CHAPTER XXXII. Mineral Springs and Choice of Spa

MINERAL SPRINGS AND CHOICE OF SPA

MINERAL SPRINGS

Though many have tried, no one has yet been able to define exactly what does and what does not constitute a “mineral water.” Criterion after criterion has been suggested—chemical, therapeutic, thermic, cryoscopic, ionic, etc.—but to all there seem objections, and doubtless will be, pending the advent of more exact knowledge regarding these—the most complex pharmacological compounds in our Materia Medica.

Naturally, “mineral waters” being so refractory of definition, it follows that all suggested classifications are equally perplexing. In fact, all attempts to reduce them to order according to their generic and specific differences are, it must be admitted, unsatisfactory. Perhaps the most serviceable differentiation at our disposal at present is one based on their chemical composition. As Sir Hermann Weber says, “a statement of the salts contained in a mineral water often tells the ordinary medical man something of the nature and probable effects of the water in question, whilst the results of an analysis expressed in ‘ions’ would simply bewilder him.”

“Probable effects,” says Weber, and, I think, advisedly; for in estimating the effects of spa treatment how difficult to discriminate between what is due to “mineral waters” and what is due to change of air, diet, mode of life, and mental occupation. Yet, again, how bewildering the fact that “waters” of the most varying chemical content prove to be equally beneficial in gout. Small wonder, then, that physicians sought to refer their therapeutic efficacy not to their mineral constituents, but to the vehicle common to all of them, viz., to the diluent and solvent action of the water itself, its flushing effects in washing out urates and other toxic substances.

From this it was but a short step to the further assumption that, other things being equal, the drinking of water at home would do just as well as resorting to a mineral spring. But, as has been shrewdly said, the “other things” never are “equal.” What of the daily worries left behind, the change of air and scene, the modifications of diet, the leisure for outdoor exercise, not to mention hydro-therapy and other integral or collateral factors of spa treatment?

But, even frankly admitting our ignorance, the lessons of experience, nevertheless, can neither be flouted nor ignored, least of all in the treatment of gout. “Mineral waters” are but used empirically, says the critic, forgetful that the use of colchicum lies open to the same aspersion. Especially valid the imputation, as he thought, in regard to the so-called “simple” or “indifferent” thermal waters. These—despite the testimony of centuries to their worth—must be discarded in favour of some pseudo-rational method, and this, forsooth, because their mode of action seems inexplicable! Yet, by the irony of Fate, within a brief span these “indifferent” waters were found to contain a substance—“radium”—whose powers few, at present, pretend to gauge or limit. There seems, in truth, a peculiar fitness in the coincidence that it should be in this very group that experimental investigations have proved so fruitful.

Is it not, moreover, a striking fact that the waters of nearly all the natural springs which for centuries have been used in the treatment of gout are thus dowered, and those which are most lowly mineralised seem to possess the greatest degree of radio-activity? It was to their possession in varying measure of this common property that the therapeutic efficacy of waters so widely different in their chemical content was presumably in large part attributable, viz., to their radio-activity.

For alike in simple thermal, sulphurous, alkaline, sulphated alkaline, or muriated waters, the presence of radio-activity has been established. But if, e.g., in the simple thermal, their therapeutic potency is referable to their higher degree of radio-activity and not to their mineral content, in others their relative deficiency in radio-activity is compensated for by their mineral constituents—these present in sufficient quantity to exert a specific action, alterative, aperient, tonic, etc.

In this matter of mineral content we are reminded of the grievous controversy that has long obtained with regard to the use of natural waters, the chief constituents of which are sodium salts. Sir William Roberts, as we know, from his experiments, ascertained that sodium salts promoted the conversion of the quadriate into the biurate, thus augmenting the precipitation of the latter.

This behaviour on the part of the carbonates, bicarbonates, and phosphates of sodium led him to the sweeping generalisation that all sodium salts, including the chloride, were, as far as practicable, to be avoided by gouty subjects. Naturally, in conformity with this view, such patients were warned to flee those spas whose waters contained these peccant salts.

Carried to its logical end, this dictum would have cut the gouty off from, e.g., the carbonate of soda waters of Vichy, the chloride of sodium springs of Homburg, the sulphate of soda waters of Karlsbad, not to mention the muriated (sodium chloride-containing) sulphur waters of Harrogate, Llandrindod, etc., despite the overwhelming clinical evidence as to their efficacy in certain cases of gout.

Fortunately, as Burney Yeo observed, “in spite of all the theoretical denunciations of the use of sodium salts in gout, the gouty, from all quarters of the globe, have resorted, and continue to resort, in steadily increasing numbers, to those Continental springs in which the salts of sodium are overwhelmingly predominant.”

In short, Sir William Roberts’s experiments, while they dissipated the fallacious view of the action of alkalies as solvents in the blood of sodium biurate, have not for one moment imperilled the clinical and practical estimate, deep-rooted in experience, of their general utility in gout.

