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THE EEGIMEN



TO BE ADOPTED



IN CASES OF GOUT



THE REGIMEN



TO BE ADOPTED



IN CASES OF GOUT



Dr. WILHELM EBSTEIN

PROFESSOR OF CLINICAL MEDICINE IN GOTTINGEN



TRANSLATED BY

JOHN SCOTT, M.A., M.B.

HONORARY PHYSICIAN, MANCHESTER SOUTHERN HOSPITAL FOR DISEASES OF
WOMEN AND CHILDREN




LONDON

J. & A. CHUECHILL

11, NEW BURLINGTON STREET
1885



PKEFACE.



The object of this treatise is almost entirely practical, It
gives a description of the mode of living which I consider
necessary not only for the actual victims of gout, but for
those who have inherited a disposition towards the disease.
Scientific questions are only entered on to the extent that
is necessary to secure a foundation for my propositions. In
the additions and explanations which are appended to the
text, I have expanded and completed, in the light of further
investigations, some questions which have been already dis-
cussed in my monograph on "The Nature and Treatment
of Gout."

WlLHELM EBSTEIN.
Gottingen, December 20th, 1884.



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TKANSLATOK'S PBEFACE.



I have translated this little work at the request of Professor
Ebstein, and while abridging it slightly in some places, have
striven to omit nothing that might interest English readers.
The decimal system, in which the weights and measures of
the original are given, has been retained in the translation
as being more suitable for comparisons of figures, but I trust
the day is not far distant when we shall see this system
universally adopted.

John Scott,

Manchester, April 9th, 1885.



THE REGIMEN TO BE ADOPTED
IN CASES OF GOUT.



While the question whether, and to what extent, the use of
pharmaceutical remedies and the application of other methods
of cure are of service in gout,(i)* has been a subject of the
liveliest controversy for ages, and we are not yet in a position
to say the final word on the subject, there has been for an
equal period not the least doubt that a judicious method of
living has a very powerful influence both in preventing the
disease and in modifying its course. Knowledge of this fact
was based, in the first instance, neither on purely theoretical
hypotheses as to the causes and nature of gout, nor on the
analysis of detailed clinical observations, but on the universal
perception of the fact that gout, cceteris paribus (in the same
country and amongst the same race), has a greater number of
victims in proportion as strictness and simplicity of life have
been abandoned in favour of luxury and effeminacy. As
early as the first century after Christ, Seneca pointed out
that the surprising increase of gout in Eome was a conse-
quence of increased luxury in living, and adduced as sufficient
proof the frequent occurrence of gout in the female sex.
Women, in fact, who in his time were not behind men in
licentiousness of life, were attacked by gout themselves ;
whereas in the time of Hippocrates, when they lived a simple
and modest life, they were spared its onsets. Areteeus of
Cappadocia (60 or 90 a.d.), the greatest physician since the

* These figures relate to the additions and illustrations at the end of
the work,

B



2 THE REGIMEN TO BE ADOPTED

time of Hippocrates, in his model description of the symptoms
and course of gout, still further developed the statements of
Seneca as to its causes. But both by Aretaeus and Ccelius
Aurelianus (in the third century after Christ) stress was laid
on the hereditary nature of gout, and the conviction gradually
made its way that luxuriousness of life was not the sole
factor in its production. The hereditary nature of gout
is duly insisted on in the writings of Sydenham, Boerhaave,
and Frederick Hoffmann. We read in Van Swieten's " Com-
mentaries on Boerhaave's Aphorisms," that the gouty subject
almost always begets gouty subjects ; that hereditariness has
actually a greater significance in the case of gout than in any
other disease ; and that he has observed boys afflicted with
the same disease as their parents. Apart from Cadogan, who
denied the hereditariness of gout, alleging that if this were
the case all the offspring of a gouty person should suffer
regularly and without exception from the disease, all other
observers have placed hereditariness in the front rank of
predisposing causes. There was really little need of Falconer's
refutation of Cadogan, for, long before the latter wrote, precise
ideas prevailed on the question of heredity. It was known
that the grandchild of a gouty subject might be the victim
of gout, the disease sparing the intermediate generation. J.
Hutchinson communicated a matter of fact which is of import-
ance in connection with the hereditariness of gout, namely,
that an individual runs a danger of contracting gout in
proportion as the gouty process is developed in the parent.
Thus, the elder members of a family may escape the disease,
whereas the younger, born at a time when the parent is more
and more under its influence, may show traces of it very
early. We may with confidence support the principle that
hereditariness is at least as important a factor in the produc-
tion of gout as is excess of eating and drinking combined with
inactivity of life ; for excesses we may avoid, but hereditary
influences we cannot escape. Sir William Temple is perfectly
right when, in his well-known work on " Health and Long Life,"
he says that the first condition lies in the strength of our race
or the surroundings of our birth. The ancients have given
concise expression to the same idea in their proverb, " Gau-



