Chapter III: Introduction: Of the Word “gout”

In the thirteenth century the Greek terms “podagra,” “chirargra,” etc., were to a large extent abandoned, and following Radulfe’s lead gave way to the use of the generic term “gout,” derived from the Latin “gutta.” Its adoption was doubtless traceable to the prevailing humoral views of the origin of the disorder, as due to some morbid matter exuding by “drops” into the joint cavities. Indeed, according to Johnson, the word “gut” was used as a synonym for “drop” by Scottish physicians even in his day.

In any case, the term found little difficulty in installing itself among all nations, taking in French the form “goutte,” in German “gicht,” in Spanish “gota,” etc. Trousseau thought it “an admirable name, because in whatever sense it may have been originally employed by those by whom it was invented, it is not now given to anything else than that to which it is applied.” In contrast therewith, that trenchant critic Pye-Smith complained of the laxity with which the Germans invoked the word “gicht.” He says it is popularly credited with all the pains which are called “rheumatics” in England. “Sometimes ‘gicht’ is nothing but bad corns and is rarely true gout.” Albeit, Pye-Smith did not, as we shall see later, hold even his English _confrères_ in this respect void of offence.

From these remote times onwards through the Middle Ages to the present day, an almost continuous series of historical records testify that not only has gout always been with us, but that its clinical characters throughout the ages have remained unaltered, conforming ever to the primitive type. During the seventeenth and eighteenth centuries many physicians, both British and continental, ventilated their views as to the nature of gout, all swearing allegiance to the old humoral pathology, notably Sydenham, Boerhaave, Van Swieten, Hoffmann, Cadogan, etc.

The English Hippocrates, as Trousseau christened the illustrious Sydenham, displayed his catholic outlook by the pregnant words: “No very limited theory and no one particular hypothesis can be found applicable to explain the whole nature of gout.” A live-long martyr himself thereto, he brought all the strength of his dominating intellect to bear upon its elucidation. As to its causation, he held it to be due to a “morbific matter,” the outcome of imperfect “coctions” in the _primæ viæ_ and in the secondary assimilating organs. He refrained from speculating as to the constitution of the _materia peccans_, but as Trousseau observes, “he made his _morbi seminium_ play the part which modern chemistry attributes to the products it has discovered. Take it all in all,” he says, “the theory of the great English physician is much more medical than the theories of modern chemists.”

EARLY VIEWS AS TO THE NATURE OF TOPHI

“Et tophus scaber, et nigris exesa chelydris Creta.”

_Georg._, ii., 214.

The word “tophus” or “tofus,” the Greek τοφος, seems to have been applied to rough crumbling rock, the disintegrated volcanic tufa. As to its constitution it is clear from the above quotation that Virgil evidently associated it with chalk, a shrewder guess than the fanciful hypothesis of Galen, though the views of Paracelsus (1493-1541) enunciated some centuries subsequently, were even more grotesque, a “mucous essence,” a “Tartarus” burning “like hell fire.”

Nevertheless, our contempt need be chastened when we recollect that, up to the latter half of the eighteenth century, equally weird assumptions found acceptance. By some “various excrementitial humours,” by others “checked and decomposing sweat” were deemed the basis of tophi.

A mucilaginous extract, derived from the solid and liquid intake, appealed to some as an explanation of their formation, while to others, tophi were compounds of subtle and penetrating salts.

But the later view, doubtless the reflex of _etiological_ hypotheses, was that tophi were of _tartareous_ nature, closely similar to that encrusting the interior of wine casks. Hoffmann declared that the _materies morbi_ actually was a salt of tartar circulating in the blood. His investigations of tophi and also of the stools, saliva, and urine of gouty subjects, convinced him that the peccant matter was tartar of wine.

