Sir Alfred Baring Garrod.

A treatise on gout and rheumatic gout (rheumatoid arthritis.) online

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are from without, being produced by external influences.

Influence of hereditary predisposition on the occur -
rence of Oout — Most writers acknowledge this influence



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HEREDITARY FREDISPOSITION. 209

to be very potent, some have even gone the length of
^considering gout purely hereditary ; such was the opinion
of Dr. Cullen ; but that it often is acquired, v^e can bring
forward abundant evidence to prove.

Scudamore found that in 523 gouty patients, as many
as 309 could trace a predisposition to the disease either
from their parents or grand-parents. And from the
results arrived at by a Commission of the French
Academy, the strong influence of hereditary predisposi-
tion is shown, though in a less marked degree than in
Scudamore's cases. Of eighty patients sufiFering from
acute or chronic gout, thirty-four^ attributed the disease
to its influence, and in forty-six, the malady seemed to
have been acquired. Among my gouty hospital patients,
^0 per cent, could establish an hereditary predisposition
to the disease ; but when the cases which have occurred
in private practice are included, a still higher per-centage
is obtained. From a somewhat rough estimate made
from some thousands of the latter I am of opinion that
nearly 75 per cent, inherited the disease from their parents
or grand-parents.

On the other hand, experience has convinced me that
in this country gout is frequently acquired even at a
moderately early age, for in many most inveterate cases
not the least hereditary influence could be discovered.
Heberden relates an instance of a female who suffered
from gout to such a degree as to have numerous sores
from chalk-stones, and yet the diwsease had never been
heard of among her relations, and several cases of a simi-
lar kind have come under my own observation. One
patient, a female, only thirty-nine years of age, who
suffered most severely from chalk-stones, could trace no
predispositi6n in any member of her family ; and another
female, even more crippled, could only ascribe the disease



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210 CAUSES OF GOUT,

,to the large quantities of port wine she had been in the
habit of drinking. On the other hand there is ample
proof of the fact that the children of gouty parents are,
cceteris panhus^ more liable to gout than those who have
no such descent.

A few years since, I was consulted by a gentleman
labouring under a severe form of gout Avith chalk-stones,
and, although not more than fifty years old, he had
suffered from the disease for a long period. On inquiry
I ascertained that for upwards of four centuries the eldest
son of the family had invariably been aflSicted with gout
when he came into possession of the family estate.

It would be needless to dilate further on this subject,
as all who have had an opportunity of becoming con-
versant with the history of this malady must be fully
convinced that hereditary predisposition plays no unim-
portant part in its development.

It is a common opinion, and one with which from my
own experience I should be inclined to agree, that gout
appears earlier in life when hereditary predisposition
exists, than when it is acquired. Scudamore held the
same view, but found, on putting the question to the test
by the examination of 214 persons who had gout in a
very severe degree, that although the influence of here-
ditary predisposition was well marked in causing the
appearance of the disease at an earlier period of hfe,
still it was by no means so strongly shown as he had
previously supposed. In a table drawn up by Patissier
in his report on the use of the mineral waters of Vichy in
the treatment of gout, the mean age of thirty-four cases
of hereditary gout was thirty-four years, the extremes
being thirteen and sixty years ; whereas in forty-three
cases of acquired gout, the mean age was thirty-eight
years, the extremes being twenty-seven and fifty years.



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HEREDITARY FRE DISPOSITION, 211

Although I have seen many patients suffering from
gout in somewhat early life who could not trace it in
any branch of their families, these cases have been all
satisfactorily explained by their habits of life, and I do
not remember a single instance of its occurrence in
youth where no hereditary tendency existed.