For myself, I incline to the view of the French authors, who would refer the value of alkalies and alkaline mineral waters in gout rather to their general influence on metabolism than to the now no longer tenable conception of their solvent action on uric acid.

Reflecting on the varied constituents of mineral springs and the claim that each and all of them are of value in gout, one naturally looks for certain conditions common to them all. These are, as Burney Yeo rightly says,—

(1) The quantity of water, more or less pure, taken into the body under regulated conditions daily.

(2) The altered mode of life, the regular exercise in the open air, the modified diet, the early hours, the absence of business cares.

(3) In many foreign spas there is the drier and hotter Continental climate.

(4) The stimulating effect to excretion and “tissue change” which the baths, douches, frictions, and manipulations applied at most of them induce.

Now, admitting, as one freely does, the important influence exerted by these factors on what may be termed the pathological groundwork of gout, still it is equally certain that some cases of gout do better than others at certain spas.

This leads me on to the further reflection that the favourable or unfavourable reaction in different cases depends on the varying nature of what I may term the “excitants” of gout. For the deviations from health that evoke the disorder are manifold and diverse, each carrying with it its own therapeutic indications. Something more is needed than what may be termed a blind or unintelligent “washing out” process. In every gouty patient there is some functional flaw or defect, and cæteris paribus, that natural spring will suit him best whose mineral or other content is best calculated to correct or minimise his particular deficiency.

In short, we must get rid of our too common habit of asserting that this or that particular water is “indicated in all cases of gout,” and its use “attended with the most remarkable results.” The question that we should be more anxious to decide is, whether of all natural springs this or that particular mineral water is par excellence the one that will most surely and most swiftly correct or minimise that particular functional derangement which in the subject under review experience has shown to be the most fertile source of gouty outbreaks. But to this we shall refer later when dealing with the individual peculiarities upon which our selection of a spa will depend.

To sum up, in consonance with these views, the general principles of spa treatment, as I take it, are:—

(1) To correct or relieve those functional derangements, gastro-intestinal or other, that appear to be the determining causes or excitants of outbreaks of regular gout.

(2) To reduce the toxicity of the blood plasma and tissues by promoting the elimination of uric acid and toxins through all avenues of excretion.

(3) To restore the organism as far as possible to a state of health or functional efficiency, and therewith to adopt such prophylactic measures as shall diminish the liability to recurrence of the disorder.

To discuss the application of these principles to all types of mineral waters is beyond the compass of this work, and I shall perforce have to confine myself very largely to discussion of the salient properties of radio-active waters, with subsequently such brief allusions to the salient therapeutic indications of other varieties as may be indispensable to intelligent selection of a spa in any individual case.

RADIO-ACTIVE WATERS

As to the physical properties of radium, it is, according to the theory of transformation, a “changing element,” emitting alpha, beta, and gamma rays, and in addition a radio-active emanation. This latter product exists in a gaseous form, and is the outcome of the ceaseless metamorphosis taking place in radium itself, each atom of which continuously ejects at high velocity an atom of helium.

This expulsion of helium having ensued, the parent atom no longer exists as radium, but as radium emanation, or niton, as it has more recently been designated. Now, from a therapeutic point of view, the salient fact is that elicited by Lowenthal, viz., that the active agent is not, as was previously thought, radium itself, but the emanation derived from it.

Now, as a reference to our footnote shows, the Bath waters are radio-active to a remarkable degree, and as Maché, Curie, and Laborde hold that “the higher the emanation from a given spring, the more striking are the physiological results,” a brief reference thereto seems called for.

Physiological Action of Radium Emanation.—When inhaled, radium emanation swiftly passes from the alveolar spaces of the lungs into the blood, and thence to the tissue cells, which, according to their specific solubility, absorb the same. Eventually, if the inhalation is prolonged sufficiently, saturation of the blood therewith ensues, to be followed by its escape viâ the lungs, intestines, kidneys, and skin.

Taken orally, radium emanation, according to Lazarus, in large amount, passes into the arterial blood, an observation confirmed by other investigators experimenting on animals. Its absorption into the blood takes place slowly from the intestines, and its exit thence out of the system is, in like fashion, only slowly effected, taking hours for complete excretion. On the other hand, when inhaled the emanation is quickly absorbed and as swiftly excreted, i.e., within a few seconds. As to its power of penetrating the skin most authorities are sceptical, but Engelmann stoutly contends that he has proved that in immersion baths the emanation does actually pass through the skin; but pending further researches this question of cutaneous absorption must remain sub judice.

Again, radium emanation appears to be endowed with the power of energising or activating the body ferments or enzymes, in other words, can stimulate to greater efficiency the proteolytic, glycolytic, and diastatic ferments that set in motion that long chain of cleavage processes in the various foodstuffs, the necessary prelude to their absorption, assimilation, and ultimate transmutation into live protoplasm. Nay more, for the same mysterious agent, it is claimed, can activate those oxidising enzymes which initiate the equally intricate disruptive processes that mark the disintegration of living protoplasm.

