Chapter VIII: Hay Fever as Gout

In the last chapter we read that the theory of a gouty diathesis as the constitutional basis for hay fever originated with Dr. Gueneau de Mussy, in 1868, on account of the many resemblances that he found between the symptoms of gout and the symptoms of hay fever. We have now to consider the fate of the de Mussy doctrine in those countries where hay fever is best known and has been most closely studied, Great Britain and America, Germany and France.

=De Mussy in Great Britain and America.= If any specialist on the nose and throat in England or America ever heard of de Mussy and his theory that hay fever is rooted in a gouty diathesis, he is keeping the secret well, for it does not appear in any of the books that he writes; but in every book I find the disease attributed to the _neurotic constitution_ first suggested by Beard. In this statement I do not include several references to "uric acid poisoning" which is not the same thing as gout, as will be explained in Chapter IX, on the Uric Acid Theory.

After reading de Mussy's argument for the dependence of hay fever on a gouty diathesis, I turned first to the English books. For centuries, England has been famous as the home of gout and, since the Englishman, Bostock's, account of his own case, hay fever, too, like parliamentary government and gout, has been recognized as an inheritance of the Anglo-Saxon race. As British physicians see more gout than any other physicians in the world and as, for many years, they have had the best opportunities for the study of hay fever, I turned first to the English books, thinking that if there was any truth in the gouty theory, the British physicians would have found it out long ago. To my surprise I searched book after book by both British and American authors, but in not one instance did I find hay fever associated with gout. These books included Allbutt's _System of Medicine_, F. T. Robert's _Practice_, Lennox Browne, Morell Mackenzie in England and, in this country, Ballenger, Bosworth, Coakley, Kyle, Solis-Cohen, Ivins and Vehslage and Hallett.

No one is more saturated with the traditions of British medicine than Sir William Osler, but, in his _Practice of Medicine_, in discussing the constitutional causes of hay fever, he seems to know nothing of the gouty theory.

Besides the article on hay fever in his _Diseases of the Nose and Throat_, Sir Morell Mackenzie wrote a comprehensive work on _Hay Fever and Paroxysmal Sneezing_ that ran through five editions and bears on the flyleaf the admiring comment of the _London Lancet_ that it "must be regarded as one of the most complete expositions of our knowledge of this curious complaint in our language." It is a wicked joy to catch such a scholarly writer as Mackenzie napping. In a footnote he even refers to the de Mussy lecture in the _Gazette hebdomadaire_, Jan. 5, 1872, as calling the disease spasmodic rhinobronchitis, with which name the disease is still known in France. One suspects that the learned Doctor was very busy that day and that the footnotes were looked up by somebody else; for, though he gives "the most complete exposition in our language," as the _Lancet_ puts it, of the constitutional causes underlying hay fever, there is never a word of de Mussy's theory of gout.

In Osler and McCrae's _Modern Medicine_ the article on Hay Fever is written by Professor Dunbar, of Hamburg, deviser of pollantin. Here at last we get away from British insularity, for, in spite of his Scotch name, Dunbar is a German. On page 863 he writes:

"For a long time it has been believed that the predisposition to hay fever rests on a gouty diathesis. This view is not on the face of it inconsistent with the pollen theory. Inquiries, however, have shown that gouty persons form only a small portion of hay fever patients."

Finally, in the great Edinburgh _Encyclopædia Medica_, 1900, Volume 4, Greville MacDonald, of London, in the article on Hay Fever, seems to know nothing of the gouty theory and says innocently at the end of the article, "No special dietary is indicated, seeing that these patients present no tendency to lithæmia, etc." He makes the extraordinary suggestion that, in relieving the attack of hay fever, "rather than give the patient cocaine, it might be wise to allow the opium pipe." In the early prescriptions for hay fever, opium sprays and nasal douches were common enough, but this is the only time I ever heard a reputable physician and a teacher, at that, advising a patient to "hit the pipe."

I think that, from the evidence examined, we may say that British and American authors know nothing of de Mussy and his theory.

Next, I looked up the gout authorities, Ewart, Ebstein, Garrod, Falkenstein, Lancereaux, Lecorche, each of whom wrote a bulky treatise on Gout, but there is never a word on Hay Fever.

=De Mussy in Germany.= For many years, whenever I have wanted to know anything from the bottom up, historically, linguistically, philosophically, I have turned to a German book and have always found what I was looking for, if it is known to man. Where an American or British author will skim over or touch a subject carelessly, not seeming to care where the idea comes from or its relation to other ideas in different times or countries, a German will plow steadily through the matter from Hammurabi to Wilhelm III and lay bare all the collateral tributaries and branches, always with an index at the end.

