Chronic Articular Gout

The gastric derangements that precede acute gout nearly always become aggravated when the disease is permanently established. Consequently from time to time many of the measures outlined in previous paragraphs must be resorted to. But there is this also to be borne in mind, that in these later stages of the evolution of the disorder the intervals of relative health grow shorter and shorter. The victim lies more or less always under the shadow of the malady, and its peculiar impress on the constitution becomes more and more ingrained. Therewith his sensitiveness to the exciting causes becomes more and more pronounced.

To detect and thereafter to eliminate the most fruitful excitant of articular outbreaks in individual examples will form no small portion of the task that falls on physician and patient alike. In the majority, it will be some indiscretion of food or drink; in some, insufficient exercise; in others, intellectual strain or worry, etc. By determining the particular nature of the excitant in the individual under review we arrive at his personal idiosyncrasy—a matter of much moment in prophylaxis.

Moreover, with increasing experience the physician cannot help noting that the vulnerability to assaults varies in different subjects. Thus the development of gouty paroxysms in some will be found to be associated with gastro-intestinal or hepatic derangements, in others with defects of elimination through kidneys, bowels, or skin.

In short, these cases must be approached in a catholic frame of mind, and the success of medicinal therapy will depend on the judgment and clinical acumen displayed in meeting the ever-varying necessities of individual instances, not by an almost flippant prescribing of alkalies or, it may be, iodides, colchicum, or guaiacum. All these are valuable, but only if invoked with discrimination, and not after stereotyped or routine fashion.

The joints in these cases are the seat of chronic change, and though they call for due attention, it is the constitutional taint that is of paramount importance. How best shall we influence this? How else save by recognition of the morbid content of the blood and cleansing of the impurities with which it is charged?

I have before stated my belief that functional derangements of the alimentary canal are the determining cause. It is through their agency that the toxicity of the blood plasma ensues. In the vast majority of cases these constitute the dominant departure from physiological righteousness. It is to these that the high uric acid content of the blood may presumably be referred. Yet nevertheless retention of the same in the form of tophi may be relatively slight. Is it that in their instance the avenues of excretion are more permeable?

In others, again—not necessarily those with more pronounced dyspeptic symptoms—the retention of uric acid proceeds apace. Clinically the explanation appears to be that cases with massive tophaceous deposits often display renal changes. In other words, it is the channels of elimination that appear to be at fault.

But, more than likely, these superficial differences hark back to infinitely more subtle inward disparities, to tissue peculiarities of function, with correlated variations in their retention capacity for uric acid. Here again the clinician waits upon the bio-chemist, and meanwhile must base his differential treatment on somewhat coarser indices.

Thus in one class of case the toxicity of the blood seems attributable to dyspepsia or mal-assimilation, and the physician’s efforts must be concentrated on correction of the same. In another type such may be absent, and yet uric acid accumulates, tophi multiply, and his attention turns to the kidneys, the avenues of excretion. In others, again, both symptom complexes may be combined, and his resourcefulness is taxed to the utmost to meet these several necessities, for, as Sydenham wisely said, “the weakness of all the digestions and the loss of natural strength in the several parts are the essence of gout. Each must be dealt with.”

Nor must we forget that long-continued gout engenders not only a depravation of general nutrition, but paves the way also for the insidious production of structural organic changes. In a word, it favours the onset of pre-senilism, with all that such connotes. So it is that in these subjects, too often past the meridian of life, we have not only gout to combat, but the grisly appanage of oncoming age.

It is this larger view of our responsibilities that we must cultivate if our treatment of chronic gout is to be in any sense rational, and not wholly haphazard. Also, if my contention be correct that the alimentary canal is the fons et origo mali, the major source of the provocatives of gout, then the basal and essential part of our therapy must be diet and regimen. As to the subsidiary medicinal indications, it will perhaps be more convenient if I proceed to discuss shortly the use of the various drugs that experience has shown to have been of most avail in chronic gout.

Alkalies.—It was formerly thought that by increasing the alkalescence of the blood its solvent effect on uratic deposits was enhanced and their formation thereby delayed or prevented. But subsequent researches by Sir William Roberts conclusively proved to his mind “that alkalescence as such has no influence whatever on the solubility of sodium biurate.”

Luff, again, from his investigations, held that administration of the ordinary alkalies, of lithium salts, of piperazine, and of lysidine, with the object of removing gouty deposits, appears to be useless. He also claims that no general acidity of the system is associated with gout, and no relationship exists between the acidity of the urine and the alkalinity of the blood.

Nevertheless let us not sin against light, which is exactly what we are very prone to do if we allow ourselves to be obsessed by uric acid and overlook the records of clinical experience. Take Sir Thomas Watson; he, without any reference to uric acid elimination, recommended as a prophylactic against gout 15 grains of bicarbonate of potash in combination with tincture of rhubarb and some light bitter, to be taken every day. Fagge, again, observes, “Alkalies are decidedly useful in gout,” and the same views were held by the elder Garrod, Lecorche, and Dieulafoy, etc.