Thus Neuberg, Lowenthal, Edelstein, and others contend that they have demonstrated such an increase of efficiency on the part of the autolytic enzymes responsible for cleavage of the protein molecule into nitrogenous bases and amido-bodies. That radium emanation should exert such a profound effect on organic metabolism, both in its anabolic and katabolic phases, would, if established, go far to dissipate the dark shadow of empiricism that has for so long clouded the practice of mineral water drinking and bathing. For it is precisely in those conditions collectively termed “disorders of nutrition” that radio-active waters have found their traditional rôle.

INFLUENCE ON URIC ACID METABOLISM

In 1909 Gudzent, working in His’s clinic at Berlin, affirmed that in gouty subjects uric acid vanishes from the blood in the presence of radium emanation; moreover, that under the same conditions tophi had been observed to melt away. The explanation proffered by Gudzent was, that the emanation inhibited the transmutation of the unstable and more soluble lactam into relatively insoluble and stable lactim urate, this latter being the salt found in the blood of the gouty.

W. His also claims that the gouty individual benefits by this method of treatment, which, he maintains, not only reduces the uric acid content of the blood, but dissipates uratic deposits in the tissues. On the other hand, at the last Congress of Internists at Wiesbaden (1912) Gudzent and His’s views, though stoutly supported by some, were unacceptable to others, who, although they admitted the favourable influence of radium emanation upon the symptoms of gout, yet contended that its effects could with difficulty be interpreted either in the sense of increasing the solubility of the monourate of sodium or its decomposition into CO₂ and ammonia.

Thus E. V. Knaffl-Lenz and Wiechowski, working in the Vienna Pharmacological Institute, were unable to confirm Gudzent and His’s claim that treatment by radium emanations resulted in destruction or increase in solubility of the mono-sodium urate. On the other hand, in view of the admittedly favourable effect of the emanation on gout, they suggest that it might be due to what they term activation of an uric acid oxidase existing in the human tissues. Yet another view is that in some obscure way radium emanation facilitates the elimination of uric acid through the kidneys.

In regard to the claim that radium emanation has the power of keeping uric acid compounds in their more easily soluble forms, it is interesting to recall the conclusion arrived at by the Lancet’s special commission for investigation of the Bath waters: “The thermal waters of Bath exert a distinct solvent action on uric acid; in our experiments, e.g., it was shown that Bath waters dissolved over five times the amount of uric acid that distilled water would similarly take up at blood heat—i.e., just under 100° F. Since the waters are drunk hot and used hot for bathing purposes, this fact may have an important relation to the therapeutics of Bath waters in the treatment of chronic gouty affections and rheumatism.”

Increased Excretion of Uric Acid.—Delayed excretion of exogenous purin is held to be one of the most characteristic signs of gout. Now, following emanation treatment, Lowenthal and others have noted that this disability on the part of the gouty was apparently removed. For when, at the close of the course, the capacity for dealing with exogenous purins was tested by the intake of large amounts of purin bodies, excretion of the same ensued after a normal fashion. It would seem then that there is not only increased uric acid excretion actually during the progress of a séance of emanation, but also that this enhanced power of coping with purins is maintained subsequently.

Subjective Phenomena of Gout in Relation to Blood Content and Excretion of Uric Acid.—Now, as we have seen, it is claimed that uric acid disappears from the blood in the presence of emanation. But, while in the majority of instances amelioration of symptoms follows reduction of the uric acid blood content, in others improvement ensues even though the amount of uric acid in the blood remains unaltered.

Thus in one of His’s patients under radium emanation striking amendment followed notwithstanding that the blood contained uric acid. In another, the subject of multiple tophi, no uric acid was found in the blood throughout the treatment, and yet the victim had repeated attacks of gout during this period.

Turning to the excretion of uric acid in the urine, similar discrepancies emerge. Thus Mandel out of seven gouty patients under treatment by radium emanation found that an increased uric acid excretion ensued in two subjects. Of the remainder, in two no alteration in average excretion took place, in two a slight diminution, and in one a marked increase, to the extent of 50 per cent.

Now in four of the seven cases an undoubted clinical and subjective improvement was observed, although the uric acid curve showed diminution rather than increase. It seems, therefore, clear that the beneficial effect of radio-active waters in gout involves something more than the dissipation of the uric acid in the blood and its increased elimination in the urine.

THERAPEUTIC ACTION AND APPLICATION

We have in previous sections emphasised the importance of treating local foci of infection, in view of their possible causal relationship to gout. For, uncertain as we are of the etiology of the disorder, we cannot afford to neglect treatment of any possible source of toxic absorption.

Now a significant number of independent workers contend that in the presence of radium emanation the growth of organisms is retarded, if not actually inhibited. The same bactericidal power has been claimed for radio-active waters even of low grade. Should recent contentions as to the efficacy of the same in states of oral sepsis be confirmed, it will constitute an important weapon wherewith to combat not only the local, but the remote malign, effects of sepsis in the mouth or its accessory cavities.