IN CASES OF GOUT. 6

deant bene nati," as quoted by Temple; while in our own
times we have a humorous appreciation of it in the saying,
" We cannot be too particular in the choice of our ancestors."
But in speaking of the hereditary transmission of gout, we
must remember that the disease does not show itself in all
the members of a family, nor is it propagated from father to
son, and thence to grandson, in a direct line. We must not,
then, expect to find the symptoms showing themselves soon
after birth, as we do in the case of syphilis. I have never
seen any cases of congenital gout, and we know that the
symptoms of gout, though somewhat more frequent than is
generally supposed, yet are comparatively infrequent in
youth. As a parallel example to those which I have men-
tioned in my book on gout, I may add one which I owe to
the kindness of my colleague, Eosenstein, of Leyclen. The
case was that of a boy ten years old. This is the only case
of gout at an early age that Eosenstein has observed in a very
extensive clinical experience of the disease.

Gout is not infectious ; still less is it contagious. For
all that, contagion has played a certain part in the history
of this disease. We read in Van Swieten's " Commen-
taries on the Aphorisms of Boerhaave," who was the first
to defend the view of the com m unicability of gout, " I have
observed that women of good family, who lead a regular life,
contract gout from gouty husbands." That women under
such circumstances do occasionally contract gout is certainly
correct, but such cases are far from establishing the conta-
giousness of gout. Cases of this nature are much more
easily explained from our modern standpoint, that even
good family and the most regular life cannot get the better
of an innate gouty disposition. Boerhaave's view, however,
found a number of supporters. Joseph Von Quarin (1734-
1814), body -physician to the Emperor, went so far as to
produce observations showing that even dogs which shared
the couch of a gouty master might contract the disease
through the emanations from his body. In the course of
time the belief in the contagiousness of gout gradually wore
out. In more recent times, Von Vering is the only one
whom I have found maintaining that gout may be com-

B 2



4 THE REGIMEN TO BE ADOPTED

niunicated through perspiration, clothes, or the occupation
of a common bed. Yet in the Prussian Sanitary Eegulations
of 8th August, 1835, we find gout classified as a con-
tagious disease, along with bad forms of scab of the head,
cancer, and consumption. In the case of gout the beds
used by the patients had to be disinfected, and articles of
clothing, including stockings and boots, to be destroyed. As
this regulation is still in force, this short excursus may be of
service in reminding us of its existence, although from our
modern point of view it is a mere curiosity.

Still more recently a further etiological factor has been
adduced as giving an impetus to the origin and development
of gouty symptoms, viz., lead-poisoning. A satisfactory con-
clusion is still far from being attained on this point; for,
granting that in those lead-workers who suffer from uric
acid gout we cannot, as a rule, look to heredity, much less
to luxury of life, for the explanation of the gouty process, yet
the scientific material at our disposal will by no means prove
that lead-poisoning alone (i.e., without the presence of a
disposition to gout, (2) which we shall soon subject to closer
examination) can develop the gouty process.