In short, forgetting for the moment the existence of uric acid and shedding all hope of their dissolving tophi, we find that alkalies have ample justification besides for their employment. They are valuable as antacids, diuretics, and as alteratives, and, moreover, their routine employment has been tried and approved.

In other words, the benefit of alkalies depends, not upon any special solvent effect upon uratic deposits, but upon their remedial influence upon associated and, I believe, causally related gastric and hepatic disorders, and through these on general metabolism. Albeit, let us be guided by rational considerations when we invoke their aid.

The fact that alkalies are incapable of dissolving tophi is a clear indication that that deleterious habit of continuously taking potash and lithia water is not only unnecessary, but undesirable. Alkalies should be prescribed in short courses and to meet special indications, i.e., intermittent, not continuous, administration.

Thus in the minor gastric disturbances which in chronic gout we are constantly called upon to treat there is no doubt as to the superiority of the sodium compounds. Moreover, apart from their value in gastric or intestinal catarrh, we have to note their usefulness in dyspeptic states complicated by torpid liver.

When constipation exists, the sodium bicarbonate may be combined with magnesia, and all will admit the striking benefit attained by short courses of these drugs with the addition of rhubarb, some simple bitter infusion, quinine, or strychnine, all rendered more effective by the addition of some carminative or aromatic.

Sydenham’s electuary was compounded of gastric tonics, and the more recent Portland and Pistoja powders are in this respect but an imitation thereof. Indeed, stomachics are the most valuable tonics in gout. Lastly, it is in the inter-paroxysmal periods of chronic gout that the sodium compounds are indicated, when the joints, though enlarged, are quiescent, and the more prominent symptom in the clinical picture is lack of gastric tone, with or without acidity.

As to the potash compounds, it is during and immediately after articular paroxysms of acute or subacute gout that they find their chief sphere of usefulness. Apart from this, they are, because of their diuretic properties, valuable at all times in cases in which the renal secretion appears to be deficient. The bicarbonate, citrate, or acetate of potash are the most valuable. The last-named is the most diuretic, but is rarely used, the citrate enjoying more favour, being more palatable and most eligible when no direct antacid effect is desired, in which case it should be replaced by the bicarbonate.

In those instances in which the skin is notably inactive Garrod thought highly of the phosphate of ammonium, holding that “there is much clinical evidence to prove its value in the treatment of chronic gout.” Many, like Burney Yeo, believe that a combination of soda and potash compounds acts better than when either is given singly. Thus Garrod in cases in which the action of the liver was defective frequently used the bicarbonate of soda in combination with the citrate of potash.

As to the lithium salts, general opinion has it that their value in the treatment of gout has been greatly over-estimated, and that they are not so serviceable as the potassium and sodium salts. They are also more toxic and lowering, and Luff some years ago issued the following caveat: “I constantly meet with patients suffering from cardiac depression, and even dilatation, as the result of the excessive and continued consumption of lithia tablets, which are so persistently, so speciously, and so wrongly vaunted as curative of gout.”

In conclusion, it will be seen that clinical experience testifies with no doubtful voice to the value of most salines. At the same time it is clear, also, that we should use discrimination, seeing that some, as Garrod says, are “certainly more adapted to particular cases than others.” They should also be given well diluted, in moderate doses, and not continuously but intermittently. These rules should certainly be followed when alkalies are invoked in gout, not for local antacid effect, but for their general influence on metabolism. Moreover, at the close of a course of alkalies for this purpose, we may often with advantage place the subject on acids in combination with quinine, nux vomica, or strychnine.

Alteratives.—Of these the salicylates and the benzoates are, by some, greatly prized, in that they act especially on uric acid, promoting the elimination thereof. The benzoates are favoured in examples in which the kidneys are not above suspicion, the latter disability contra-indicating the use of the salicylates. Some, like Ewart, advocated a course of benzoates in alternation for periods of a week or a fortnight with a saline treatment. By Lecorche and Haig, salicylate of soda in doses of 60 grains or more per diem was advocated continuously for prolonged periods.

In my opinion, salicylates are best used during a paroxysm, when, for some reason, colchicum is contra-indicated, or immediately after, to promote elimination of uric acid and to minimise or inhibit the development of tophi. As to the benzoates of sodium and potassium, they are now rarely, if ever, prescribed, though hexamine is growing in favour as a “urinary antiseptic diuretic and anti-lithic.” Occasionally I have met with B. coli infections in gout, and in such cases one of the preparations of hexamine, with lithium or sodium benzoates, is of value, whilst among the laity urodonal stands in high repute as a means of removing uric acid and allied bodies.

Iodides.—Turning to well-tried alterative remedies, there is no doubt that the iodides well deserve their high repute in the treatment of chronic gout. Thus in subacute and obstinate swelling of the joints, and alike in painful gouty affections of the muscles, fasciæ, and nerve sheaths, iodine in one or other of its forms is par excellence our most reliable remedy.