Again, it is recognised that pharyngeal and nasal affections when present derive benefit from the inhalation of radio-active waters atomised by steam or air. In this connection it may be noted that, by an ingenious apparatus installed at Bath, the natural “niton” gas is now extensively used for inhalation or douching of the mouth and neighbouring cavities.

Alimentary Disorders.—Accepting the fact that gastro-intestinal derangements are the most common excitants of gouty outbreaks, it seems to me highly probable that the good effects of radio-active waters are partly attributable to their mysterious power of activating the body ferments. Thus, through their stimulating action on the digestive enzymes, they may inhibit the formation of abnormal substances, or, through their quickening of the autolytic ferments, may hasten the disruption and excretion of such when formed.

How frequently in these cases do we find that some functional hepatic or gastro-intestinal derangement is the prelude to a gouty outbreak. Again, as pointed out, how often do these subjects suffer with fermentative dyspepsia and “organic acidity,” with associated lowered tolerance for carbohydrates. In such cases, if given in copious quantity and frequently, the radio-active waters prove most beneficial. This is in part attributable to the mechanical flushing of the alimentary canal and tissues, and in part perhaps to their activating influence on the digestive enzymes.

In contrast to the foregoing, such abundant ingestion of the waters is inadvisable in atonic types of dyspepsia marked by dilatation and diminished secretion. But here again, if given in small amounts, radio-active waters undoubtedly exercise a beneficial effect. Also in those gouty subjects who suffer from neurasthenia and nervous dyspepsia a similar favourable reaction is frequently observed. This I apprehend to be due to the fact that radium emanation exerts a sedative effect on the nervous system. Thus it has been noted that guinea-pigs when exposed to radium emanation drop into a state of somnolence and torpor. May not this account for the undoubted fact that highly strung individuals when subjected to a combined bath, drinking, and inhalation cure become less irritable and lose their distressing tendency to insomnia?

Again, intestinal irrigation with these radio-active waters after the Plombières technique is justly esteemed in those cases of gout attributable to intestinal catarrhs and mucous colitis. The constipation these subjects so frequently suffer from is counteracted, and the regular removal of waste and toxic material achieved.

As to the morbid affections associated with gout, notably fibrositis, it is well recognised that muscular and nerve types of this disorder prove very amenable to a course of these waters. Here I would lay stress, too, on the swiftness with which the glycosuria of gouty subjects vanishes under the same conditions. The pruriginous and eczematous eruptions met with are also favourably influenced by a combination of internal and external treatment. I may note, too, that this mode of therapy is not contra-indicated in increased arterial blood pressure. For it has been shown by Deutelmoser, Saubermann, and others that under the influence of radium emanations the blood pressure is reduced.

As regards the administration of radio-active waters, it cannot be doubted that the combined bath, drinking, and inhalation cure is the most advantageous. The subcutaneous injection of radio-active waters does not seem to possess any outstanding advantages, while the danger of sepsis has always to be considered.

As to the relative merits of artificial as opposed to natural radio-active waters, it does not appear to me that the therapeutic action of the former is swifter or more infallible than the products that issue from nature’s laboratory. The limitations and capacities of the latter have been fixed by centuries of experience, and, as far as present researches go, the newly born commercial imitation, at any rate as regards the treatment of gout, has yet to prove itself endowed with a greater range of therapeutic efficacy.

CHOICE OF SPA

While naturally my attention has been largely centred upon the mineral waters of Bath, I would by no means convey the impression that a thermal radio-active spring is the only one that I think beneficial in the treatment of gout. Far from it, for if, from my description, I appear to have claimed such to be universally applicable to all gouty subjects, the explanation really resides in the fact that the resources of most spas can be readily adapted so as to suit different kinds of cases.

Nevertheless, as I have said, I favour the tendency towards specialisation of spas, as bit by bit the indications for their differential application become more and more sharply defined. In view, then, of this trend, it is manifestly only fair to our patients that we endeavour to select that particular spa that seems most eligible in their particular instance.

Let us assume, then, that the subject is in such circumstances that a certain latitude of choice is permissible. This being so, the physician’s selection will be the more satisfactory if regard is had not only to the gout, but to the individual himself, and not the least important of the considerations involved have been already embodied in my remarks on climato-therapy. For the ideal sought, if I may again say so, is not only physical, but psycho-physical; and the physician who leaves out the mental element will scarcely choose wisely.

Narrowing our field to consideration of the physical requirements of the subject under review, what manner of man is he, metabolically speaking? Is he of spare habit, one in whom katabolic changes hold sway and “the vital fires blaze more fiercely,” or is he obese, one in whom anabolic processes are dominant, with hoarding up of substance?

Now, I have taken these two types, the spare and the obese, as in gout we are dealing primarily with a “disorder of nutrition.” Cæteris paribus, we wish to correct the morbid metabolic trend, in other words provide differential treatment. Obviously the salient indication in the lean individual is that he shall drink of a spring which will tend to enhance digestive capacity and facilitate assimilation of foodstuffs, with as its outcome increase of general nutrition.