We have accordingly, up to this point, learnt to recog-
nize only two factors as of importance, viz., heredity, and
luxurious riving combined with idleness. The first alone was
recognized as a determining cause by single observers such
as Cullen and Hamilton. But as we can have no prophylactic
measures against heredity, these must be confined to warning-
gouty patients against all excesses, and inculcating upon
them exceptional moderation and abstinence. This precept
we meet with in all directions, both old and new, as to the
mode of living to be adopted by the gouty. It came to be
seen that the ultimate cause of gout could not consist merely
in luxurious living, for it was found that people occasion-
ally suffered very severely from the disease, although they
were anything but luxurious in their living, and might even
be distinguished for activity and industry ; and in the second
place, numerous persons could be seen leading a life of luxury
without ever suffering from gout. Hence commenced a
search for the ultimate cause of gout. How long a search it



IN CASES OF GOUT. O

has been ! and what is there that has not been blamed for the
gout ? (3) The outcome of these endeavours was a number
of special prescriptions on the mode and scheme of life,
by means of which the ultimate cause was supposed to be
conquered. These prescriptions underwent manifold modi-
fications and changes according as the views of individuals
changed about the ultimate cause. Xo real advances were
made in scientific knowledge. An exaggerated specialization
was in vogue, which, starting from unsound premises, never
hit the right path, and too often neglected the interest of the
patient in vain contests over the materies morbi. Along with
a special anti-gout diet, numerous pharmaceutical and other
remedies were employed to neutralize the gouty poison. It
does not lie within the compass of this essay to expound
these, or to follow their historical development ; but it may be
of interest to make a few remarks on the treatment of gout by
so called secret remedies, the more particularly as in a disease
like gout, which is characterized by a chronic course and
lengthened remissions, a wide door is opened for quackery
and unscrupulous puffing. A system of puffing may indeed
vindicate itself by producing cases where favourable results
have been obtained by the remedy employed; but it is
unfortunately too easy for it to plume itself with results that
are not to be ascribed to the remedy, and it is easy enough
to fool credulous patients. This charlatanism is not a pro-
duct of our time, but even centuries ago boldly raised its
head under the mask of science. In the middle of the
seventeenth century, when the tartarus of Paracelsus (1493-
1541) was still regarded as the final cause of many severe
illnesses — when this saline earthly entity, which Paracelsus
called tartarus, " because wherever it penetrates it burns
with hellish pains," was considered to be the product of
defective digestion, and more particularly to be the materia
peccccns of gout — J. Zipffell, of Leipzig, advertised his remedy
for gout. This he did in a book dedicated to John George,
second Duke of Saxony, Julich, Cleves, and Berg. His " Medi-
camentum Antipodagricum " was "a spirit warranted to seize,
resolve, and precipitate the Materia, Tarta/rea, to carry off and
out the disease bit by bit, and all for hard cash." A worthy



6 THE REGIMEN TO BE ADOPTED

companion to this same gentleman was M. Le Febure, of
Bochelle, who asserted that, through the grace of God Him-
self, the remedy for gout had been revealed to him ; but he
was very anxious to dispose of the revelation for a pecuniary
consideration, as his book on the subject (1720) shows.

Coming nearer to our object, which is to establish rules for
the guidance of those who suffer from gout, or who are pre-
disposed to it, we shall best fulfil our task by looking at the
subject from two points of view. (1) We must sift entirely
the results of medical experience; and (2) we must bring
our scientific knowledge of the nature of gout to bear on its
therapeutics and prophylaxis. In this last respect we stand
upon firmer ground than our predecessors, and however many
gaps there may be in our knowledge, yet we have enough
of it to give us many a useful hint. Even although here,
as in so many other domains of medicine, our advances in
scientific knowledge are not accompanied by corresponding
advances in remedial measures, yet it would be a great mistake
to undervalue our knowledge. It is only by keeping our
eyes steadily fixed on the goal we wish to reach that we shall
ultimately find the means of attaining all that may be
possible ; for in gout, at any rate, we ought not to trust to any
lucky chance putting us in the way of discovering specific
remedies.