Hoffmann’s views, however, were laughed to scorn by M. Coste as being obviously absurd, inasmuch as gout was not uncommon amongst those who had never partaken of wine, _ergo_, never of tartar. How infinitely more physicianly the inference of Sydenham, who, like some of the older humoralists held the tophus to be “undigested gouty matter thrown out around the joints in a liquid form and afterwards becoming hardened.”

So it went on until, alchemy being displaced by chemistry, uric acid was in 1775 discovered by Scheele, and in 1787 Wollaston established its existence in tophi, and to the further elaboration of our knowledge of this substance we shall allude later. Here we would only observe that Wollaston’s researches marked the coming substitution of the humoral and solidist theories by a chemical hypothesis as to the etiology of gout.

THE “HONOUR OF THE GOUT”

The absurd delusion, not wholly dissipated even to-day, that to have the gout, “Morbus Dominorum,” was highly creditable, a mark of good breeding, was firmly ingrained in our forefathers. We all recall the story of the old Scottish gentlewoman who would never allow that any but people of family could have _bonâ fide_ gout. Let but the _roturier_ aspire to this privilege, and she scouted the very idea—“Na, na, it is only my father and Lord Gallowa’ that have the regular gout.” As to the origin of this mistaken ambition, it most probably was the outcome of the fact that it was peculiarly an appanage of the great, the wealthy, and alas! those of intellectual distinction!

Statesmen, warriors, literary men and poets loom large amongst its victims. Lord Burleigh suffered greatly therefrom, and good Queen Bess on that account always bid him sit in her presence, and was wont to say, “My Lord, we make much of you, not for your bad legs, but for your good head!” With more humour, Horace Walpole complained, “If either my father or mother had had it I should not dislike it so much! I am herald enough to approve it, if descended genealogically, but it is an absolute upstart in me, and what is more provoking, I had trusted in my great abstinence for keeping it from me, but thus it is!”[3]

Of warriors, Lord Howe, Marshal Saxe, Wallenstein, and Condé were among its victims; while of literary men and poets thus afflicted may be mentioned Milton, Dryden, Congreve, Linnæus, Newton, and Fielding. Of physicians, the great Harvey was a martyr to gout, and was wont to treat it after the following heroic fashion. Sitting, in the coldest weather, with bare legs on the leads of Cockaine House, he would immerse them in a pail of water until he nearly collapsed from cold. Mrs. Hunter, wife of John Hunter, in a letter to Edward Jenner about her distinguished husband, dated Bath, September 18th, 1785, laments that “He has been tormented with the flying gout since last March!” In short, the disorder, with a notable frequency, figures in the life history of some of the ablest men in all ages, hence the complacency with which lesser men, often without good reason, affect to have the gout.

“But nothing,” as Sir Thomas Watson says, “can show more strongly the power of fashion than this desire to be thought to possess, not only the tone and manners of the higher orders of society, not their follies merely and pleasant vices, but their very pains and aches, their bodily imperfections and infirmities. All this is more than sufficiently ludicrous and lamentable, but so it is. Even the philosophic Sydenham consoled himself under the sufferings of the gout with the reflection that it destroys more rich men than poor, more wise men than fools.”

“At vero (quod mihi aliisque licet, tam fortunæ quam Ingenii
dotibus mediocriter instructis, hoc morbo laborantibus solatio
esse possit) ita vixerunt atque ita tandem mortem obierunt
magni Reges, Dynastæ, exercituum classiumque Duces, Philosophi,
aliique his similes haud pauci.

“Verbo dicam, articularis hicce morbus (quod vix de quovis alio
adfirmaveris) divites plures interemit quam pauperes, plures
sapientes quam fatuos.”

The Scotch at one time regarded gout as fit and meet punishment for the luxurious living of the English. But, as was pointed out, the cogency of the moral was somewhat spoilt by the fact that the disorder was found to exist even among the poor and temperate Faroe Islanders. In truth, although “the taint may be hereditary, it may be generated by a low diet and abstinence carried to extremes.”