In no type of case is it more serviceable than when the joint inflammation is of low asthenic type—enlarged, stiff, and painful. It may be given in some such combination as the following:—

If colchicum be contra-indicated, a useful substitute to quell pain is tincture cimicifugæ in 15-minim doses. The dose of the iodide need not exceed 3-5 grains, as, from my observation, no appreciable advantage is gained by larger doses. Iodine-albumen compounds may be substituted for the alkaline iodides as less likely to cause derangement of the stomach, inasmuch as assimilation is believed to take place in the intestine. Thus iodo-protein may be administered in doses from 10-15 grains. A tablet containing 10 grains is equivalent to 1 grain of combined iodine. Excretion being taken as the measure of absorption, it has been experimentally shown that, six hours after administration, a lower percentage of iodine was excreted in the case of iodised protein than with potassium iodide. In other words, the iodine-albumen compound yield up their iodine to the system at a slower rate. In short, they disintegrate more slowly and are, therefore, the more likely to exert a longer continued activity.

An organic compound of iodine with vegetable albumen, i.e., iodo-glidine, has been somewhat extensively used in gout, as being non-depressant. Said to undergo almost complete disruption in the intestines, it is slowly absorbed without toxic symptoms. Iodo-casein and seroden, a combination of iodine with blood proteins, are similar preparations, with which, if necessary, the alkaline iodides may be replaced.

More recently the advantages of collosol preparations of iodine have been emphasised, and these colloidal solutions, unquestionably, have an increasing sphere of usefulness in all cases of gout where iodine is indicated. It has been truly said, collosols “are not new drugs, they are simply familiar drugs in a new form—a form in which their therapeutic potency is greatly heightened while their undesirable properties are reduced to vanishing point.”

Doubtless, collosols exist in a form very meet for assimilation, inasmuch as they conform to the essentially colloidal character of all the normal fluids and secretions of the organism. Moreover, toxins or bacterial poisons appear also to exist in colloidal form, and also, according to A. B. Searle, “to a large extent in the reactions which create immunity.”

These physical similarities between collosols and the bodily fluids and tissues ensure their ready assimilation with minimal constitutional disturbance. Inasmuch as the colloidal state, too, predicates low chemical affinity, the combination and absorption of collosol preparations take place gradually and uniformly.

For internal administration colloidal iodine is prepared in aqueous suspension. It is stated that the whole of the iodine is absorbed in molecular combination with protein. An iodo-amino acid results, and ultimately reaches the blood-stream. Arrived there, it, through its reducing action on lipoids, exerts an alterative effect.

The dose of collosol iodine ranges from 1-4 teaspoonfuls daily after meals. It does not cause nausea if the amount be slowly increased, and only exceptionally does it set up iodism. In these respects it has an undoubted advantage over the alkaline iodides. As to whether they will wholly usurp the place of this latter is, I think, very doubtful; this, if only for the convenience with which the alkaline iodides lend themselves to combination with other alterative remedies. But in individuals intolerant of iodide of potassium they are excellent substitutes when the indication is to improve and modify the general metabolism.

Lastly, too, apart from their use in chronic gouty arthritis, we have to recollect that the iodides are the most reliable means we possess of influencing the renal and vascular changes so often associated with gout. Garrod doubted if they possessed any power of promoting the dissipation of uratic deposits, but their power of eliminating lead must not be lost sight of when treating gout in the subjects of plumbism. Obviously, when invoked for this purpose or to arrest or retard degenerative processes in kidneys and vessels, their administration must be continued for long periods—six to eight weeks. The same persistence, too, is demanded to remove the inflammatory products in the joints. Simultaneously or alternately short courses of atophan—30-40 grains for two to three days in a month or oftener in more severe cases—will also be of help in dislodging articular deposits in the form of tophi.

Guaiacum.—Many years ago, Sir Alfred Garrod[62] highly eulogised the value of this drug in the treatment of chronic gout. Said he, “There is no remedy of which I can speak so confidently. I have known patients who have been confined to their beds for many weeks with asthenic chronic gout so far recover within two or three days under the use of this remedy as to be able to walk about.” He held that it exerted a specific action on the fibrous tissues, and advocated its exhibition in chronic forms of gout with feeble circulation. He adds the further interesting differentiation regarding the employment of guaiacum as opposed to iodide of potassium. Both these drugs he held valuable when the fibrous coverings of the joints were especially affected. If the articular pains were increased by warmth, iodide of potassium is “peculiarly indicated”; but, under such circumstances, “the use of guaiacum is either altogether contra-indicated or, at least, it should be administered in combination with iodide of potassium or some other saline.”

As to its mode of action, Bain noted that, while the excretion of urea fell somewhat, that of uric acid was markedly increased. But he found, also, that “neither the phosphorus pentoxide nor the bases showed a corresponding increase—thereby denoting that this drug probably acts, not by increasing the production of uric acid, but by eliminating a part of that stored in the blood.” Moreover, it was noted that the increased uric acid excretion did not cease with cessation of the drug, but continued for some time after, the patient’s condition meanwhile undergoing amelioration. Bain considers that his researches confirm the opinion arrived at, on empirical grounds, by Sir Alfred Garrod—that guaiacum was a powerful prophylactic agent in gout.