We look nowadays for the materia peccans of gout in uric
acid. It was a long time, however, before this knowledge
became widely disseminated. After the investigations of
Wollaston, Tennant, and Fourcroy, towards the end of last
century, had already shown that gouty concretions contain
uric acid, and when the notion was not far off that there
might be a bond of union between gout and uric acid, C.
Scudamore, in his well-known and serviceable book, published
in the second decade of this century, maintained that gouty
concretions occurred so seldom and in so few individuals that
it was impossible to build a theory upon them, still less
to look for the ultimate cause of gout in them. The sure
natural basis was again abandoned, and vague unripe theories,
which would not ally with definite conceptions, took its place.
Thus we see S. A. Turck putting forth the view that gout



IN CASES OF GOUT. 7

was founded on galvanic life, and had its origin in a morbid
electro-chemical process ; and Eeichel, a physician attached to
the baths at Steben, starting from analogous considerations of
the polarity of mineral waters, sought to bring into vogue his
galvano-electric chains of pure gold ore. Meanwhile even
investigators of repute could not reconcile themselves to the
uric acid theory. The want of actual data as to the influence of
uric acid upon gout, and the complete stagnation of pathological
investigation in this respect, explain to us how Henle, in
1847, regarded the deposition of uric acid as something acci-
dental, and sought for the origin of gouty inflammation in an
internal, perhaps central, affection of the nerves. Henle thus
championed views in his time which have again been revived
by Duckworth and others, even at the present day, when we
are in the possession of new and weighty facts pointing to
the influence of uric acid upon gout. The latter observer
regards gout as a tropho-neurosis, which is either primary and
congenital, or secondary and acquired through a blood-poison-
ing ; but, as a matter of fact, I maintain that all the nervous
symptoms which are observed in gout are to be regarded not
as causes, but as consequences of the uric acid.

It is incomprehensible to me how any one can ever again
fall back on such unsatisfying theories as these.

We owe an actual advance in our knowledge of this
subject to A. B. Garrocl, who, in his work on Gout, in 1859,
was the first to show that urate of soda is present in
abnormal quantity in the blood of gouty patients. Still,
highly as we must estimate the proof given by Garrocl, there
was not enough of material brought forward to satisfy the
demands which Henle, in his " Rational Pathology," had justly
required as a preliminary condition for a physiological history
of gout. From the facts adduced by Garrod, the conclusion
could not really be drawn that the symptoms of gout are
a necessary consequence of uric acid, i.e., really come into
existence under its influence. With the view, therefore, of
working out a physiological history of gout, I published my
monograph on " The Nature and Treatment of Gout," in
which I endeavoured to establish the proof that uric acid is a
chemical poison, which can cause not merely inflammatory



8 THE REGIMEN TO BE ADOPTED

but also necrotizing and necrotic processes in animal tissues.
I succeeded in establishing, by anatomical investigation of
gouty organs, that the only typical appearance in gout was
that of elements undergoing necrosis or already necrosed.
These were found by me not merely in the hyaline joint-
cartilages of gouty subjects, and in the rest of the so-called
connective tissues (I examined the fibro-cartilages, the
tendons, and the loose tissue beneath the skin and between
the muscles), but also in the kidneys. Among the manifold
anatomical changes which may be induced in the kidneys by
gout, this was recognized as the only actual and characteristic
appearance. The formation of these foci of necrosing and
necrosed elements follows directly from the fluid parenchyma
being exceedingly rich in neutral urate of soda, and stagnating
in the affected parts. The separation of crystallized urates
in the affected tissues is the secondary process, and only
follows after the tissue has been completely destroyed by the
uric acid. This deposition of the crystallized acid combina-
tions of uric acid does not follow, in my opinion, from the
fluids undergoing an alteration of their reaction in gout, in
consequence of which the neutral urates would be changed
into acid — for in that case we should constantly see these
depositions in very many places of the gouty organism, — but
simply from the fact that through this local necrosis an acid
reaction ensues of the affected tissues, in which the neutral,
easily soluble uric acid combinations circulating in the blood are
changed into the less soluble acid salts of uric acid, or even
into uric acid itself. This change is an easy one, because the
combinations of uric acid with the alkalies are very unstable.
In the typical gouty foci that arise in this way — that is to say,
necrosed tissue with deposition of crystallized urates, or
ultimately of uric acid itself — calcareous salts may be subse-
quently deposited, just as in other dead tissues. In the
neighbourhood of the typical gouty foci there is generally
developed early a reactive inflammation of greater or less
extent. Matters may remain permanently in this condition —
that is to say, no urates are deposited — if the uric acid accu-
mulation is too insignificant to cause necrosis of the tissues.
In order to establish the deleterious effect of uric acid upon