THAT GOUT CONFERS IMMUNITY FROM OTHER DISORDERS

The fallacy that longevity and freedom from other maladies was ensured by gout was prevalent among our forefathers. In satire of this, one Philander Misaurus issued a brochure entitled “The Honour of the Gout,” and purporting to be writ, “Right in the Heat of a violent Paroxysm; and now publish’d for the common Good” (1735). “Bless us,” says he, “that any man should wish to be rid of the Gout; for want of which he may become obnoxious to fevers and headache, be blinded in his understanding, loose the best of his Health and the Security of his Life”; and forthwith in his zeal for the common good gives us the following invocation:—

“Blessed Gout, most desirable Gout, Sovereign Antidote
Of murdering Maladies; powerful corrector of Intemperance;
Deign to visit me with thy purging Fires, and throw off the
Tophous Injury which I may have suffer’d by Wine and Wit,
Too hard for the Virtue of a Devotee upon a Holy Festival.
But fail not thy humble Supplicant, who needs thy
Friendly Help, to keep his tottering Tenement in
Order: Fail him not, every Vernal and Autumnal
Æquinox.”

He quaintly suggests that Paracelsus, if he would ensure men against death, had but to inoculate them with gout. Gout, indeed, was held to be a jealous disorder, intolerant of usurpation by any other disease, recalling the remark of Posthumus to his gaolers:—

“Yet am I better
Than one that’s sick o’ the Gout: since he had rather
Groan so in perpetuity, than be cur’d
By the sure physician, death: who is the key
To unbar these locks.”

_Cymbeline._

Still the fallacy that gout was salutary died hard, and although it seems incredible, yet, Archbishop Sheldon is said not only to have longed for gout but actually to have offered £1,000 to any one who would procure him this blessing; for he regarded gout as “the only remedy for the distress in his head.” How ingrained the notion may be gathered from the fact that in the early part of the last century, M. Coste in his “Traité Pratique de la Goutte,” observed: “A popular error, which I wish to expose in a few words, is this prejudice, which has already lasted more than two thousand years, and which has reached even the thrones of princes, where the disease commonly shows itself, viz., that gout prolongs life (_que la goutte prolonge la vie_). This error,” says he, “has taken the surest method of introducing itself, by making flattering promises, by persuading its victims that there is a singular advantage in having gout, and that the malady drives away all other evils, and that it ensures long life to those whom it attacks.”

In like refrain, our own countryman Heberden deplores that people “are neither ashamed nor afraid of it; but solace themselves with the hope that they shall one day have the gout; or, if they have already suffered it, impute all their other ails, not to having had too much of that disease, but to wanting more. The gout, far from being blamed as the cause, is looked up to as the expected deliverer from these evils.” Such deluded views being prevalent, it is hardly a matter for surprise that misguided persons deliberately courted a “fit of the gout” by resorting to excess and intemperance.

But alas, while the initial visitations of gout, after their passing, may leave behind them a renewed sense of well-being, it is no less certain that, when once installed, the intervals of respite grow shorter and shorter. Crippledom grows apace, the general health breaks and untimely senescence overtakes the worn-out victim, and, as Heberden puts it, “that gout causes premature death, when all the comforts of life ...

‘Multæ formæ infortunatorum,
Meditatio pœnæ, et consuetudo,
Podagros miseros consolentur.’

_Lucian._

are destroyed, and the physical powers either insensibly undermined or suddenly crushed by an attack of paralysis or apoplexy, should hardly be reckoned among the misfortunes attending the disease.”

But for our encouragement it may be observed that not always does gout carry with it such a terrible Nemesis. “Gout is the disease of those who _will_ have it,” said a wise physician, and though the inbred gouty tendency may be so strong as to cast defiance at abstinence, yet it is by no means always so. A man may inherit gout, but he need not foster it by self-indulgence. Much less need he, as so often happens, acquire it by depraved habits of life. In no disease do sobriety and virtuous living ensure so great a reward. As Sir Thomas Watson long since said to those inheriting this unwelcome legacy: “Let the son of a rich and gouty nobleman change places with the son of a farm servant, and earn his temperate meal by the daily sweat of his brow, and the chance of his being visited with gout will be very small.”