In concluding the discussion of this point, it may be
well to relate the particulars of a case illustrating the
fearful influence of hereditary taint which has recently
come under my notice ; the history is very remarkable.
The patient is a gentleman, 48 years of age, whose
health has been good with the exception of attacks of
gout which commenced at the age of 36, in one great
toe ; for the first few years he had about three or four
fits each year, confined to the feet, but the knees and
upper extremities were soon implicated, and the attacks
became more frequent and more prolonged, and now he
is scarcely ever free from them. About 10 urate deposits
are seen on the left external ear, and 8 on the right, a
moderate amount of chalk-stones about the hands and a
considerable quantity around the heels ; these latter have
often discharged. The urine is pale, has a specific
gravity of 1016, but there is no albumen. No fresh
gouty symptoms were present at the time of his visit.
As far as hereditary influence is concerned it may be
thus summed up : the father had very severe gout, the
mother, when 70 years of age, began to sufier from it ;
he has had six brothers, of whom one died of very severe
gout, and was crippled from chalk deposits in both upper
and lower extremities; another had severe gout and
chalk-stones and died of albuminuria; these two had been
under my care ; a third had gout and paralysis, of which
he died; a fourth had gout, and died of erysipelas ; a fifth
died of gout compUcated with some urinary affection;

p 2



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212 CAUSES OF GOUT.

and a sixth is alive, but suffers from gout in the same
way as the patient himself.

Influence of sex upon the occurrence of Gout — ^That
women are less subject to gout than men is beyond
doubt ; at the same time the aphorism of Hippocrates,
**Mulier podagra non laborat nisi ipsi menstrua defe-
cerint," although possibly correct at the time it was
written, certainly does not hold good now ; but even at
the present time, gout in its regular and developed form
is comparatively rare among females. The reason of-
the immunity enjoyed by the female sex will not be
difficult to understand, when we have fully discussed
the many predisposing and exciting causes which tend
to its development ; for we shall find that women, from
the different character of their habits, are much less
exposed to these influences; besides which, a most
powerful counteracting influence exists in the presence
of the catamenia during a considerable portion of their
lives ; exceptions however are sometimes met with, and
I have seen patients in whom, at the time of pregnancy,
the great toe and other joints have been severely
attacked.

In the degenerate times of the Roman Empire, when
ladies gave themselves up to every kind of licentious-
ness, they appear, from Seneca's account, to have become
the subjects of acquired gout equally with men; but in this
country gout in the female is most commonly inherited.

In women, gout is more prone to assume an asthenic
form, and to exhibit its masked and irregular manifesta-
tions ; it is also most liable to appear shortly after the
-cessation of the menstrual discharge.

In the French table before referred to, in 80 cases of
gout, 78 of the patients were men, and only 2 women,



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INFLUENCE OF SEX. 213

and my own experience quite accords with these results.
The influence of sex on the occurrence of gout is so great
that it becomes a diagnostic mark between gout and
rheumatism, for the latter disease is perhaps more fre-
quent among women than men.

Influence of age upon the occurrence of Gont. —
Youth, for the most part, enjoys immunity from gout.
Hippocrates expressed his opinion on this subject in the
following aphorism : — " Puer podagra non laborat, ante
veneris usum ; *' and Sydenham states that he had never
seen either gouty minors or children; the most that
he had observed was the slight foreshadowing of a
fixture attack in the younger branches of gouty families.
Heberden, again, never knew a certain case of gout
before the age of puberty. On the other hand, instances
are related in which gout is said to have occurred in very
young children, but I am of opinion that in many of these
cases considerable doubt may be entertained as to the
correctness of the diagnosis, for in young subjects other
joint affections, such as rheumatism and more especially
rheumatoid arthritis, may readily be mistaken for gout.

The period of the first attack was noted by Sir C.
Scudamore in 515 cases, and the results of his inquiry
are seen below : —

At the age of eight 1

„ twelve 1

y, fifteen •!

„ sixteen 1

,, seventeen 1

„ eighteen 6

,, nineteen 8

Between twenty and twenty-five years of age . . 57

twenty-five and thirty ,| . . 85

thirty and thirty-five „ . . 105

thirty-five and forty „ . . 89

forty and forty-five „ . . 64

forty-five and fifty „ . . 64



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214 CAUSES OF GOUT.

Between fifty and fifty-five years of age . . .26
„ fifty-five and sixty „ ... 12

„ sixty and sixty-five „ ... 8

At the age of sixty-six 2

C15



Scudamore, in alluding to the above table, remarked
that he had not himself witnessed many examples of a
first attack of gout before twenty, nor any after sixty-six.

