management of gouty patients is enforced exercise. The axiom of
Abernethy, "to live on a shilling a day, and earn it," comprises the
philosophy of the true relations of food to work, and of both to the
highest development of physical health. Exercise is to be enforced not
simply as a means of securing an active respiration, and thereby an
abundant supply of oxygen, but also as a means of converting the
potential energy of the food consumed into vital energy. The essential
condition, moreover, of healthy nutrition in every organ and in every
tissue is the maintenance of a vigorous functional activity. Over-use
is not more productive of tissue-degeneration than disuse. Hence the
question of exercise in its largest sense involves not only muscular
work, but work of all kinds, which tends to promote a healthy activity
of the psychical as well as the physical functions. Muscular exercise
in the open air has a special value for the victims of this gouty
dyscrasia by equalizing the circulation, quickening the respiratory
movements, and stimulating the elimination of effete matters from the
skin and lungs, but mental work and wholesome diversions are not less
important as antagonizing the evil effects of indolence and
over-feeding, which are among the common predisposing causes of
acquired gout. In persons who are incapacitated by neuræsthenia or by
excessive corpulence, the result of long indulgence in indolent and
luxurious habits, it may be necessary to resort to passive exercise by
rubbing, massage, and electrical excitation in order to secure the good
effects of voluntary work.
BATHING.--Another hygienic regulation of great value in the treatment
of gouty dyscrasia is the promotion by bathing and friction of the
eliminative function of the skin. Daily sponging with cold water, where
it is not contraindicated by a feeble circulation and a slow reaction
from the shock, is a practice to be commended. Where, for the reasons
mentioned, it is not practicable, tepid baths and frictions may be
substituted. In cases where the arthritic lesions are progressive and
advanced much benefit may be derived from hot baths. It is doubtful
whether the thermal alkaline and sulphur spas owe their renown in the
treatment of chronic gout so much to the mineral ingredients of their
springs as to their high temperature. The Russian and Turkish baths
furnish most efficient means for increasing the functional activity of
the skin, but they often have a depressing effect on the action of the
heart, producing faintness and dyspnoea, and should always be advised
with caution.
CLIMATE.--In rebellious forms of the gouty dyscrasia a warm climate is
unquestionably a hygienic condition of great value. The geographical
distribution of gout, which shows that the disease is much less common
in warm than in temperate and cold climates, while it may not perhaps
be wholly explained by temperature alone, is very certainly largely due
to it. The possibility of out-door life and the increased functional
activity of the skin which warm climates favor are circumstances more
or less antagonistic to the development of the gouty diathesis.
{131} MEDICINAL TREATMENT.--The objects to be aimed at in medicinal
treatment of the gouty dyscrasia are--
1st, the improvement of the primary digestion.
2d, the relief of the gastro-intestinal catarrh, which is the cause of
the direct and reflex dyspeptic symptoms which belong to this
diathesis.
3d, the augmentation of food-oxidation, so as to secure its thorough
combustion.
4th, the promotion of the elimination of the waste products of
nutrition.
1. The improvement of primary digestion--or, as it has been aptly
called, exterior digestion--often requires very strict attention beyond
the proper selection of alimentary substances. The distressing symptoms
that indicate primary gastric and intestinal indigestion are certainly
often relieved by the rigid exclusion of certain articles of diet, but
in many cases it is necessary to assist the preparatory processes which
are essential to perfect food-absorption by artificial methods based
upon the knowledge derived from physiological experiment. To no one is
the knowledge of these methods more largely due than to Roberts of
Manchester. Preparations of pepsin and pancreatin, by which the
proteids and starches are peptonized and the fats emulsified, are often
of inestimable value in the treatment of gouty dyspepsia. Pancreatin,
especially, which by means of its trypsin, diastase, and emulsive
ferment possesses the threefold property of aiding the digestion of the
azotized, amylaceous, and fatty elements of food, is certainly the most
valuable of the artificial means for augmenting the efficiency of
primary digestion.