Returning to its method of exhibition, it must be admitted that it is most unpalatable when given in the form of a mixture, and is preferably prescribed in a cachet or tablet. The resin of guaiacum may be given in doses of from 5-15 grains, and the larger doses may excite nausea or purging. In smaller amounts, however, it merely exerts a beneficial laxative effect; it is also useful in cases where the liver is torpid. This latter action may be reinforced by simultaneous administration of calomel in fractional doses.

Such is useful as a corrective in intestinal fermentation when given for three or four days, after which the calomel may be withdrawn and the guaiacum and sulphur continued in doses adequate to produce a daily evacuation.

The compound confection of guaiacum or the Chelsea Pensioner Powder have also stood the test of time, and may be taken in the appropriate dose daily for weeks. Personally, I have for years employed a cachet containing guaiacum, iodide of potassium, colchicum, and cinchona as a prophylactic measure in the inter-paroxysmal periods of chronic gout.

I would here, too, advance a plea for the use of guaiacum as the most useful laxative for constipation in the gouty, and in combination with sulphur where there is inactivity of the skin. The following is an excellent and well-tried formula:—

Such is a useful laxative and, during the day, may be often advantageously combined, in lingering articular gout, with a mixture containing iodide of potash, nux vomica, and cinchona. Luff, by the bye, holds that iodide of potash acts more beneficially when given in the compound decoction of sarsaparilla—the latter also is lauded by Garrod as having properties somewhat similar to guaiacum.

In conclusion, the subjects of long-standing gout not infrequently are anæmic. In such cases iron is often not well borne, and has been said to favour recurrence of acute attacks. Small doses, however, of a less astringent form agree well, always provided that the bowels are kept freely open. The ammonio-citrate, the iodide of iron, or one or other of the organic iron compounds are most suitable. These may be given alone or in combination with arsenic. For improving the general condition and promoting the nutrition of such subjects, Robin speaks highly of the following:—

In drawing to a close our discussion of the drugs most useful in the treatment of chronic articular gout, it will be noted that our usage of them is largely empirical, viz., the outcome of experience. We do not know exactly their mode of action, but this we do know, that they have stood the most searching of tests—that of results. That we should be largely, if not entirely, ignorant of their mode of action is regrettable, but no reason whatever why we should discard them in favour of newer compounds administered on some pseudo-rational basis.

What we need in gout is, rather, what Harry Campbell calls “a broad commonsense-rationalism—not a meddling finnicking pseudo-rationalism.” Ignorant of the intimate etiology of gout, we are not as yet capable of determining the exact nature of the underlying morbid processes. Much less are we in a position to devise a rational system of drug treatment whereby to antagonise the same. For us, then, the wiser, if more humble, rôle of correcting, if we may, such obvious deviations from physiological righteousness as we may discern, but ever mindful that we assist, not thwart, the subtle workings of the vis medicatrix naturæ, whereby the balance of the nuclein exchanges is restored.

Local Measures in Chronic Articular Gout

When treating of these in relation to acute articular gout, we dealt with the topical applications best calculated to achieve the absorption of inflammatory exudates and mitigation of the pain and stiffness associated therewith. It now remains for us to discuss the treatment of that specific product of gouty inflammation, viz., uratic deposition.

Treatment of Tophi.—Subcutaneous tophi in the neighbourhood of joints sometimes become tense and painful, and restrict the movements of the adjacent articulations. Garrod held that the continuous application of pledgets soaked in solutions of carbonate of lithia or of potash to tophaceous swellings had some power in reducing their size, and even effecting, in some cases, their total absorption. Also, with the intent of dissipating collateral inflammatory thickening, he sometimes used a solution composed of equal parts of iodide of potassium and carbonate of lithia.

More recently, Robin states that the resolution of tophi may be hastened by local applications of mineral waters containing magnesia and sodium chloride or a solution of sodium perborate, these affixed with considerable pressure over the harder parts of the tophus, gentle massage of which, he thinks, at other times, will aid absorption.

Luff, however, on this point, holds that “the application of the so-called solvents externally to affected joints is useless, as they are not solvents of sodium biurate,” and I am inclined to agree with him that but little is to be hoped for from this method of treatment. A more effectual method of local medication is by the electrolytic introduction of drugs.

Ionisation.—We may enlist cataphoresis, either for its analgesic or its sclerolytic effect. If relief of pain be desired, the electrolytic introduction of the salicylic ion from a cathode of a 2 per cent. sodium salicylate solution is most valuable. A current of 20-40 milliamperes, but only gradually raised, should be passed for twenty to thirty minutes. Too frequent applications of the latter strength may cause injury to the skin, and, in Lewis Jones’s opinion, are inadvisable oftener than twice a week.

If we wish to exercise a favourable stimulant effect in alterations of nutrition and atrophy caused by gouty inflammation, the chlorine ion definitely accelerates return to the normal state. Six-fold pads of ample size, soaked in a warm solution of sodium chloride, are used as a cathode and bandaged round the joint. The other “indifferent” electrode, similar in nature, is applied to different parts at different sittings, and in this way the pathway of the current through the joint changed. Currents up to 100 or even 200 milliamperes may be tolerated when applied to the knee; but the intensity of the current should only be raised gradually, as the burns that sometimes ensue occasion no small pain to the subject as well as discomfiture to the operator.