It will be observed from the above, that in by far the
majority of cases, gout makes its appearance in adult
age, after the growth of the body is complete, and
before the powers begin to decline; when the age is
measured by decennial periods, the greater number of
cases are found to occur between the thirtieth and
fortieth year.

Between genuine gout and rheumatism, or rheumatic
fever, a marked distinction is seen in the age at which
they appear ; for while a first fit of the former seldom
occurs before thirty-five, the earliest attacks of the
latter are rarely delayed till that age.

Some years since I was called upon to treat a first
and only attack of the disease, in a gentleman at the
age of seventy. The patient was suffering from valvular
disease of the heart, with dyspnoea and anasarca of much
severity. Early one morning, and at a time when there
was scarcely any anasarca, the ball of the left great toe
became hot, swollen, and painfiil ; after a few days the fit
passed on in the usual manner, and was succeeded by
desquamation of the cuticle. During the time the gouty
symptoms were present, marked relief in the breathing
was experienced.

I have known several cases in which the first attack
occurred after seventy years of age. In 1866 I attended
a lady, then in her ninety-first year, who was labouring



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INFLUENCE OF AGE. 215

under a first attack of gout in the great toe : this lady
had up to the age of eighty-seven been active in her
habits, but for a year or two before the seizure had been
kept ahnost entirely to her bed. I have recently seen
several cases in which the patients were nearly eighty
years of age ; one, a gentleman with strong inherited
tendency to gout, but in whom it had probably been
delayed by residence at Gibraltar for forty years.

A late Bishop of Durham' experienced a first attack of
gout at the age of ninety, but although congratulated by
his friends and assured that it would be the means of
prolonging his life many years, he only lived to ninety-
two ; when about twelve years old this gentleman had the
operation for lithotomy performed upon him. .

On the other hand I have seen gout in comparatively
young subjects ; for instance, I was consulted some years
since by a young gentleman, only seventeen years of age,
just recovering from a second attack of gout in the left
great toe ; his first fit had occurred about twelve months
previously m the same joint. In this instance the influ-
ence of hereditar}'' predisposition was very strong, both
father and mother and many other members of his family
on each side having suffered from tlie malady.

Sev.eral patients have informed me that they had ex-
perienced distinct attacks of gout at very early ages,
when they were pupils at the public schools ; one gentle-
man, now a severe sufferer from gout, assures me his
first attack occurred at nine, his second at twelve years
of age.

A little girl not quite ten years of age once came
under my care, whose case is somewhat remarkable.

When only seven years of age, the right great toe ball
became suddenly swollen, red, and painful ; it was sup-
posed that this must have arisen from some sprain ; her



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216 CAUSES OF GOUT.

general health was not good at the time ; two years after^
wards, she had a very slight return in the same joint.
About nine months after this a third attack came on^
much more severe, and extending over the arch of the
foot. There was also a slight eruption of psoriasis on
the legs. At the time when I first saw this patient a
fourth attack had commenced, and the great toe was hot
and shining, the rest of the foot being cool; desquamation
of cuticle occurred subsequently. The urine at 8. a.m.
had a specific gravity of 1020 and was free from albumen ;
it frequently became thick on standing, especially about
the time of an attack. The child was rather anaemic.

Dm'ing the next twelve months she had three or four
attacks, implicating for the first time one knee, then one
hand. No beer or wine had been taken, in fact no alco-
hol in any shape. On enquiry it was found that there
was only slight hereditary predisposition to gout : on the
father's side one great uncle, on the maternal side a
great grandfather and several great uncles had suffered
from the disease, but not her grandfather ; her mother
had occasionally slight threatenings in the toe.

Another less marked case came under my care in 1866,
in a child under eight years of age, who within the previous
year had two attacks in one ankle ; the first induced by a
slight injury, the second occurring without any known
cause. This child inherited gout from her father, who
had it severely, and from her mother's family.

Influence of tempei^ament or constitutional peculiarity
on the development of Gout. — It must be remembered
that the ancients, from the time of Hippocrates, held
the opinion that there existed four kinds of humours
in the human body, — blood, bile, black-bile, and phlegm,
and that, as one or other of such humours was present



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INFLUENCE OF TEMPERAMENT. 217

in excess, the individual was said to be of a sanguineous,
bilious, melancholic, or phlegmatic temperament. These
terms, though still employed in medicine, are used with
little precision, and much reliance cannot be placed upon
the indications they are supposed to give. The term
"nervous temperament'' is also occasionally employed,
to characterise a peculiar irritable state of the nervous
system.

