7/28/2019 The Pathogenesis of Gout

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BMJ Publishing Group

The Pathogenesis Of GoutAuthor(s): Chalmer WatsonSource: The British Medical Journal, Vol. 1, No. 2247 (Jan. 23, 1904), pp. 219-220Published by: BMJ Publishing GroupStable URL: http://www.jstor.org/stable/20279286 .

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Jan.'23, I9Q4-] _ CORRESPONDENCE._[m^^SSa? 2*9THE PREVENTION OF SYPHILIS.

Sir,?Is it not high time that some serious attempt weremade to attack this disease as we do others less far-reachingin their evil effects ?The Act which was in force for a short time some years ago

failed, despite good intentions, because it was built upon aninsecure foundation. "The State regulation of vice" was aterm which started off public opinion (and the whole work inconnexion with the scheme) upon a wrong basis. The question became one of morals and caused great misunderstanding.If the State took in hand the "suppression of disease" witha view to its elimination no one could complain, especiallyas syphilis is so insidious and far-reaching in its ill-effects.Such an Act should deal not with the question of morals, butwith means of eradicating, as thoroughly as possible, a disease which is day by day being reproduced. Morals must betreated separately, although, as regards syphilis, very manysuffer through no immoral act of their own.If a man contract small-pox by contagion when picking^theocket of an infected person, we do not ignore his disease,owever great a criminal he be, but require that he be treated

medically as a source of public danger ;,when he doubtlessreflects upon the immorality of the act through which hecontracted disease !My desire is to raise the question whether great good mightnot be achieved by a carefully-prepared Act of Parliament

giving the State power, by all possible means, to suppress andif possible eliminate syphilis. The difficulties to be faced inframing such an Act are many and great, but not insuperable.Indirectly moral conditions would improve with the physicalimprovement and the education of the people in this matter.bufferers in the upper classes, who already understand to agreat extent what syphilis means, generally receive for themselves a proper course of treatment ; but this cannot be saidof the lower classes ; and it must be remembered that it is inthe upper orders only that the birth-rate has been artificiallylowered, and that, therefore, the upkeep of the population ofthe country is very largely left to the lower rank so widelytainted with syphilis.Is it not time that the State ceased to ignore this one of themany contagious diseases which is at present left to be propagated by a callous and ignorant people ??I am, etc.,Church Crookham, Hants. R. JoBNSTONE STIRLING.

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HUMAN SERUMTHERAPY.Sir,?According to accepted views, specific immunity is?due to the presence in the blood of a definite antitoxin,

developed in reaction to the introduction of a definite pathogenic organism. It follows that the rational treatment ofthose diseases which confer this immunity should be theinjection of the serum of a person who has successfullyfought through the same disease. If antidiphtherial serumobtained from the horse is effectual, so probably would behuman serum from a patient recovered from diphtheria, withthe additional advantages of freedom from undesirable by

effects, and of longer action. The acute eruptive fevers,especially small-pox and scarlet fever, which confer amarkedspecific immunity, might on this theory be combated fromthe outset by injections of serum drawn from patients whosehealth is re-established after passing through the same dis?ease. Experiment alone could determine the immunizingtherapeutic value of serum taken, say, from a patient re?covered from small-pox, and the quantity and frequency ofthe injections required to influence the clinical course of thedisease.

The practical difficulty would be to obtain a sufficient supply of the serum, but when it is remembered how readily apast generation submitted to bleeding for trivial maladies itcannot be doubted that many patients would be foundaltruistic enough to allow themselves to be bled on behalf offellow-sufferers. If the comparative immunity of infants atthe breast from acute infectious diseases is correctly explained by the fact of their taking inwith the milk the protective antitoxin which is the result of the mother havingpassed through the same disease in childhood, there is a presumption that the injection of the mother's serum would havethe same effect on older children. Many a mother would unhesitatingly be bled for the benefit of her child, endangered,?ay, by scarlet fever.I am not aware whether the same idea has occurred toothers, or whether the experiment has been tried, but I venture to send the suggestion for publication in the hope that

those in charge of fever hospitals, or others having the opportunity, may deem it worthy of trial.?I am, etc., Theory.

