MEDICINAL AND OTHER MODES OF THERAPY (_continued_)—CHRONIC ARTICULAR GOUT
AND ASSOCIATED MORBID CONDITIONS
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:—
℞ Pot. iodidi gr. 5-10
Pot. bicarb. gr. 15
Spts. ammon. aromat. ♏︎ 20
Vin. colchici. ♏︎ 5
Tinct. capsici. ♏︎ 1
Inf. aurantii co. ad unciam ter in die sumenda post cibos.
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.
℞ Hydrarg. sub chlor. gr. ⅟₁₀
Guaiaci resinæ gr. 3
Sulph. precip. gr. 3
Fiat. cachet. Ter in die sumenda post cibos.
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:—
℞ Sulph. precip.
Pulv. guaiaci
Pot. bitart. āā ʒj.
Pulv. tragac. co. ʒij.
Fiat pulv., ½ to 1 teaspoonful to be taken stirred up in water
or milk at bedtime.
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:—
℞ Acidi arseniosi gr. ⅟₈₀
Potassii iodidi gr. 1
Pulveris rhei
Extracti gentianæ āā q.s.
Misce. Fiat pilula i. “Two pills to be taken daily at meal time.”
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:—
℞ Pot. bicarb. gr. 15
Pot. nitrat. gr. 10
Vin. colchici ♏︎ 10-15
Aquæ ad unciam, quartis horis sumenda.
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:—
℞ Quin. hydrochloratis ½ drachm.
Pot. iodidi 2 drachms.
Vin. colchici 1 ounce.
Tinct. aurantii 2 ounces.
Aquam chloroformi To 8 ounces.
Sig., 2 teaspoonfuls in a wineglass of water twice a day.
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:—
℞ Sodium nitrite gr. ½-2
Potassium nitrate gr. 10-20
Potassium bicarb. gr. 10-30
Fiat pulvis, to be taken in a tumblerful of water every morning.
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.