To compass such effects, muriated chloride or common salt waters are, other things being equal, most desirable; that is to say, unless they are taken in such quantities as to produce catarrh of the stomach and intestines, they do not cause emaciation. On the contrary, I have, for example at Llandrindod, seen an increase of weight in these persons ensue during, and, moreover, continue after, a suitably arranged course of these waters. Among other muriated waters in this country may be mentioned Llangammarch Wells, which, as Sir Hermann Weber suggested, is suitable in cases of chronic gout, “especially where any emaciation is to be avoided,” and Woodhall Spa also deserves mention in this connection, or, reverting to the Continent, the waters of Homburg, Kissingen, Wiesbaden, Baden-Baden, etc., may be selected.

The muriated (chloride-containing) alkaline waters are also eligible in cases where loss of flesh is to be avoided, such as Ems, Royat, Chatel Guyon, or La Bourboule. They should, for this reason, be given the preference over the simple alkaline waters, such as Vichy, Vals, Neuenahr.

Reverting now to the obese, plethoric type of man, a heavy eater and often of sedentary habit, what is the end to be achieved? Here loss of flesh is to be courted, and a spa sought whose mineral waters will by their action supplement the all-important dietetic and regimenal treatment of the subject.

The class of waters pre-eminently suitable will be those known as the sulphated and the sulphated alkaline varieties, which, taken internally, will through their purgative and diuretic effects assist our purpose. The stronger varieties of the sulphated waters are chiefly used as occasional aperients at home, as, generally speaking, at the site of the spring there is no proper spa accommodation. We allude to Franz Joseph, Hunyadi Janos, Rubinat, and Condal waters, etc.

In England several sulphated springs exist, but, as far as their use is concerned, may be regarded as obsolete. Perhaps the best known is the original spring, no longer used, at Epsom, whence the English term for magnesium sulphate, “Epsom salts.” According to Weber, in Charles II.’s reign these native laxative saline waters were taken at the wells early in the morning, and Pepys in his diary tells how on August 11th, 1667, at seven o’clock on a very cold morning, he found many people drinking the waters at Barnet Wells.

It is, however, the sulphated-alkaline springs that have achieved the greatest reputation in this sphere, notably Karlsbad, Marienbad, Franzensbad, Tarasp Schuls, etc., and perhaps of these Marienbad is the most frequented. But in any case, in exercising a choice, we should take into consideration not only the temperature and mineralisation of the waters and their balneo-therapeutic resources, but also the climate and the time of year. Thus, for example, the climate at Tarasp is alpine, and the altitude of Marienbad is over 2,000 feet, while that of Karlsbad is but 1,200. Another point to consider is whether the obesity of the subject is attended with anæmia. If so we may with advantage choose Tarasp, which, in addition to sulphated alkaline, has chalybeate waters, and the same dual advantages are to be found at Marienbad.

For those unable to go abroad the muriated sulphated waters of Leamington or Cheltenham in this country are available. The flat contour of these spas is very suitable for those cases in which obesity is complicated by cardiac debility. I may note, too, that Bain and Edgecombe, discussing the treatment of obesity at Harrogate, speak well of the strong muriated sulphur water, substituted in anæmic cases by a chalybeate water in conjunction with an aperient.

So much for the broader indications, metabolically speaking, that should guide us in our choice of a spa. And now to consider other special conditions which in the gouty call for consideration, notably digestive disorders.

Dyspepsia and Chronic Gastro-intestinal Disorders.—In these conditions it is especially imperative that we take a broad view, particularly in respect of climate and altitude. Inland spas at moderate or high altitudes are generally preferable. Doubtless the beneficial result is in part due to the influence that change to a mountainous region, with abundant open-air exercise, exerts on the nervous system. But the same has its drawbacks in the “gouty dyspeptics,” for often, as I have observed, they tend at first to overeat. As Weber rightly says: “The feelings of ‘sinking’ and ‘lowness’ in the gouty and dyspeptic are frequently mistaken by the patients themselves as indications for taking food, stimulants, or tonic medicine.” In short, we must in their instance institute immediately at the commencement of their course the requisite dietetic innovations. Again, being in these more bracing localities more disposed to take exercise, the adverse effect on digestion of over-fatigue must be guarded against.

Indeed, in the more aggravated types of so-called gouty dyspepsia there is little doubt that sojourn in a sanatorium may at first be advisable, so that the patient’s digestive disabilities may be thoroughly studied by the help of test meals, while dietetic treatment can be more readily and surely supervised.

Passing to the question of mineral waters, there is no doubt that a previous investigation of the secretory and motor functions of the stomach would supply valuable indications as to the type of “waters” most suitable. Incidentally, too, researches in this line might tend to clear up the obscurity that enshrouds the mode of action of mineral waters in cases of gouty and other forms of dyspepsia. For experimental findings and clinical observations are here somewhat conflicting.