THE PATHOGENESIS OF GOUT.Sir,?I have read with interest the letters appearing in theBritish Medical Journal of January 16th, dealing with myarticle on the above subject. I appreciate the criticisms of

your correspondents and feel it incumbent upon me to dealwith certain points they raise.Dr. Kingston Barton is in error in suggesting that an imperfect acquaintance with the usual post-mortem changes in.the digestive tract has led to a misinterpretation on my part,of the appearances shown in the section. If Dr. Barton will;dome the honour of referring to a paper published by me inthe Journal ofMental Sciences in July, 1903, he will see that I>? ave studied the normal intestinal tract in the human sub-.!ject and have there given clear illustrations of the unavoid-;able gost-mortem changes. I have similarly studied thedigestive tract in fowls and other animals in a number of ?cases in which the tissues were fixed at periods ranging froma few minutes to several days after death, with results confirmatory of those illustrated in the foregoing paper. Thisexperience has taught me to attach no significance to anapparent loss or destruction of tissue provided the numberand arrangement of the glandular elements in the deepest!part of the mucous membrane are fairly normal. But if, asin the section in question, the number and arrangement of.these glands is far removed from the normal, and if thischange is associated with a great excess of lymphoid tissuesuch as is referred to in my paner, we have conclusive evidence of an ante-mortem condition. These appearances areindicative of formative changes of the nature of a vital reaction to an irritant. For the rest I note with satisfactionthat Dr. Barton is in perfect agreement with me in regardingthe changes throughout the tissues as characteristic of a

general infective process. It would be premature at thisstage with the insufficient data at our disposal to attempt todefine the precise nature of this infective process, but if thetheory is correct and is adopted as the basis of future investi*g?tions, it will have the effect of still further concentratingattention on dietetics and especially on the interaction ofparticular forms of food and the bacteria normally existingin the digestive tract.Dr. Bradshaw disagrees with the jpost-mortem diagnosis ofgout on the following grounds. It is very unusual for a firstattack(1) to affect numerous joints; (2) to be attended withvarious visceral inflammations ; (3) it is almost unknown fora first attack to prove fatal ; and (4) as gout is characteristic;of a high civilization, it isunlikely to be found in birds at all.How far are these statements justified ? In Garrod's classicalwork on gout there is a record of 516 cases (Scudamore) drawnup for the purpose of showing ?the seat or seats of the firstinvasion of the disease, and in 202 of these cases more thanone joint was involved. His first statement, so far as it can:traverse the actual record in my paper, is therefore inaccurate. With regard to his second ground, it would be interesting to learn the foundation of his statement. So far as I amaware, no opportunity has ever arisen of ascertaining theactual condition of the viscera in the acute phase of gout.

This information is one of the chief desiderata for a trueknowledge of the disease, and the notorious difficulty inobtaining it in the human subject is one of the cardinalreasons for turning to comparative pathology if the necessaryconditions for obtaining it either exist in animals, or can,'like other diseases, be induced in them. His second state

ment, therefore, is a pure assumption. It is quite accurate to say that it is almost unknown for a firstattack of gout to prove fatal in the case of human subjectsunder treatment, but this can form no basis for the conclusion that a fatal result is unlikely in the adverse conditions that obtain in the animal kingdom. On the lastpoint, which Dr. Bradshaw mentions incidentally, I maymention that a disease presenting the clinical and pathological features of gout has been successfully induced infowls (Kionka), and I submit that this proved susceptibilityto the disease is sufficient reason for anticipating its occasional existence where a faulty system of dietary coexistswith a diminished power of resistance to the toxic influencesat work.