Iodine has a like sclerolytic action, and is commonly held to be superior to that of chlorine. On the other hand, the iodine ion is much less readily tolerated by the skin, and, according to Leduc, the necessary reduction in intensity of the current employed goes far to nullify the greater sclerolytic effect it may possess.

In chronic gouty arthritis we are, as before remarked, confronted not only with inflammatory products, but also with uratic deposits. Fortunately, these latter also are benefited by the electrolytic introduction of the lithium ion under an anode of lithium chloride. The current serves a double purpose in this case, for it not only drives in the lithium, but removes the uric acid ion which is to be found in the electrode. Edison, some years ago, suggested ionisation with lithium in gout, and the good results he obtained have since been abundantly confirmed by others.

The Schnee four-cell bath may be used where ionisation is indicated. It possesses obvious facilities for local or sectional application, as drugs can be added to the water in the cell and carried through the skin by means of the continuous current. Thus, in cases of large gouty deposits, the joint may be placed in a bath containing a 2 per cent. solution of iodide of lithium or of 5 per cent. bicarbonate of potash. The positive electrode is then located in the bath, while the negative pole, moistened with hot water, is applied to the lumbar region. Working with lithium in this manner, Bordier detected the presence of uric acid in the fluid of the bath, thus demonstrating introduction of the cation-lithium and removal of the anion-uric acid at one and the same time. In this way proof is adduced that the lithium penetrates the tissues, and coming directly into contact with uratic deposit, tends partly to dissolve it.

To achieve the dual purpose, viz., absorption of inflammatory and uratic deposits, we may with advantage give the chlorine or iodine ions, for their sclerolytic effect on the tissues, in alternate sittings with the lithium ions. When time is no great object, two or three séances a week will suffice, but where time presses, the sittings, according to Leduc, may be given daily, always provided that the position of the electrode and therewith the direction of the current in its passage through the joint be changed at each application. It is necessary to emphasise the fact that the use of too mild currents is futile, and to secure adequate results a prolonged series of séances is necessary. Also I would suggest that the simultaneous taking of a course of atophan would appear to be indicated.

Surgical Treatment.—In pre-antiseptic days, catastrophes, e.g., erysipelas, gangrene, etc., having occasionally followed the evacuation or removal of tophi, it was deemed inadvisable to interfere with them by any surgical methods. But, the danger of sepsis having been largely removed, it is now regarded as quite permissible to attempt the removal of uratic deposits for aesthetic reasons, or, more cogently, when they give rise to pain or restrict the movement of the related articulations.

Moreover, the old view that incision or evacuation of tophi was followed by obstinate ulceration is not borne out by modern experience. Thus my colleague Lindsay found that healing takes place quite naturally provided the incision is made over the more healthy skin towards the base of the swelling. With this I am in agreement, and furthermore would suggest that tophi when of large size and fluctuating are better opened with aseptic precautions than allowed to evacuate their contents spontaneously, for in this last event suppuration ensues, the sores become troublesome, and remain open for a long time. Sir Alfred Garrod in such circumstances advised touching up of the indolent parts with nitrate of silver.

In my search through the literature I have only come across two instances in which operation has been undertaken for the removal of gouty deposits in relation to tendon sheaths, bursæ, and skin. These were performed by Alexis Thomson. In one the subject was a medical man, aged thirty, the subject of inherited gout. Multiple tumour-like nodules, ranging in size from a pea to a cherry, were located over the knuckles, and the same were attached to the extensor tendons and moved with them. At the patient’s request, they were removed on account of their unsightliness. Their dissection from the tendons was achieved with some difficulty, and healing, though retarded a little by watery discharge from the wounds, was “in the end quite satisfactory.”

The other example occurred in a tailor, aged thirty-seven, in whom massive tophi developed at many sites. The larger deposits were located over the left external malleolus, the left olecranon, and the right malleolus. Because of their exposure to injury and pressure, removal of these various gouty tumours was decided upon. In all save the specially large swelling over the left external malleolus this was easily accomplished by cutting through the surrounding healthy tissues. But that at the site named “was so fixed to the bone that it had to be separated with a chisel; it was then seen that the chalky deposit occupied spaces in the spongy interior of the bone, and in the substance of the internal lateral ligament; the removal of the chalky material in the area of the wound was carried out more satisfactorily by scrubbing the tissues with gauze and hot water than with the sharp spoon. The peronei tendons exhibited a very pretty deposit of urates under the endothelium covering them.”

Healing of the wounds took place very satisfactorily, and nine months later the general health was excellent; no further tophaceous deposits had accumulated, and the scars of the wound had remained quite sound. As Alexis Thomson observed, that though, even as this particular case showed, spontaneous disappearance of tophi may follow a subsequent attack of gout, still such could not be hoped for in the case of a massive deposit in the left internal malleolus, invading as it did the interior of the bone. He sums up his conclusions in the following words: “My own experience is limited. So far as it goes, it establishes not only the safety of the removal of gouty tumours by surgical means, but also the improvement in the general health which follows the removal of large masses of urates from the exposed parts of the body. So far as appearances are concerned, the substitution of linear scars for unsightly tumours is a decided improvement.”