First I tried Heymann's _Handbuch der Laryngologie und Rhinologie_ (Wien, 1900) and found hay fever described in the article on _Die Nasalen Reflexneurosen_, by Professor Jurasz in Heidelberg; but there was no mention of gout. By this, I was truly convinced that nothing was known on the subject. If a Heidelberg Herr Professor does not know it, it does not exist. And "Professor Jurasz in Heidelberg" had failed me.

However, looking further in Heymann, my faith in German thoroughness and all-inclusiveness revived. Hay fever appears also in the article on Acute Rhinitis, by P. H. Gerber, of Königsberg, and here, on page 371, we find a complete "Literatur" spread out in true Teutonic style from Bostock to date. However, Gerber does not discuss the matter of gout in the text, but says merely, "Recently Bishop asserts that the nervous disturbances of hay fever are due to an excess of uric acid in the blood."

The gouty theory of hay fever receives scanty recognition from most German writers. Strümpell does not mention it. In his _Handbuch der Specielle Pathologie und Therapie_, Berlin and Wien, 1904, Eichorst says skeptically, page 326, "It has been stated often that gouty families are especially apt to develop hay fever," and on page 330 "Grote saw hay fever patients of gouty families cured (?) by a course of waters at Neuenahr."

In Eulenberg's _Real-Encyclopædie der gesammten Heilkunde_, 1887, page 509, article Hay Fever, we read:

"Of general diseases, malaria and gout have been advanced as the basis of hay fever, but without convincing proof."

We may conclude, then, that while British and American physicians know nothing about the gout theory, German physicians know about it but do not believe it.

Finally, in my wanderings through German encyclopædias, I came to the many-volumed Nothnagel and here, at last, found a modern writer who knew de Mussy and recognized the importance of his observations. At the end of Volume 4 there is a monograph on Hay Fever by Dr. George Sticker, of the University of Giessen, the most thorough and satisfactory book on the subject that I have found. It may be read in English in the American edition of Nothnagel, Philadelphia, 1902. Sticker resists the impulse to begin with Galen, though he notes rather wistfully that John Mackenzie of Baltimore succumbs to it. He gives the most complete statement in any modern book of the gout theory of hay fever, but, alas, Sticker misses the pearl in the oyster. He says nothing of de Mussy's recognition of the urticarial nature of the lesion in hay fever.

As this volume of Nothnagel may not be easily available to the gentle reader, I copy a paragraph from Sticker for his or her benefit.

Nothnagel's _Specielle Pathologie und Therapie_, Band 4, 1896. Article _Bostock's Catarrh_, by Dr. George Sticker, page 118. "In the last few years convincing proofs are accumulating that there is a certain constitutional disorder on which the individual tendency to hay fever depends. Though further careful proof is desirable, it can scarcely be doubted that the pathogenesis of hay fever is based on that constitution that the English and French describe as arthritic, which expresses itself in a hereditary or family tendency to rheumatism, gout, diabetes, obesity, migraine, furunculosis, bronchitis, asthma, etc. Bostock himself mentioned his gouty tendency. Phoebus found it in many patients. But it was Gueneau de Mussy who first recognized the prevalence and necessary basis of the disease in the arthritism of the hay fever patient; and his teaching has been accepted and enriched with new material by Herbert, Leflaive, Lermoyez, Ruault, de Dreyfus-Brissac, Rendu, Molinie.... And so it is probably no coincidence that, like gout, the _morbus principum_ of Sydenham, so also the aristocratic hay fever is a prerogative of the Anglo-Saxon race."

Reading this praise of Englishmen and Frenchmen by a German makes one sad to-day. Hasten the day when the old hearty comradeship in science will return, the day when German and Frenchman and Englishman will again praise one another's achievements ungrudgingly and each learn eagerly as of old what the other had to teach.

=De Mussy in France.= As might be expected, among French rhinologists and writers on general medicine, de Mussy's teaching is well known and has many advocates. Note that the writers mentioned by Stickerare all Frenchmen. The usual view is well expressed by André Castex in his _Maladies du Larynx, du Nez et des Oreilles_. Paris, 1907, page 425.

"Hay fever attacks especially those who belong to an arthritic stock, whose parents have had or who themselves have migraine, gravel, eczema. This explains its frequency in England and America; for the Anglo-Saxon race is especially subject to arthritic disorders. In France it exists but is infrequent. In this way also we must explain why hay fever is rare among the laboring classes who frequent the hospitals and is observed almost exclusively among wealthy patients, people of sedentary habits and sluggish digestion (nutrition ralentie)."

In Brouardel and Gilbert's _Traité de Médicine et de Thérapeutique_, Volume 27, page 66, another André, André Cartaz, expresses mild skepticism as to the proof offered.