Accordingly, the negative considerations put forward byyour correspondent appear to have little weight, and inthe absence of an adequate alternative diagnosis that of gout[must be accepted. This diagnosis was based upon the

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g go M^wSSj_CORRESPONDENCE._[Jan. 23, 1904^generally-accepted definition of that disease?that "gout" isa constitutional disorder characterized by paroxysmal attacksof inflammation of the joints associated with formation ofchalk-like concretions (urates) in and about the joints (Roberts).Dr. Bradshaw suggests that the case was one of acutenephritis, and that the deposits in the tissues were the resultof the suspension of the functions of the secreting elements ofthe kidney, whereby uric acid accumulated in the tissuesproducing a condition analogous to uraemia in the humansubject. A weak point in this analogy is the fact that uraemiais now generally believed to. be not simply dependent on theretention of urea in the system. Apart from that, his theoryof the kidneys being thrown out of action, and the function ofan eliminating organ being suspended, is not supported bythe pointed statement of fact (Fig. 7) that the secretingelements of the kidneys?the convoluted tubules?weresingularly healthy, notwithstanding the existence of markeddisease in adjacent structures.I would point out that Dr. Bradshaw does not indicate asingle respect in which the histological features illustrateddiffer from the type of gout as above defined, and I ampleased to observe that we are in substantial accord inbelieving that the case was one of an " acute and fatal intoxication." On the question of labelling the disease, hiscriticism reminds one of the Shakespearean humourist who,in dealing with the Baconian theory, admitted that the playswere not written by Shakespeare but by another man of thesame name.?I am, etc.,Edinburgh, Jan. 17th. Chalmer Watson.

"DOCTORS IN PARLIAMENT."Sir,?In view of a probably approaching general election, Iatn glad to see letters in the British Medical Journal

urging the necessity for more doctors in Parliament. Moremedical men are certainly required in the House of Commonsfor the sake of the profession, but there are even betterreasons for wishing to see them there?they are greatlyneeded for the sake of the country. Medical measures,amongst which I class measures dealing with the feeding andwith the housing of the people, are engrossing more andmore the attention of the Legislature, and must be dealtwith by an assembly which fully understands them.For more than twelve years I have had ample opportunityof watching the control of medical institutions by lay and bymixed medical and lay committees and, without enteringinto undesirable detail, I would state my clear conviction thatno merely lay body, however intelligent, however empoweredto consult medical men outside itself, can safely administerpublic medical affairs. For safe administration of publicmedical affairs, I am convinced that medical men in reasonable numbers must be actually members of the governingbody. I believe further that this is as true in nationalmatters as in local matters, and that consequently there isa great need at the present time of adequate medical representation on all bodies dealing largely with medical publicquestions. This is particularly the cas? in both Houses ofParliament, on the Privy Council, and on the CountyCouncils.

The medical profession is by no means a wealthy one, andthe number of its members with sufficient means and leisureto represent a constituency in Parliament is necessarilylimited. But I fancy that, if the national need for medicalmembers of Parliament were once grasped by the profession,more medical candidates would be forthcoming for election.It is a great pity that we possess no fund which could beused for defraying in part the expenses of medical membersof Parliament. The fact that their presence in the Commonswould be a clear gain to the whole profession constitutes, itseems to me, an obvious claim upon the whole profession toshare the burden of expense.?I am, etc.,Exeter, Jan. 9th. W. GORDON.

SCHOOL CHILDREN OUT OF SCHOOL.Sir,?I have read with much interest the articles by yourCommissioner on Physical Degeneration, and especially thatin the British Medical Journal of January 16th, whichgave such an admirable account of the Passmore EdwardsItecreation School, and the work of the Children's HappyEvening Association.Some of your readers may be interested in a further effortwhich is being made by the Women's Industrial Council inthis direction. The Council lately, and on the lines proposedby your Commissioner, appealed for funds to enable it to

start "recreation classes" for school children whose mothershave to go out to work, and who therefore miss home life andparental care until perhaps the late evening.