“O fortunatos nimium, sua si bona norint
Agricolas!”

_Georg._, ii., 458.

GROWING INFREQUENCY AND ATTENUATION OF GOUT

So accurate and graphic were the clinical pictures of gout depicted by the ancient physicians that there is no doubt the gout of to-day conforms to the primitive type as met with among the Greeks and Romans. This certainly as regards the _arthritic_ phenomena of the disease; for in those remote ages little or no account seems to have been taken of its _irregular_ or _ab-articular_ manifestations. While disregard of the latter group renders more credible their claims as to the widespread prevalence of the affection, nevertheless, I think there can be no doubt that the frequency of _gout_ amongst the ancient Greeks and Romans was probably over-estimated.

Can it be questioned that a large percentage of the cases of gout in those bygone times consisted of undifferentiated _infective_ forms of _arthritis_. _Syphilis_ and _gonorrhœa_ must have existed then as now, and their _specific_ forms of _arthritis_, how easily confused with “rich man’s gout!” Surely too, they, like ourselves, must have suffered with states of _oral sepsis_, _pyorrhœa alveolaris_, etc., not to speak of _infective disorders_, with their correlated _arthritides_. In short, the _differentiation_ of arthritic disorders was then hardly in its infancy, and it is in light of this disability that we must appraise their clearly extravagant assertions as to the widespread ravages of gout in their day.

But passing to more recent times, there is little doubt that the classical type of _podagra_ is very much rarer to-day than, say, in the time of Sydenham. Indeed, it may be said to be becoming progressively infrequent. Thus, writing in 1890, Sir Dyce Duckworth tells us that some twenty-six years prior to that date, Sir George Burrows informed him that “he then saw fewer cases of acute gout than he was accustomed to see in his earlier practice.” It may be recalled, too, that Sir Charles Scudamore, in retrospect of his own experience, of still earlier date, was led to much the same conclusion. Moreover, not only is the disorder less frequent, but its virulence seems to have suffered attenuation, and this to a marked degree.

Again, Ewart, writing in 1896, observed that “goutiness” is becoming relatively more common than declared gout. This, he thought, by reason of the increasing attenuation in transmission of the “gouty” taint. In this, as well as the more mitigated character of the arthritic manifestations, he saw hope of “an ultimate extinction of the bias in ‘gouty’ families.” For, as he rightly says, side by side with “the tendency to a reproduction of morbid parental peculiarities, there is a yet stronger tendency in Nature to reproduce the healthy type of the race in each successive generation.”

But while there is a general consensus of opinion as to the growing rarity of acute regular gout, on the other hand, many, as if loth to part with the disorder, claim that _pari passu_ with the decline of regular types the incidence of _irregular_ manifestations grew proportionately.

In my experience the incidence of _regular_ gout has appreciably diminished during the past twenty years. Moreover, such examples as one has met with incline much more in character to the _asthenic_ than to the sthenic variety of _podagra_. But, in contrast to many, I have observed no increase in the _irregular_ manifestations of gout. On the contrary, a steady diminution in the nebulous content of this category, but to this vexed subject we shall recur in a subsequent chapter dealing with the propriety or not of retaining this ill-defined term in medical nomenclature.

My conclusion, then, is that not only is arthritic gout becoming less prevalent, but that the type of the disease also has suffered attenuation. Probably this dual change is the outcome of many factors, not the least of these an increase in national sobriety. For as Sir Alfred Garrod long since observed, “There is no truth in medicine better established 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 being indulged in.

“Αυσιμελου Βάκχου, και λυσιμελους Αφοδίτης,
Γένναται θυχατηρ, λυσιμελὴς, Ποδὰγρα.”