Thus it has generally been supposed that simple alkaline mineral waters promote the secretion of acid gastric juice. But Pawlow, experimenting on dogs, found that alkaline sodium salts tended rather to inhibit than to stimulate gastric and pancreatic secretions. In order, therefore, to reconcile his findings with the well-ascertained benefit that follows their exhibition in gastric disorders, he suggests that they prevent the too prolonged or excessive secretion that is so often a concomitant of catarrhal conditions.

Adolf Bickel, again, has confirmed Pawlow’s conclusion that the simple alkaline group of mineral waters depress rather than stimulate the secretory activities of the gastric mucous membrane; but Sir Hermann Weber, discussing Bickel and Pawlow’s deductions, puts forward, as I think, a more reasonable hypothesis than that advanced by the latter authority.

Thus he suggests that “a possible explanation of the beneficial effects of alkaline salts in many digestive disorders (gouty dyspepsia, irritable hyperacidity, etc.), in tendency to ‘biliousness,’ and in various so-called ‘gouty manifestations’ is that these salts when taken up into the circulation exercise a favourable influence on the metabolic processes generally, thereby improving the general health and thus indirectly, apart from any special local action, helping to remove conditions of dyspepsia, gouty bronchitis, etc.”

From his experiments Bickel came to the conclusion that in conditions of subacidity supervening on chronic gastric catarrh the most suitable are muriated waters, or muriated alkaline waters, or simple gaseous waters.

Gastric Insufficiency, or Atonic Dyspepsia.—Now, as I have before emphasised, this is the functional gastric disorder most commonly met with in the gouty; the hyperacidity is due to excess of organic acids, and this, again, is the outcome of not excess, but deficiency, of HCL. Now in cases of this nature with subacidity of the gastric juice numerous observers—Von Noorden, Dapper, Boas, and others—have reported an increase in the secretion of hydrochloric acid following a course of muriated waters.

My own clinical experience of the muriated waters of Llandrindod abundantly confirms the results obtained by these authorities. The enhanced digestive capacity of the patients is evidenced by relief of epigastric pain and discomfort after meals and the decline of flatulent distension. For, following the increased secretion of hydrochloric acid, their intolerance of carbohydrates, due to subacidity, disappears, and, fermentation no longer taking place, the over-distended walls of the stomach gradually recover tone. It is customary for patients to walk either during or after the consumption of water. But in decidedly atonic conditions of the stomach with dilatation it is better, as Ageron suggests, that such subjects lie down after drinking. Nor must the beneficial effect of muriated waters on the associated constipation be overlooked. The daily thorough evacuation of the intestinal canal minimises or prevents toxic absorption, and at the same time depletes the overloaded portal system.

The sources of blood contamination being removed, the general symptoms of languor, drowsiness, and mental depression give place to a more cheerful tone of mind. At the same time relaxation from business, an outdoor life, and bracing air, with change of scene and society, doubtless contribute to dissipate those feelings of supreme misery which are the bane of the dyspeptic.

As to the foregoing remarks, I have but chosen Llandrindod as a type. Thus some of the Harrogate waters are equally eligible for inclusion in the muriated as in the sulphurous group. Again, to these may be added Builth Wells and Llangammarch Wells, the latter distinguished by its content of chloride of barium, which is said to raise the blood pressure and promote diuresis through its tonic action on the muscular coat of the arteries. Woodhall Spa, too, calls for mention, the presence of iodides and bromides in its muriated waters investing it, according to some, with special alterative properties; lastly, the strong brine waters of Droitwich, which find their special sphere in external application by baths.

As to the Continental springs in this category, the most noteworthy are Homburg, Kissingen, and Kreuznach, the last decidedly radio-active; while of thermal muriated waters Wiesbaden and Baden-Baden are the most representative.

Chronic Gastric Catarrh.—In this condition, not uncommon in the gouty, and which Ewald aptly characterises as “the best fostered and widest spread of this world’s ills,” a deficiency of gastric secretion with impaired motility is constantly present. With this is frequently correlated distension of the small intestine, due to abnormal fermentative and putrefactive changes in the food.

Leaving aside the vexed question as to whether muriated or saline waters can be regarded as direct excitants of gastric secretion, it cannot be doubted that the prolonged and systematic lavage of the stomach, ridding it of viscid mucus and hastening the removal of retained fermenting foodstuffs, must favour restoration of a healthy state of the mucous membrane, and thus indirectly promote its secretory activities. Again, inasmuch as the bulk of saline waters undergoes absorption in the small intestine, the duodenal catarrh usually associated with this condition is also markedly benefited by the removal of toxic accumulations. Indeed, Niemeyer, discussing the therapeutic efficacy of mineral waters in such states, goes so far as to remark that “the results obtained are the most brilliant that have ever been attained in medicine.” To achieve these salutary effects the “waters” must be taken in amounts adequate to produce copious daily evacuation. For, if insufficient to ensure this same, discomfort and distension ensue pending the more tardy removal of the water by the kidneys.