Now, if we take Riedel’s two instances of acute gout and their tolerance of incision and local cleansing of urates and the equally happy tolerance exhibited by Alexis Thomson’s two cases of chronic gout, we see that, in these days of aseptic surgery, even gouty arthritis can no longer be regarded as outside the pale of operative interference. But, as a caveat against rash ventures, I would point out that recently I canvassed the desirability of operation in a case of massive tophaceous deposits in the hands and feet; but fortunately a skiagraph was taken which revealed that several of the phalangeal shafts had at some sites in their length undergone total absorption.

Nevertheless, given sound general health and failure of other modes of treatment, I think that operative measures should be seriously considered, for in the more inveterate types of tophaceous gout the crippledom and painful ulceration renders the victim’s life a misery, and one incapable of appreciable amelioration by medicinal or other methods of therapy.

Treatment of Associated Morbid Conditions

When dealing with the clinical account, it was pointed out that acute gout is frequently complicated by symptoms pointing to involvement of the fibrous tissues in muscles and nerve sheaths; moreover, that both during acute attacks and alike in the inter-paroxysmal periods gouty subjects are prone to two special varieties of fibrositis, viz., lumbago and sciatica. I may add, too, that in these individuals it is not uncommon for them to suffer with these local varieties of fibrositis from time to time prior to the advent of regular or articular gout.

Fibrositis.—As Bassett Jones and I in our work on fibrositis have dealt exhaustively with the treatment of its various forms, our remarks here must necessarily be devoted largely to the general principles of therapy, and for further details we would refer the reader to our treatise on the subject.

Whatever the type of fibrositis we are confronted with, the therapeutic indications are precisely similar to those advocated for articular gout. In other words, the indispensable preliminary measures are to control the production, absorption, and elimination of toxins. To this end, we must secure adequate evacuation of the bowels, free action of the skin, and diuresis. These ends will the more surely be attained if at the onset a temporary fast be enjoined, or a suitable dietary with copious drinking of bland, unirritating fluid. The general malaise and pyrexia indicate clearly that these cases of acute fibrositis must be treated in accordance with the general rules applicable to the febrile state.

Acute Lumbago.—Brisk purgatives are here our most efficient allies, for there is usually marked functional derangement, with high-coloured urine and dark, offensive fæces. In such cases it is well to give 3-4 grains of calomel at night, followed in the morning by a saline purge, and the same often has to be repeated once or twice during the acute stage. Also the following prescription, preferably rendered effervescent by adding a few grains of citric acid to each dose, may swiftly abate the intensity of the suffering:—

Or, as in acute gout, we may give an initial large dose of 30-40 minims of colchicum wine, with subsequent attenuation of the same. It is in cases with scanty, high-coloured urine and costive bowels that colchicum succeeds best. On the other hand, in some cases of acute lumbago the urine is copious and light-coloured, and the bowels regular, and the fæces normal in appearance. Here the value of the initial purge is not so apparent, and a mixture containing salicylates and alkalies will be more likely to give relief, aided, if necessary, by nightly doses of Dover’s powder, followed by a morning draught of some aperient.

Where the case shows some disposition to linger on in a sub-acute form, and the urine still remains charged with lithates, a mixture of citrate or nitrate of potash, spirits of nitrous ether, and infusion of buchu should be given thrice daily. Sometimes, too, in broken-down subjects with sluggish circulation, we have found the addition of a few minims of tincture of digitalis most helpful in clearing up the condition.

Next to lumbago, pleurodynia is the most common muscular type of fibrositis to be met with in the trunk. I have seen its subsidence prove the signal for an outbreak of acute articular gout in the great toe. This significant sequence indicates the necessity of being alive to the possibility of a gouty basis in such cases and the advisability of combining colchicum with our remedies.

Sciatica.—This almost invariably is the outcome of a preceding attack of lumbago, of which, indeed, it is but an extension. If seen sufficiently early, and certainly when there are febrile symptoms, a mercurial purge, followed by an alkaline and diuretic mixture in combination with colchicum or salicylate of soda, should be resorted to vigorously, so as to abort, if possible, the attack.

If the underlying constitutional anomaly has been correctly diagnosed as gouty, the colchicum will exert its specific effect, and quickly, and the more speedily the sooner it is exhibited in the early stage. But even when seen later it is well worth trying the following combination:—

Having regard also to the gouty origin, it is hardly necessary to insist on regular and adequate evacuation of the bowels.

Of all varieties of gouty fibrositis the acute brachial type is the most difficult to treat, owing to the marked tendency to prolongation of the acute stages. The only chance of cutting short such an attack is not to treat lightly its earlier manifestations, but to bear in mind its evil potentialities; but only too often they do not come under observation until the condition is well established.

Gowers, who has written so illuminingly on this particular type of fibrositis, obtained the best results in the early stages from a combination of nitrous ether, citrate of lithium, and colchicum, with in addition, in the more intense forms, small doses of perchloride of mercury. Of the salicylates, salicin and aspirin, he speaks with but faint praise, and I have myself known them afford but little aid.