With regard to the influence of the so-called tempera-
ment upon the occurrence of gout, I have little informa-
tion to offer, having derived nothing satisfactory from
my own observation, and having met with the disease in
individuals presenting every variety of bodily conformation.
In general terms it may be said that acute sthenic gout
occurs most frequently in subjects of a sanguine tempera-
ment, and those inclined to corpulency; whereas the
asthenic and irregular forms are usually seen in indi-
viduals of a nervous temperament and spare habit of
body.

Dr. CuUen made the following observations on the
influence of temperament : — " If, with the ancients, we
might define by certain terms the temperaments of men,
I could say that the gout attacks especially men of a
choleric-sanguine temperament, and that it seldom at-
tacks the pure sanguine or melancholic. It is, however,
very difficult to treat this matter with due precision."
And in another place he says, "It attacks especially men
of robust and large bodies, men of large heads, and of
full and corpulent habits, and men whose skins are
covered with a thick rete mucosum, which gives a
coarser surface.''

Influence of fermented qnd distilled liquors in inducing
Gout. — There is no truth in medicine better established



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218 CAUSES OF GOUT,

than the fact that the use of fermented liquors is the
most powerful of all the predisposing causes of gout ;
nay, so powerful, that it may be a question whether gout
would ever have been known to mankind had such
beverages not been indulged in.

A considerable difference, however, exists between the
various fermented liquors in their power of inducing
gout, and many interesting observations and facts can be
elicited in relation to this point.

On the first consideration of the question, it would be
natural to suppose that, as the chief peculiarity of all
fermented liquors consists in the alcohol they contain,
their power of causing gout would be in proportion to
the quantity of spirit in their composition, but a more
careful investigation of the subject fails to establish this
supposition. Distilled spirits, when exclusively taken,
appear to exert little or no power in inducing gout,
whereas wines, strong ales, and porter, are potent
agents, a fact which is forcibly impressed on the mind on
taking a review of the prevalence of the disease in differ-
ent countries and among different classes of individuals.
In Scotland gout is much less frequently met with than
in England, and I have been assured by physicians in
that country that they very seldom see a case, and when
it does occur it is generally in the upper classes of
society and in large cities, where wines and ales have
been largely substituted for whisky. Dr. Gregory, at
the Royal Infirmary of Edinburgh, had only two cases of
gout in two thousand two hundred clinical patients ad-
mitted under his care, and Dr. Hamilton, during nearly
thirty years, had likewise but two such patients. Sir
Robert Christison bears similar testimony, for he informed
me that he had only met with two cases of gout in the
Infirmary, although physician to it for thirty years, and



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INFLUENCE OF ALCOHOLIC DRINKS, 219

both the subjects were fat and overfed English butlers.
The same freedom from gout is enjoyed in other Scotch
cities, as Glasgow and Aberdeen, as likewise in Ireland,
where whisky is the principal beverage ; and Russians,
Poles, Swedes, and Danes, who usually drink distilled
spirits, also enjoy comparative immunity from gout.

Van Swieten states that in Holland gout was but
little known until wine was introduced as a substitute for
small beer ; and Linnaeus, from his observation upon the
habits of the Laplanders, was inclined to regard wine as
almost the sole producer of gout, as the people partook
of malt liquors with impunity.

These statements of Van Swieten and Linnaeus merely
render it probable that wine is more powerful in pro-
ducing gout than the beer drank in those countries; we
shall soon, however, have occasion to show that malt
liquors, more especially the stronger varieties,, are most
potent predisposing agents.

There are many instances on record which illustrate
the relative powers possessed by spirits, wines, and malt
liquors, in this respect. Scudamore gives an account of
two ; the first was a strong and corpulent man, about
30 years of age ; in the earlier part of his life he had
been constantly on the sea coast as a smuggler, and had
drunk two or three pints of Hollands a day ; this habit
was continued during a period of four or five years, with-
out further result than to make him somewhat nervous
and dyspeptic. He afterwards became a bricklayer, and
being possessed of property, indulged both in wine and
porter, and in two years afterwards was attacked with
gout.