Now, while in these cases the muriated waters above alluded to are suitable, the muriated alkaline are equally eligible. Of these the highest in repute are Royat, Chatel Guyon, and Saint Nectaire, and in Germany Ems, Wildbad, Assmannshausen, and Wildungen.

Here a reservation in regard to Bickel’s researches, viz., it has been found that in some cases of chronic gastric catarrh in robust subjects simple alkaline springs, such as those of Vichy, Vals, and Neuenahr, have, despite his experimental findings, proved actually beneficial. On the other hand, these same waters have this cogent objection, that long courses are apt to cause depression and emaciation, and, moreover, may aggravate the gastric trouble. Worse still, these simple alkaline waters are more likely to produce an attack of acute gout, whereas the muriated alkaline varieties are free from these objections.

Hyperchlorhydria.—Bickel’s experiments led him to this further conclusion, that in organic gastric disorders accompanied by excess of HCL the simple alkaline and sulphated alkaline group are to be preferred to the muriated waters.

Now, inasmuch as some authorities hold hyperchlorhydria as due to a chronic glandular gastritis, it would seem that these should be given a trial. Personally, I have no practical experience that I can draw upon for substantiation or refutation as to the correctness of Bickel’s assumption. Nor have I on this question been able to find any reference in the literature or clinical findings emanating from these spas.

Much controversy, again, obtains in regard of the usage of muriated waters in these cases. Formerly their employment was unreservedly condemned, but more extended experience has modified this too dogmatic attitude. Albeit, that the results obtained in hyperacidity (excess of HCL) are uncertain is undeniable, and unfortunately it is impossible to foretell whether or no any given case will derive benefit. The pronounced nerve element in these cases, with probably other unknown factors, has doubtless much to say to the conflicting clinical results.

But the experience of most of us will accord with that of Dapper and Von Noorden, that muriated waters, such as those of Homburg, Kissingen, etc., often prove beneficial in cases of neurasthenia with hyperacidity. On the other hand, it is equally true that some examples of apparently the same nature derive no benefit, indeed are aggravated. But, according to Von Noorden, such are in the minority.

Fortunately this secretion of an abnormally acid gastric juice is relatively rare in the gouty. Being of the nature of a secretory neurosis, it occurs most frequently in those of neurotic or neurasthenic type. Now, holding the view that many cases of neurasthenia are due primarily to toxic absorption, secondarily to alimentary derangements, the beneficial effects observed are, I presume, probably attributable in large part to the removal of toxic accumulations through flushing. These deleterious substances not being absorbed in such amounts as before, improvement in the general nerve tone ensues, in which doubtless the secretory mechanisms of the digestive system participate.

But, as we have seen, these same muriated waters prove most salutary in precisely the opposite condition—hypochlorhydria, or deficiency of HCL. That such a beneficial effect should ensue in diametrically opposed states, viz., hyper- and hypo-acidity, gives point, I think, to the contention that the action of muriated waters on the digestive organs must in great part be exerted not locally, but indirectly, that is, secondarily to improvement of the general health and toning up of the nervous system.

Indeed, the pronounced nerve element in these cases is probably the explanation why, especially in instances palpably due to mental fatigue, insomnia, etc., a course of baths or hydrotherapy at some simple thermal spa, preferably those at certain altitudes, such as Buxton, Wielbad, Gastein, Plombière, Ragatz, etc., often suffices without any internal treatment.

Functional Hepatic Disorders.—Fothergill held that some persons were born with “congenitally incompetent livers,” an unwelcome legacy unduly incident among those of gouty heritage. Now the intimate interdependence of hepatic and gastro-intestinal disorders has long been recognised; indeed, the swiftness with which retribution, in the shape of so-called “biliousness,” overtakes those who fare not wisely, but too well, is proverbial even among the laity.

Thus chronic hyperæmia of the liver, due to stasis in the portal area, commonly ensues in those gouty subjects who eat and drink too much, especially alcohol. The same Nemesis awaits those who lead too sedentary a life, and in the train of chronic constipation develop such hepatic congestion, with in some instances attacks of catarrhal jaundice.

As to treatment of these cases by mineral waters, a preference must be given to alkaline, sulphated alkaline, or muriated waters, according to the special indications of individual cases. Thus suppose the subject is stout and plethoric, and given perhaps to hæmorrhoids or pruritis ani, then spas with sulphated alkaline waters (Marienbad, Karlsbad, etc.) may be recommended. But equally good results will follow a course at home of muriated waters, or muriated sulphur waters, such as Harrogate, Llanwyrtid, and Strathpeffer, etc.

Bearing in mind that functional hepatic disorders are in large part secondary to gastro-intestinal derangements, it is probable that the beneficial effect of the above types of waters on the liver is exerted indirectly, though we must recollect that the salts of soda have a direct stimulant action on the hepatic function.