In reviewing the foregoing acute types of fibrositis, I would, as to relief of pain, insist on internal medication of all sorts being held as purely secondary to the infinitely more important matter of procuring rest and fixation for the inflamed structures. Immobilisation, indeed, supplemented by thermic and anodyne applications, hardly, if ever, fails to alleviate the suffering. If these prove futile, aspirin and phenacetin, either singly or in combination, should be exhibited. Here I would remark also on the value of cimicifuga, which I have found strikingly useful. Lastly, only very exceptionally in my experience is morphia called for.

In chronic or recurring forms of fibrositis we should mark any deviation from health in the shape of gastro-intestinal or hepatic derangement, while noting also any inactivity on the part of the kidneys or skin. As to drugs, chief reliance must be placed on the iodides guaiacum, arsenic, and sulphur. They are most useful, of course, when exhibited during the early stages, before organisation of the inflammatory products ensues. When hard and resistant nodules or infiltrations have formed, their administration is of little value.

It is for this reason that I have elsewhere advocated early resort to local massage, viz., at the close of acute attacks, as only by this means can we hope to dissipate these new formations, the persistence of which determines the inveterate tendency to recurrence. In the space at my disposal it will be impossible to consider in detail all the special modes of therapy—electrical, thermal, hydrotherapeutic, etc.—and for this information I must refer the reader to the next chapter.

Oxaluria.—This condition is sometimes met with in the gouty. The subjects are often nervous, irritable, and languid, complaining at the same time of vague pains, most frequently in the loins and along the distribution of the sciatic nerve. It occurs more commonly in persons of sedentary habit, and correction of this, as well as revision of their diet, is almost the only effectual method of getting rid of the complaint.

All vegetables rich in oxalates, such as rhubarb and spinach, must be eliminated, and likewise tea. At the same time, as Sir Alfred Garrod suggests, we should, to influence the proportions of the bases present in the urine, cut off all foods rich in calcium, i.e., milk and eggs. On the other hand, we should advise the intake of such as are rich in magnesium and yet poor in oxalic acid, viz., peas, beans, and coffee, and oxalate-free foods, such as all kinds of meat.

In my own person I suffered for some weeks with obstinate lumbar pain, the cause of which appeared to be obscure until the existing state of oxaluria was discovered by a professional colleague. I would here emphasise the fact that when a case of lumbar or sciatic pain is defiant of cure by the usual methods of therapy we should always suspect this possibility of oxaluria, for commonly the urine is copious and clear; hence perhaps the frequency with which the condition is overlooked.

As to medicinal measures, we should bear in mind that Sir John Rose Bradford pointed out that the production of oxalates was initially due to deficient HCL, with secondary fermentation of foodstuffs, i.e., carbohydrates, especially sugar. The primary indication, then, is to reinforce the digestive capacities by administering hydrochloric acid or, as many prefer the dilute nitric muriatic acid, in combination with nux vomica, and in some cases pepsin. As Sir William Whitla remarks, if organic acidity be prominent, this may be intensified by mineral acids, in which event alkalies combined with a few grains of papain two hours after meals are indicated.

In conclusion, the nerve element in these cases is so pronounced that a thorough change of air and habits is often indicated, combined with freedom from worry, abundance of exercise, and a stimulating course of hydrotherapy.

Glycosuria.—The variety met with in the gouty, being of the alimentary type, is usually very responsive to dietetic measures, and these have been already dealt with. A course of spa treatment is often the best possible mode of therapy for these cases.

As to medicinal measures, these certainly should not be embarked upon until the effect of dietetic revision has been ascertained. If under their influence the glycosuria wholly disappears, then drugs may be uncalled for, save perhaps occasional aperients, antacids, or similar remedies of like nature. If, on the other hand, the glycosuria cannot be kept under control by dietetic measures, then recourse must be had to drugs. Here it may be noted that guaiacum diminishes the amount of sugar excreted, and it may be given a trial before resorting to codeia. Generally speaking, when the case requires codeia it has passed out of the realm of gouty glycosuria into that of true diabetes, the treatment of which grave disorder is beyond the scope of this work.

Hyperchlorhydria.—The disorder is rare in gouty patients, and its diagnosis from organic acidity cannot be made without examination of the stomach contents. Moreover, when found to be present an endeavour should be made to elucidate its cause. If gastric and duodenal ulcer can be excluded and the condition appears to be of the nature of a secretory neurosis, then the underlying nervous defect will call for treatment.

In some cases the exciting cause lies in errors of diet and habits of living. These when faulty require correction; very often in these cases it is not so much the nature of the food as the hurried manner in which it is bolted that is responsible. At times, when free from hurry or worry, they can eat any kind of food with impunity. When the attacks are on, it frequently happens that all types of food, whether easily digestible or not, are equally provocative of acidity. We see then how large a part general hygiene plays in the successful treatment of these cases.

As to diet, this is, of course, of primary importance, the main indications being the reduction or withdrawal of farinaceous foods, and for a short period on a Salisbury regimen or some modification thereof.