In the second instance the patient lived in the country
until he was 28 years of age, and partook freely of
Hollands. He then engaged himself as a butler in



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220 CAUSES OF GOUT.

London, indulged freely in wine and malt liquors, and at
the age of 35 had gout, which returned in each year.

In neither of the above mentioned cases did the
slightest hereditary predisposition exist ; but in relation
to them it may fairly be urged that along with the
change from spirits to malt liquors and wine, there was
considerable alteration in the occupations of these
patients, and that they were approaching the age at
which gout commonly manifests itself.

A striking example, illustrating the same fact, is
recorded by Dr. William Budd, who states that, " There
is a body of men employed in the Thames, whose occupa-
tion it is to raise ballast from the bottom of the river ;
as this can only be done when the tide is ebbing, their
hours of labour are regulated by this circumstance, and
vary through every period of night and day. They
work under much exposure to inclemencies of weather ;
their occupation requires great bodily exertion, occa-
sioning profuse sweating and exhaustion. In considera-
tion of this, their allowance of liquor is very large ; each
man drinks from two to three gallons of porter daily,
and generally a considerable quantity of spirits besides.
This immoderate consumption of liquors forms the only
exception, as far as relates to food, which these men
offer to the general habits of the lower classes, and,
although not a numerous body, many of them are yearly
admitted to the Seamen's Hospital Ship affected with
that disease (gout)/' This very interesting fact seems
to show that no amount of bodily exertion is adequate to
counteract the influences of such large quantities of
porter. These men are almost all derived from the
peasantry of Ireland, and can rarely or never inherit a
disposition to gout.

My own experience of the relative power of alcoholic



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INFLUENCE OF ALCOHOLIC DRINKS. 221

liquors in inducing gout, may be thus stated : port,
sherry, and other stronger varieties of wines ordinarily
drunk in this country, are most potent in their operation ;
but the fact must not be lost sight of, that those who
are in the habit of drinking wine, are, at the same time,
able to procure other luxuries of the table, which greatly
favour the development of the disease. A few years'
liberal indulgence in port or sherry wine will often of
itself produce gout, when no hereditary tendency exists ;
and even among the labouring classes this may be
occasionally observed, when, from the peculiar nature of
their occupations — as in the case of cellarmen, and wine-
bottlers, &c. — men have an opportunity of taking wine
in considerable quantities.

The lighter wines, as claret, hock, and moselle,
although capable of acting as the exciting cause of an
attack in gouty subjects, have, when taken in modera-
tion, but comparatively little inducing power, and in
this respect rank with the weaker kinds of malt liquors.
The wine-drinking population of France and Rhenish
Germany are but little aflBicted with gout, and the same
remark holds good of our own agriculturists ; but
when the finer qualities of these wines are freely par-
taken of, especially if combined with excess of animal
food, gout is by no means tardy in manifesting itself.
In some of the larger cities of France and Germany gout
is common, although considerably less so than in Eng-
land, and in Bavaria and Berlin, where a large amount
of beer is drunk, gout also prevails.

Champagne differs much in its effects; probably, if
very dry, it would not act so powerfully as a predisposing
cause as port or sherry, but it is certain it is often a
most active exciting cause of an attack.

Dr. Wood, of Philadelphia, whose opinion I asked on



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222 CAUSES OF GOUT,

this subject in 1862, says that the stronger wines, as
sherry, madeira, and port, have appeared to him to be
the most proUfic source of gout in the States, and that
since the lighter wines had been in more general use,
he thought there had been a decided diminution of gout ;
he was quite certain that the excessive use of malt
liquors led to the disease.

Stout and porter rank next to wine in their power of
inducing gout, and some of the most severe and invete-
rate cases I have ever met with in hospital practice
have been in patients who had drunk heavily of these
beverages; as happens, for example, among the men



Online LibrarySir Alfred Baring GarrodA treatise on gout and rheumatic gout (rheumatoid arthritis.) → online text (page 17 of 48)