2. The relief of the gastro-intestinal catarrh in gouty dyspeptics may
often be accomplished solely by dietetic restrictions and by the aid
which may be given to primary digestion. It is often necessary,
however, to direct some special medication toward the relief of the
catarrhal lesion. The circumstances which demand this special
medication are the existence of portal congestion, the result of
functional derangement, or of chronic atrophy of the liver, or of
chronic diffuse or interstitial nephritis, or of cardiac disease. The
hydragogues, such as calomel, podophyllin, colocynth, and other
vegetable cathartics, with the salts of sodium and magnesium,
constitute the most common and efficient means of relieving portal
congestion, whether it arise from temporary functional derangement or
from organic disease. The renown of some of the more famous mineral
springs in relieving the miseries of gouty sufferers is due mainly to
the relief of portal congestion and the washing away of the catarrhal
mucus which obstructs the process of primary food transformation and
absorption. This is especially true of the sulphate of sodium waters,
like those of Carlsbad, Marienbad, Friedrichshall, Pullna, and Hunyadi
János. While the value of these waters in chronic gout is
unquestionable where their use is properly regulated, there is good
reason to believe that their long-continued employment is often harmful
by relaxing the mucous membrane, and thereby tending to aggravate the
condition they are given to relieve. This is markedly true of their use
in weak and anæmic persons. For these the milder magnesian waters, such
as those of Kissengen, Hombourg, Wiesbaden, and Saratoga, are to be
preferred.
3. The augmentation of food-oxidation may be accomplished in a large
degree by regulation of the diet and by out-door exercise. The {132}
regulation of the diet according to the occupation and habits of life
is a point of primary importance in securing proper blood-elaboration.
My experience leads me to believe that the evil consequences of in-door
occupations and sedentary habits are most common in those who live upon
a diet composed largely of starchy and saccharine foods, and that a
diet in which animal foods and fats predominate is best suited to
indoor workers, whether they be engaged in mechanical or intellectual
labor.
The medicines which help to promote the oxidation of the food-elements,
especially the carbohydrates, are alkalies and iron. Clinical
observation establishes this fact as strongly in the treatment of gout
as in that of glycosuria. The relative power of the salts of potassium
and sodium in augmenting oxidation is not clearly determined. The salts
of sodium appear to be most useful in aiding the process of primary
digestion, and the potassium salts in improving the process of
sanguification. It is well known that potash predominates in the
corpuscles and soda in the serum of the blood. The efficacy of the
combinations of iron with the salts of potassium, as in Blaud's pills
and in the citrate and tartrate of iron and potassium, in the treatment
of anæmia, is well known. In the most renowned ferruginous springs,
however, such as those of Schwalbach, Spa, Pyrmont, and St. Moritz, the
iron is combined with salts of sodium, calcium, and magnesium. It would
appear, therefore, that the increased energy of iron in augmenting
hæmatosis, when combined with alkalies, is not relatively greater with
potash than with either of the other alkaline bases.
4. The promotion of the elimination of the waste products of nutrition
is to be accomplished by remedies which act as solvents of uric acid
and as diuretics. As solvents of uric acid the salts of lithia and
potash have been shown to be superior to those of soda. The urate of
lithia is the most soluble of the uric-acid salts, and the low chemical
equivalent of the metal lithium makes the neutralizing power of the
oxide much greater than that of equal proportions of the other
alkalies. It is used in the forms of carbonate and citrate, and is
generally combined with potash and soda. It exists in some of the
mineral springs of Europe and of this country, but in such minute
proportion as probably to be of little value. In administering the
salts of potash and soda it is generally admitted that the carbonates
and the neutral salts of the organic acids are to be preferred to
solutions of the caustic alkalies. They have less power in neutralizing
the acid of the gastric juice, and enter the circulation as neutral
salts, where they are decomposed into alkaline carbonates by the
oxidation of the organic acids, increasing the alkalinity of the serum
and acting as diuretics. The combinations of the alkalies with sulphur,
with iodine, and with mineral acids, as in the alkaline springs, are
frequently used in the treatment of gouty lesions of the subacute
variety. The sulphur salts probably owe their chief value to their
alkaline bases when they are used internally; and in sulphuretted
baths, as before remarked, the good effects are probably due to the
high temperature at which the bath is usually administered.
