ; — After haTing passed in review the various causes wHch
are closely or remotely associated with the production of gout, there re-
mains for us to seek a rational theory of this disease, and to combine the
data of physiology with those furnished us by clinical observation. We
may not, besides, flatter ourselves that we can obtain complete success in
this direction ; for, even though we know the morbid principle whence
arises, in this case, the pathological series of events, we are yet far from
grasping aU. the links in the chain ; the conditions presiding over the for-
mation and elimination of uric acid are still unknown to us, and will, no
doubt, long elude our investigations.

In order to understand, however, the present state of the question, it is
necessary to trace the various phases it has passed through during the
course of years untU the present day. Let us see, then, what the opinion
of our predecessors was in this respect.

The theories which were formulated concerning gout during all the
seventeenth and part of the eighteenth century were essentially associated
with humorism ; this is always the theory of Sydenham, in slightly differ-
ent words. There is morbific material in the body, the result of imper-
fect digestion occurring either in the primcB vice or in the secondary appa-
ratus, and the efforts of nature to eliminate this peccant material (phlegm,
bile, tartar) constitute the symptoms of gout.

But a reaction against these old ideas set in from Cullen's time. This
celebrated author held that there was no proof of the existence of a morbific
material in the blood. He regards tophi, adduced by the humorists in
support of their theory, as purely accidental occurrences. For him, gout
results from a sort of plethora, with loss of tone in the extremities.

The progress of chemistry stepped in~to modify, to a certain extent,
this method of regarding the disease. Lx 1775, Scheele discovered lithio
acid (uric acid) in urinary calculi and in the urine ; in 1793, Murray Forbes,



96 CLINICAL LECTURES ON"

■by reason of the analogies subsisting between gout and gravel, promulgated
the view that uric acid existed in the blood of the gouty ; in 1797, Tennant
and WoUaston estabUshed the composition of topM to be of urate of sodji.

Cullen's theory, however, still held sway in England. Scudamore con-
tinued to regard gout as a sort of plethora without any relation to the ex-
cess of uric acid in the blood ; he considers tophi as exceptional phenomena
in gout, having found them in but forty-five out of five hundred gouty
subjects. Barlow and Gairdner share this opinion ; and recently Barclay '
has again recurred to this point, relyiag, it must be said, much more on
sentiment than upon observation. But Parkinson, Home, and Holland are
identified with the uric acid theory.

In France, gout has been studied only by a limited number of writers ;
but those who have devoted themselves to this subject admit, at least theo-
retically, the presence of uric acid in the blood, and fully understand, the
importance of this cardinal fact. In this connection we may especially cite
Andral, Eayer, and Cruveilhier; " the latter regards the deposit of tophaceous
matter in the interior of the articulations and in their vicinity as the char-
acteristic lesion of gout. Now, these tophi consist of urate of soda ; and
Cruveilhier is thus led, he says, in spite of himself, to the theory of Syden-
ham and the older investigators : he regards urate of soda as the material
cause of gout, and he considers that there is no doubt but that the first
attack of gout coincides with a secretion of this product, which is repeated
afresh with each subsequent attack of the malady.

Notwithstanding all the interest offered by the works, we have just men-
tioned, the period of positive knowledge seems to us to date from Garrod's
investigations in 1848. This observer, so often quoted in the course of
these lectures, has established : first, that in acute or chronic gout there is
an excess of uric acid in the blood : secondly, that from the first attack
there is a deposition of urate of soda in the joints ; thirdly, that during the
attack or paroxysm there is an appreciable diminution in the excretion/jof
uric acid by the kidneys.

These are the fundamental facts that may serve as elementary princi-
ples of a pathogenic doctrine ; but there is stUl no physiological ttieory of
gout in it. A few attempts, however, have been made in that direction, and
I shall present you with the chief results thereof.

I. — The presence of an excess of uric acid in the blood does not consIS'-
tute gout,' but merely induces a marked predisposition to this malady.
We must, then, study the various circumstances that may augment the
proportion of this excrementitious product ; but we are met vriSi difficul-
ties at the very first step.

What is the origin, what are the sources of the uric acid excreted?
Authorities do not agree concerning this point.

A.— The theory of direct combustion, advanced by Liebig, seems to af-
ford a ready solution to the problem. Uric acid has its origin in the blood
itself, at the expense of the albuminoid matters (fibrin, albumen, globulin)
which have not been oxidized sufficiently to convert them into urea.

' On Gout and Rheumatism, p. 3 and following. London, 1866.

'Andral: Precis d'Anatomie Pathclogique. Vol. i., p. 533, and Vol. Ji, p. 387.
1839. Rayer : Traiti dea Maladies des Reina. Vol. 1., p. 243. Paris, 1839. Cru-
veilhier : Atlaa d'Anat. Pathologique. Part 4, Plate iii.

' Albuminous nephritis and the saturnine cachexia are also among the number of
diseases accompanied by an excess of uric acid in the blood.



THE DISEASES OF OLD AGE. 97

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