APPEAL.The Women's Industrial Council is anxious to follow in London the

example set by the Kinderorte or recreation schools of Germany. Theaim is to keep safely and happily occupied outside of school hourscertain carefully-chosen children who owing to poverty or familycircumstances cannot be properly cared for in their homes. Such, forinstance, are children who have lost one parent and whose remainingparent has to be at work all day. It is desired to obtain the useof the infant departments of certain elementary schools from 4.30 to7.30 or 8 p.m. on five days a week, and in these schools to havegames, drill, classes in various handicrafts?such as carving, basketmaking, etc.?in sewing, and in drawing. Half an hour would thusbe left for airing the rooms at the close of the afternoon session.Alight meal at very low prices might be provided. One paid superintendent would be required for each school ; the rest of the workwould be carried on by voluntary helpers, while the school premisesit is hoped would be lent free of charge. It is desired to set twosuch schools going immediately as an experiment, and voluntaryhelpers are forthcoming for both. The expenses of each are estimated at about ?1 a week. A sum of ?100, that is, will carry onthe two recreation schools for about a year. For this sum we nowappeal to the public. The neglected children of to-day are thecriminals, the wastrels, and the paupers of to-morrow. Every littleone who can be taken from that dangerous and demoralizing playground, the street, and can be taught to find pleasure in healthy games,physical exercise, and intelligent occupations, will become, not only a*happier and healthier, but also a more productive and less burdensome member of society. To preserve children from evil ways is alikethe truest philanthropy and the truest economy, and the children forwhom we plead are those who are least able to help themselves.Isabel Aberdeen, President.Clementina Black ,Vice-President.Nettie Adler, Chairman, Executive Committee.Elsie M. Cadbury, Vice-President.Margaret E. MacDonald, Secretary, Education Committee^.L. Wyatt-Papworth, General Secretary.19, Buckingham Street, Strand, W.C., Dec. 8th, 1903.

Any of your readers who may be interested in work of thi?nature will obtain full information about it from the officesof the Council, 19, Buckingham Street, Strand, W.O.?I am,etc., Alice R. Joseph,Honorary Secretary, Recreation School Committee,,Women's Industrial Council.19, Buckingham Street, Strand, Jan. 19th.

ST. BARTHOLOMEW'S HOSPITAL.Sir,?With the sanction and sympathy of His Royal Highness the Prince of Wales, President of this hospital,

who hasgraciously associated himself with the appeal, a public meeting will be held, under the auspices of the Right Hon. theLord Mayor, at the Mansion House, at 3 p.m. on the 26thinst., to promote the appeal of this hospital for funds toenable it to undertake the works which are absolutely necessary to bring it up to modern requirements.

May I earnestly beg you to give the hospital your valuablehelp and support at this meeting ?St. Bartholomew's is the only hospital for the sick withinthe City limits. It is of great antiquity, and has carried on avast work of mercy and charity on the same site for nearly800 years. The value of this work will be realized when it isknown that,in the last fifty years of the nineteenth centurvthe hospital gave relief to more than 7,000,000 of the sickpoor. For many generations it has been a prominent centreof medical education, and its pupils are found in every partof the empire.St. Bartholomew's has not asked the public for help formore than 150 years, but now help is urgently required to

meet the demands made by the unceasing advance of medicalscience. These demands, with the.requisite addition to thehospital site, will cost not less than ^500,000.?I am, etc.,.London, E.c, Jan. 15th. Trevor Lawrence, Treasurer-.

THE POOR-LAW SERVICE IN SCOTLAND.Sir,?The Poor Law medical officers of Scotland owe you ardebt of gratitude for the zeal with which you from time totime champion their cause in the British Medical Journal.Dr. Macara's case is but a sample of the spirit which in many

pirts of this country is manifested towards parochial medicalofficers, and unless such treatment be rendered impossibleby legislation the time is not distant when the services ofqualified medical men will be absolutely unattainable in theremote Highlands of Scotland. In this connexion let us sin

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