The salts of iodine are generally supposed to have a special action in
removing the consequences of chronic fibrous inflammation in gout and
rheumatism. They often disturb the digestion and provoke troublesome
irritations of the skin and mucous membranes. In removing the sclerotic
{133} effects of gouty inflammation they do not exhibit the same
sorbefacient power which they show in their action upon the granulation
tissue of syphilitic origin. It must be admitted, however, that in
certain catarrhal affections of a gouty nature the iodides of potassium
and sodium are almost specific in their good effects. In the
pharyngeal, laryngeal, and bronchial catarrhs from which some gouty
persons suffer, where there is a dryness and irritability of the mucous
membrane, the administration of these salts produces the most prompt
and beneficial result. As solvents of uric acid they do not appear to
equal the salts of the organic acids.
As to the mode of administering salines in the treatment of the gouty
dyscrasia, it is hardly necessary to observe that it must vary with the
effect desired. As antacids in acid dyspepsia they should be given soon
after meals, and for this purpose the salts of soda are to be
preferred, for the reason that they not only neutralize excessive
acidity, but they increase the efficiency of the peptonizing process.
Where it is desired to introduce these salts into the circulation for
their solvent action, as diuretics or to assist the process of
sanguification, they should be given three or four hours after meals
and largely diluted with water.
Before concluding the consideration of the treatment of the gouty
dyscrasia it should be remarked that the ability of water as a solvent,
as a means of stimulating tissue-changes and eliminating waste, is not
generally estimated at its true value. The use of copious libations of
hot water in the treatment of gout, recommended by Cadet de Vaux in
1825, has been revived from time to time, and is at present attracting
considerable attention.
TREATMENT OF ACUTE ARTICULAR GOUT.--There are three distinct methods of
managing an attack of acute gout--the antiphlogistic, the expectant,
and the abortive.
The antiphlogistic method, in the strict application of the term, is
practically obsolete. Bloodletting, both general and local, brisk
catharsis and diaphoresis, with low diet, were formerly advocated as
the natural and imperative antagonists of gout as well as of all other
acute inflammatory affections. Carried to its extreme degree, this
method was deprecated by Sydenham and his disciples as tending often to
prolong the attack and precipitate the manifestations of atonic gout.
The natural reaction from the vigorous antiphlogistic practice was what
has been termed the expectant method.
The expectant method may be said to be founded upon the aphorism of
Mead that "gout is the cure of gout." The discovery of the salts of
uric acid in the blood-serum and in the affected tissues gave a
scientific basis to the humoral pathology of gout and led to the
formulation of definite principles in the application of the expectant
method of treatment. These principles are the prevention of the further
accumulation of the urates in the blood and the promotion of their
oxidation and elimination. The first principle involves restriction to
a rigid diet during the attack, excluding albuminous foods and the
fermented preparations of alcohol, and allowing only milk and
farinaceous gruels. The oxidation of the urates is encouraged by the
administration of alkalies and by an abundant supply of air, the
inhalation of oxygen even having been recommended. The elimination of
the urates is accomplished chiefly {134} by diuretics and moderate
catharsis. The local treatment commonly used with this medication
consists in the application of alkaline and anodyne fomentations or of
dry flannel or cotton. Local bloodletting and blistering are now rarely
commended. Under this treatment the intensity of the inflammatory
process is abated, the suffering is allayed, but the progress and
duration of the disease are not materially modified. The recovery,
however, is satisfactory, and it is claimed that the chances of early
recurrence of the attack are diminished. This method has many
advocates, though it cannot be said to represent the common practice of
the present day. It is becoming traditional, and may be said to be
gradually giving place to the specific or abortive method.
The abortive method consists in cutting short the attack by the
administration of colchicum, veratria, or the salicin compounds.