IN CASES OF GOUT. i*

the tissues, I found it necessary to have recourse to experi-
ment, for the foregoing results, though based on anatomical
investigations, were always open to the objection that the
deposition of uric acid was accidental and non-essential, while
the real cause of the disturbance of the tissues might be
some nervous cause, tropho-neurotic or otherwise.

Experiments were accordingly made upon birds, healthy
cocks being selected for the sake of convenience. The
principal object of the investigation was to ascertain the
results of ligature of the ureter in these animals. I may
expressly state that these experiments were not undertaken
with the intention of producing artificial gout, but merely
to show the extremely pernicious effect of accumulation of
uric acid upon animal tissues. By the ligature of the ureter,
retention of the urine — which in birds is composed almost
exclusively of uric acid — is produced, and we are enabled
to produce with certainty in different tissues and organs of
these animals, as in the liver and heart, tissue-changes which
are analogous to the gouty accumulations observed in human
organs. There are developed, for instance, as the result of
ligature, not merely depositions of uric acid salts in the
tissues and organs of animals experimented on, but necrosis
can be demonstrated everywhere that the crystallized deposits
are formed. Besides this, there is set up a more or less
extensive reactive inflammation in the neighbourhood of
these experimentally-produced tissue-changes. It did seem
surprising in these experiments that in the kidneys of these
animals, in which accumulation of uric acid was specially
marked after the ligature, these necrosed patches should be
wanting. If we look at this fact from the teleological point
of view, it is not unreasonable to suppose that healthy
kidneys have a greater power of resistance than other organs
to the deleterious influence of uric acid. A further series of
experiments seemed to show that this hypothesis borders upon
certainty. Instead of tying both ureters of the birds, I pro-
cured complete retention of the uric acid by destroying the
secreting epithelium in the tubuli uriniferi of the cortex, and
the result was that I was able to demonstrate extensive depo-
sitions of crystallized urates, and eventually of uric acid, even



10 THE REGIMEN TO BE ADOPTED

in the kidneys of these animals. We possess such a means
for the destruction of the renal epithelium in the subcutaneous
introduction of chromic acid salts. These poisons penetrating
to the secreting structure of the kidney, destroy it ; and after
this is done we see, even in the kidneys of birds, the develop-
ment of patches such as were observed in the liver and other
organs when the ureters were tied. These experiments show
the correctness of the hypothesis that the healthy tissue of the
kidneys in birds has a greater power of resistance to the action
of uric acid than have, for example, the liver and muscular
structure of the heart. But as against the significance of
these experiments it might still be urged that, even although
uric acid is, as we have observed, the chief nitrogenous waste
product in birds, yet there may possibly be other substances
present in the urine, which, in spite of their insignificant
quantity, may interfere with the nutrition of the tissues.
Furthermore, it might be objected that in the organism of
these animals, damaged, as it was, by the ligature of the
ureters, or by the subcutaneous injection of chromic salts,
additional pathological processes might be at work causing
inflammation and necrosis. There was nothing for it but
to seek for the means of overcoming these objections.
The way was clearly indicated. I had to find out whether
even chemically pure uric acid and its combinations with
soda in the gouty foci displayed toxic qualities against
animal tissues. By using pure uric acid and its soda salt I
succeeded in constantly producing infiltration in the cornea
of a rabbit's eye. Similar experiments with urea, xanthine,
guanine, kreatine, kreatinine, and hippuric acid produced no
results, and there were equally no results in my control-
experiments with 5 per cent, solution of sodium phosphate.
It was thus proved that chemically pure uric acid and its
solution in sodium phosphate have a highly pernicious influence
on the nutrition of certain tissues. Supported by these facts,
we may therefore unhesitatingly assume that the gouty changes


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