Part 18

Next to the fermented liquors, the use of saccharine food in the diet of gouty persons needs to be restricted. This limitation also is one which common experience confirms. Sweet foods cannot be said to be as provocative of the dyspeptic derangements of the lithæmic subjects as wine and beer, but they are certainly often responsible for the formation of {129} the dyscrasia and for perpetuating many most distressing ailments. Their more or less strict prohibition may constitute the essential point of treatment not only in controlling the progress of the constitutional vice, but in subduing some of the most rebellious lesions. It is important to observe that this prohibition sometimes involves abstinence from sweet and subacid fruits, in the raw as well as in the preserved state. Paroxysms of articular gout have been known to follow indulgence in strawberries, apples, watermelons, and grapes, and the cutaneous and mucous irritations which follow even the most moderate use of these fruits in some gouty persons are certainly not uncommon.

Next in order to the saccharine foods as the source of indigestion in gouty persons come the amylaceous aliments. These constitute, necessarily, so large an element in ordinary diet that the limitation of them in the dietary of gouty persons applies, in the majority of cases, only to their excessive use. This excessive use, however, is often observed. There is a popular prejudice in favor of this class of foods, and a corresponding prejudice against the too free indulgence in animal foods. The purely starchy aliments, such as potatoes and the preparations of corn and rice, and even those which contain a considerable portion of gluten, like wheat, oatmeal, and barley, often provoke in gouty subjects a great deal of mischievous and painful indigestion. This feeble capacity for the digestion of farinaceous foods is most frequently observed in the children of gouty parents, and especially in persons inclined to obesity, and in those whose occupations are sedentary and whose lives are passed for the most part in-doors, and they are least common in those whom necessity or pleasure leads to much active muscular exercise in the open air.

The fats are as a rule easily digested by gouty dyspeptics. This is a fortunate circumstance, for the reason that in the anæmia which is frequently one of the consequences of chronic gout the fatty foods are of inestimable value. In cases of persistent and rebellious lithæmia an exclusively milk diet constitutes a precious resource.

The succulent vegetables, such as tomatoes, cucumbers, cauliflower, cabbage, and the different varieties of salads, constitute for the gouty as well as the diabetic subject agreeable and wholesome additions to a diet from which the starchy and saccharine vegetables have to be largely excluded.

The quantity of food proper for gouty persons to consume can only be determined in individual cases by the age, the habits, and the occupation. It is fair to assume that in adults, in whom there is no longer any provision to be made for growth, the daily quantity of food must be regulated according to the amount of energy which is expended. In this energy must be reckoned the amount necessary for the maintenance of animal heat and the other vital functions, and the amount which is necessary for the operation of every variety of nervous force. In other words, the potential energy latent in the food must correspond to the active energy exhibited in the daily evolution of vital, intellectual, and mechanical work. The more nearly this balance is maintained the more closely the physiological standard of health is preserved. That an excess of food is a most frequent cause of the gouty dyscrasia among the well-to-do classes is undeniable, and it is possible that regulation of the quantity according to the rule above mentioned {130} may, after all, be the most important point in the management of many gouty patients. It may be, also, that the reason why the withdrawal of the carbohydrates produces its good effects upon these patients is that we thereby exclude a large amount of force-producing foods which do mischief because they are imperfectly consumed.

EXERCISE.--Next in importance to diet as a hygienic regulation in the 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.