The value of colchicum in joint affections is a tradition of the
earliest records of medicine. It shares its curative effects in acute
gout with veratria, and, though the active principle of the meadow
saffron and the veratrum album are not isomeric, their effects are
similar. They constitute the basis of the famous nostrums so
extensively patronized by sufferers from gout. Colchicum is the active
agent in the eau médicinale de Husson, in Wilson's and Reynolds's
specifics, and in the pills of Lartigue and Blair, while veratria is
supposed to be that of Laville's remedy. The action of these substances
is not understood. The physiological action of colchicum is that of a
local irritant and a cardiac depressant of great energy. It purges
violently when given in large doses, causes nausea and vomiting, and
may produce collapse. In therapeutical doses in a gouty paroxysm it
acts as a diuretic and an antipyretic, and allays, sometimes in a most
magical manner, the objective and subjective symptoms of the disease.
As simple purging by other cathartics does not abort the gouty seizure,
the value of colchicum cannot be ascribed to its purging effect, and,
besides, purging is by no means necessary to its efficiency. Nor can
its utility be ascribed to its diuretic property. There is some
question in regard to its claims as a diuretic, and there seems to be
no doubt that it often does good where this effect is not observed. Its
influence upon the heart does not explain its marvellous action upon
the local process, for the same influence obtained by other drugs has
no such result. We are driven, therefore, to the conclusion that
colchicum has a specific action in gout as certain and as inexplicable
as that of quinia in malarial fever, or iodide of potassium in
constitutional syphilis. For those who accept the theory that gout is a
tropho-neurosis the therapeutical action of colchicum is a strong
confirmation of its neurotic origin, for the reasons that colchicum has
no influence upon arthritic lesions which are not gouty, and that its
physiological effects point to its action on the nervous system.
It is useless, however, to speculate on the way in which colchicum and
allied substances affect gouty inflammation; the practical question to
be determined is: Are they the best and safest remedies to control it?
Upon this point there is a wide diversity of opinion. The objections to
the colchicum treatment are based upon humoral pathology, and upon the
idea that the attack is an effort of nature to cast out the poison and
purify the blood. Colchicum, it is claimed, arrests this process; the
poison is retained, diffuses itself through the tissues, and lays the
{135} foundation of vascular and visceral lesions. It shortens the
intervals between the attacks, and tempts the patient to continued
indulgence in the habits which perpetuate and exaggerate the disease.
The advocates of the abortive treatment, on the other hand, claim that
these arguments have no real force as applied to its therapeutical
value. The cure accomplished is, to all appearances, complete, and the
patient is saved the suffering and exhaustion which result from the
expectant method. The fact that he is so easily and speedily cured, and
that he resumes his vicious habits and suffers recurring attacks in
consequence, proves only that the treatment lacks the quality of moral
discipline which belongs to prolonged suffering and the penance of
vigorous medication. It is an acknowledged fact that the great majority
of sufferers from acute gout decide sooner or later in favor of the
abortive treatment; and as professional opinion has heretofore
generally advocated the expectant or eliminative treatment, they
commonly resort to the use of some one of the quack remedies which
contain colchicum or veratria.
In view of the present uncertainty of our knowledge of the true
pathology of the acute gouty arthritis, as to whether it is a
tropho-neurosis or the result of the local irritation caused by the
salts of uric acid, the specific treatment seems to be justified by a
regard for the comfort of the patient and as a means of protecting him
against falling into the reckless use of quack remedies. A speedy
relief of the acute symptoms, followed by the treatment appropriate to
the gouty habit, would seem to be the most rational and safest mode of
managing the acute articular attacks of gout.