The medicinal indication is to afford relief during the acute attacks. Fortunately these are usually intermittent, and when the occasion arises are fairly readily controlled by massive doses of alkalies, frequently combined with an artificial digestive, i.e., papain. While magnesia and bicarbonate of soda are, as a rule, invoked, others speak well of sodium phosphate (5 grams) with menthol (0·25 gram), given two hours after each meal.

Luff, discussing hyperchlorhydria in the gouty, highly extols hopogan (magnesium peroxide), in doses from 20-30 grains, one hour after food, the amount to be reduced if it causes purgation. To inhibit excessive production of HCL, belladonna, in 5-minim doses of the tincture, before meals results in reduction of acid values, both absolute and relative, of the stomach contents, and, moreover, relieves spasmodic contractions. Constipation in these gouty subjects is best combated by an occasional nightly pill containing colchicum in combination with aloes or other laxative. Lastly, when digestion becomes more normal nervine tonics, such as arsenic, valerian, and the like, may be given to correct, if possible, the underlying nerve element in these troublesome cases.

Gouty Phlebitis.—To obviate the risk of embolism, absolute immobilisation of the affected limb is imperative, and it should be slightly elevated and protected by a cradle. In many cases it will suffice if the limb be enveloped in cotton wool and a broad, many-tailed bandage lightly and evenly applied. If the pain be severe, equal parts of glycerine and the green extract of belladonna should be smeared along the course of the inflamed vein and hot fomentations applied. Internally saline aperients should be given to secure daily evacuation of the bowels, and a mixture containing iodide of potassium and ammonium carbonate taken three or four times a day, to promote solution of the clot.

Gouty Eczema.—In these cases the primary indication is to revise thoroughly the diet, to the end of correcting a frequently associated gastro-intestinal derangement, notably any tendency to constipation. If these the basal indications are not fulfilled, all local forms of medication will be futile. As to these last, the primary desideratum is to protect the parts from all accidental irritants, and the chief source of offence is scratching by the victim himself. Otherwise we should take every care to prevent irritation by clothing, hard collars, etc.

While cleanliness is essential, the soaps used should be of the neutral kinds, or bran or barley-water substituted. Ointments and lotions are best avoided. In the milder cases protection of the parts is the essential. In the limbs this may be attained by glyco-gelatine zinc; but on the neck, the groin, the inside of the thighs or lower parts of the abdomen, the tragacanth pastes or similar preparations are more suitable. Both the gelatine and the pastes and varnishes may be readily medicated with drugs of anti-pruritic properties, such as oil of cade, carbolic acid, resorcin, or salicylic acid.

Gouty Nephritis.—This must be treated on the lines recognised as suitable for chronic Bright’s disease, the underlying gouty condition being always borne in mind, as also any contamination with lead. As general measures any excess in eating or drinking must be avoided, the skin kept active, and the bowels open; and where possible favourable climatic conditions should be attained.

Frequently the treatment resolves itself into that of the associated arterio-sclerosis with high blood pressure. This we should endeavour to control by regulation of the subject’s habits in the matter of diet, work, exercise, etc., rather than by flying forthwith to the use of vaso-dilators, premature resort to which has often proved the beginning of the end.

Moreover, I would, like many others, strongly deprecate the far too prevalent practice of dilating to these subjects on the evil potentialities of raised blood pressure. Not a few thenceforth literally walk in the valley of the shadow, and the fear of sudden death is ever before them. It is not only cruel, but frequently unnecessary. Often the increase of tension is no more than their age would account for, and equally often no symptoms indicative of raised blood pressure are complained of. Why then make the subject miserable?

By all means, take the blood pressure, but say as little as possible about it. These people, in my experience, need more often to be reassured than frightened. Only now and again does one meet with individuals who must for their own sake be gravely warned of the dangers incidental to their condition, men who, despite the warnings afforded by giddiness, epistaxis, etc., will not alter their ways of living.

As to medicinal measures, all agree that an occasional blue pill or a dose of calomel, ½-1 grain, for three or four nights in succession, and followed in the morning by a saline purge, is one of the most satisfactory procedures to adopt. Hand in hand with this, a course of iodides, gr. 10-15 three times a day, for some weeks, is also most beneficial. After six or eight weeks of the above we may substitute a course of nitrites, e.g., nitro-glycerine, sodium nitrite, or erythrol tetranitrate. Nothing is better in the milder cases than Sir Lauder Brunton’s formula, the efficacy of which I have often proved:—

Needless to say, vaso-dilators should not be exhibited if signs of waning cardiac power are evident. Also when there is much albumen the use of mercurial purges calls for great discretion, and saline aperients should be given the preference. Insomnia, a frequent trouble in these cases, is best met by bromides, and I agree with Luff that in gouty subjects sleeplessness is better combated by measures which reduce arterial tension than by resort to hypnotic drugs.

Lastly, symptoms of cardiac dilatation and failure, which should be suspected when the arterial pressure falls without the previous use of vaso-dilators, will call for the exhibition of cardiac tonics: digitalis, strophanthus, and strychnine; and threatened uræmia may be postponed by a judicious dietary, saline purgation, and diaphoretic measures.