"The presence of an arthritic diathesis is accepted by many authors. Leflaive thinks it the sole predisposing cause, especially gout. During the attack he has demonstrated, as I would say, and that is proof for him, an appreciable decrease in the quantity of urine and percentage of urea, an increase in uric acid and, in one case, the presence of indican."

Lermoyez also advises caution in accepting the gouty theory to the neglect of known remedies for the disease. I abstract his sensible remarks from his _Thérapeutique des Maladies des Fosses Nasales_, Paris, 1896. Article _Rhinites spasmodiques, rhume des foins_, page 300.

"It would be a mistake to hold with the German school that the nasal lesions were the only cause of hay fever; for these lesions are completely absent in many true cases of the disease and, on the other hand, many people affected with hypertrophic rhinitis breathe air full of pollen without showing symptoms of hay fever. There is certainly a general predisposition. In hay fever certain patients present a peculiar idiosyncrasy, often inherited, almost always neuroarthritic. But to say with the French school that the arthritic diathesis (trivial diathesis, commonplace diathesis, _diathèse banale_) is the only cause of hay fever is to make a mistake that leads to inefficient treatment."

=Conclusion.= How this discussion of the gouty nature of hay fever escaped English and American authors is a strange thing. British physicians frequent French hospitals and are familiar with French medical writings. In 1868 American physicians studied in Paris as they went later to Vienna and Berlin. It is strange that they never brought back with them this French theory of the gouty nature of hay fever and that no British or American author seems to have quoted from their books.

I must make one partial exception to this statement. In his _Diseases of the Nose, Throat, and Ear_, Philadelphia, 1906, Professor Grayson says that, in hay fever, there is "some diathetic state that is rooted in defective nutrition. Whether we term this lithæmia or gout or uric acid diathesis is immaterial, the central fact being that through intestinal toxæmia or some disturbance of normal metabolism we have resulting a persistent poisoning of the blood-current."

Now this is simply substituting one theory for another without proof of either; for the origin of hay fever in auto-intoxication is as little proved as its origin in gout or uric acid. Auto-intoxication has simply replaced uric acid in the Doctor's mental picture gallery; for, like uric acid, auto-intoxication often exists in the imagination of the physician and not in the patient. For further discussion of this point, the reader is referred to the next chapter, on the Uric Acid Theory.

A novel and interesting article in Grayson is the description of angioneurotic oedema as affecting the nose and throat, page 182. He writes:

"I have no doubt that in this disease, as in hay fever, the gastro-intestinal tract is the birthplace of the toxic material. Although the disease may occur in gouty or rheumatic individuals, there is scarcely sufficient reason for ascribing any pathological connection between it and these other affections."

The comment on this is that, until we know what gout is, which we do not at present, we cannot argue satisfactorily either way. Some day I shall tell a listening world what I know about gout. I shall elaborate my favorite theory that the American neurasthenia, now rapidly increasing in other countries, is a form of gout, a gout of the nervous system. And here, too, I find that Frenchman, de Mussy, anticipating me in his remark that "_Behind a vast number of nervous troubles, behind a vast number of functional anomalies stamped with a nervous imprint, we find arthritism._" The name _neurasthenia_ was not known in de Mussy's day, but he hit off the condition neatly as "functional anomalies stamped with a nervous imprint."

The defect in all these discussions of the gouty or non-gouty nature of hay fever or of neurasthenia is our lack of a sure diagnostic sign of the disease gout. Gout occurs in two forms, typical and atypical, irregular gout. In typical gout, with the deposits of urates in the joints and cartilages, the diagnosis may be easy. In atypical or irregular gout we may have a group of inflammations or functional disturbances in any tissue of the body. From their frequent occurrence in gouty people, we suspect them to be gouty, but can prove nothing. When they appear in people who have never had typical gout we can only say that a gouty origin is probable. There is no sign in the blood or in the urine or anywhere else by which we can say that gout is or is not present. It is in this class of atypical gout that hay fever and neurasthenia belong, if they be gouty at all. Until somebody discovers a diagnostic sign of gout that is available in these irregular cases, the evidence of the gouty nature of hay fever and neurasthenia must remain exactly what it was to de Mussy fifty years ago, analogies of symptom groups, and not an exact laboratory diagnosis based on physiological or chemical tests such as we have come to depend upon with such confidence in recent years.

One matter that should be made clear in the reader's mind is that the so-called _uric acid poisoning_ or _uricacidæmia_ is not the same thing as gout by any means, though Grayson confuses it with gout, as do nearly all American authors. For fuller discussion of this point, we will pass to the next chapter.