The selection of the preparation of colchicum in the treatment of an
acute paroxysm is a matter of individual experience and preference. The
acetous extract and the wine of the seeds are most commonly used, and
many practitioners are not scrupulous in prescribing the proprietary
preparations of Reynolds, Laville, and Blair. The wine of colchicum may
be given in doses varying from 20 to 40 minims, alone or combined with
Epsom salts in drachm doses, with small quantities of opium, every six
or eight hours. Under this medication the pain, tenderness, and
swelling rapidly abate, and sometimes with an abruptness that is
magical. As soon as the acute symptoms subside, the colchicum should be
continued in smaller and less frequent doses until the fever and local
tenderness subside. The use of quinia with small doses of colocynth
after the colchicum has been discontinued helps to re-establish the
strength and regulate the digestive functions. The patient should
always be warned against the possible demoralizing effects of a speedy
recovery from a serious disease. Recurrence after the colchicum
treatment is certainly more common than after the expectant method, but
this should not be ascribed so much to a defective cure as to the
temptation which the antidote offers to trifling with the poison. The
accidents which have been ascribed to colchicum through its causing
heart-failure are probably to be explained by its injudicious
administration in large doses where acute gout is complicated with
cardiac or renal degeneration.
Next in importance and value to colchicum in the abortive treatment of
gout are salicin, salicylic acid, the sodium salicylate, and the oil of
wintergreen. Unlike colchicum, which has no marked effect upon acute
rheumatism, these medicines appear to act with similar energy on {136}
gout and rheumatism. The rapidity and the almost uniform way with which
they allay the inflammatory symptoms in rheumatic fever are well known;
their value as specific remedies in both acute and subacute gout is not
so generally appreciated. Whether the specific action of colchicum in
gout differentiates this disease from rheumatism, or whether the
similar action of the salicin compounds indicates that these diseases
are allied in their etiology, are questions yet to be solved. The good
effects of salicin and the sodium salicylate in many of the forms of
irregular gout, and notably in the dyspeptic disorders and the
erythematous tegumentary lesions, are especially worthy of notice. In
acute attacks of articular gout the salicylic acid or the sodium
salicylate, in 15 or 20 grain doses repeated every three or four hours,
will often cut short the attack, and will very certainly allay within
twenty-four hours the acuteness of the symptoms. As in rheumatism, the
medicine should be continued in smaller doses after the acute symptoms
have subsided for several days, the tendency to relapse being marked if
the drug be discontinued too soon. In subacute articular gout and in
the irregular forms of the disease, where the medicine has to be
continued for some time, salicin and the oil of wintergreen are to be
preferred to salicylic acid and the sodium salicylate. They are less
liable to disturb the stomach and to produce toxic effects.
It is unnecessary to describe the treatment of the different forms of
irregular gout, inasmuch as the general principles described in the
treatment of the gouty dyscrasia involve the most important
considerations in the management of these affections.
{137}
RACHITIS.[1]
BY A. JACOBI, M.D.
[Footnote 1: There is a difference of opinion as to the correct
spelling of this word, and strong reasons exist to regard the form
_rhachitis_ as the proper one. It is true that this spelling of the
word has been remarked upon as unorthographical by many, mostly modern,
authors. Even Virchow writes "Rachitis," claiming that Glisson took the
term from "the then popular _rickets_." This is a mistake, as H.
Rohlffs points out (_Deutsches Arch. f. Gesch. d. Med._, 1883, p. 294).
Rachitis is a Greek word, and was used in the classical time of
Hellenism. It has, however, seemed best to preserve here the usual
spelling, rachitis, which has become sanctioned by general usage.]
DEFINITION.--Rachitis is a general nutritive disorder, almost always of
long duration, usually with an introductory stage of weeks or months
and a course mostly extending over months or years. Its beginning is
mostly gradual, its final recovery slow. It is complicated with or
dependent on disorders of the digestive or respiratory apparatuses,
which are preceded by a disposition probably created by an undue width
of the arteries. It exhibits amongst its prominent symptoms muscular
debility; perspiration; anomalies of the subcutaneous tissue, which is
either very much infiltrated with fat or deprived of it; disturbances
of the intellectual and moral functions, and of those of the large
thoracic and abdominal viscera and lymphatic glands; changes in the
latter may outlive all others. Its most perceptible symptom, however,
consists in an inflammatory disease of the primordial cartilage of the
epiphyses, a copious deposit in that region and also under the
periosteum of the bones; curvature of the diaphyses, and, while
absorption remains intact, softening and retarded ossification of the
bone. Without these affections of the osseous system the diagnosis of
rachitis is not complete.