Given in adequate doses, they act as mild, unirritating laxatives, the daily evacuations thus produced relieving hepatic congestion and coincidently any tendency to portal engorgement. Through their dual action of flushing the digestive canal and stimulating hepatic and gastro-intestinal secretory activities, we find the explanation of the decided benefit that follows their use in gastric catarrhs, especially of alcoholic origin, also in catarrhal jaundice, incipient cirrhosis of the liver, and so-called abdominal venosity.

As we know, Sir Lauder Brunton long since pointed out that the ingestion of saline mineral waters tends to counteract any tendency to catarrh of the biliary passages, the biliary secretion tending to become less viscid; consequently the passage of gall-sand is promoted. Some, like Hans Kehr, of Holberstadt, advise a course of saline waters after operations for the removal of gall-stones; others advocate their employment before surgical intervention. It is obvious, however, that their range of usefulness in this affection must be limited and is largely to be attributed to their power of mitigating inflammatory or catarrhal changes in the gall bladder and its related ducts.

Intestinal Derangements.—Constipation is, as is well known, the bête noire of the gouty, and, while the basal indications of its therapy have to be carefully ascertained in every individual, still much may be done by a properly chosen and adequately supervised course of spa treatment. This, of course, entails revision of the diet and habits, notably in regard to exercise; in some of sedentary habit a mere change of air to a more bracing climate, with its associated increase of exercise, may suffice; in others of stout plethoric type a visit to one of the sulphated alkaline spas will be of benefit; while in weaker subjects of the lean kind muriated waters will be more suitable.

In many the habitual constipation is due to a catarrhal condition of the intestine. Trautner, as we know, considers that gout originates in a mucous colitis. In France the gaseous muriated waters of Chatel Guyon are in great vogue for chronic catarrhal conditions of the intestines, especially those associated with abdominal plethora and constipation. Indeed, because of its success in these cases, it is sometimes called the French Kissingen.

On the other hand, the Plombières Spa is the one that par excellence devotes itself to the treatment of mucous colitis by a combination of (1) intestinal douches, (2) sedative warm baths, and (3) “under-water” douches directed against the abdomen. Treatment by the Plombières method is now available at most English spas, and, while I can speak highly of its benefits, I think perhaps there is sometimes a tendency to resort to it after a routine fashion irrespective of the presence of any special indications for its usage. The after-results in some cases are not enviable, and recently a distinguished surgeon informed me that he had met with instances in which ill-advised and prolonged usage of such irrigation resulted in an atonic condition of the colon.

ASSOCIATED MORBID CONDITIONS

Glycosuria.—The more chronic and benign forms met with in gout frequently derive benefit from a course of mineral waters, though, of course, revision of the diet and regimen in general are essential concomitants thereof. Indeed, the high reputation achieved by certain Continental spas—Karlsbad, Vichy, Neuenahr, etc.—in this disorder is in large part due to the care and attention bestowed on these the basal indications.

In the gouty obese, with a tendency to piles and abdominal plethora, the sulphated alkaline and simple alkaline waters, such as Karlsbad, Vichy, Neuenahr, Brides-les-Bains, etc., are suitable, and in this country the muriated sulphurous waters of Harrogate and Llandrindod.

In some of the gouty obese their bouts of glycosuria sometimes alternate with attacks of uric acid gravel, and not infrequently there is also present a slight degree of albuminuria. In these cases the earthy or calcareous waters enjoy a considerable reputation, notably Contrexéville, and not a few with uric acid gravel and slight albuminuria resort to Wildungen.

I have before alluded to the beneficial effects in glycosuria of Bath waters, which, like Contrexéville and Wildungen, have an earthy or calcareous content. For the less robust and lean type of glycosuric Sir Hermann Weber recommends “simple thermal baths, such as can be obtained at many resorts of moderate elevation (Gastein, Wildbad, Buxton, Schlangenbad, and Ragatz).” As an alternative, he states that “the internal use of muriated alkaline or simple alkaline waters (Vichy, Neuenahr, Obersalzbrunn, Royat, La Bourboule), in association with thermal baths or alone, may often be recommended.”

Oxaluria.—This condition, like glycosuria, is often met with in the gouty. It is of course often due to faulty diet, but in many instances there is a strong nerve element in the case. In the former instance dietetic restrictions are the basal indication. In these cases, if there be constipation, a visit to the muriated springs in this country or to Kissingen, Homburg, etc., is advisable. Otherwise, alkaline springs, i.e., Vichy, or alkaline earthy springs, such as Vittel, Contrexéville, or Martigny-les-Bains, may be given the preference. For those instances in which the nerve element is predominant the character of the mineral waters is quite subsidiary compared with the all-important point of procuring the subject freedom from worry.

Gouty Phlebitis.—It is believed that gaseous muriated waters, both internally and in the form of baths, are useful in counteracting any tendency to phlebitis. Obviously, if there be any symptom or sign of existing phlebitis, any such procedure would be fraught with risk. Still patients who have had phlebitis frequently resort to such spas, notably Bagnoles-de-l’Orme, where the resident physicians have made a special study of the constitutional tendencies to chronic phlebitis. The waters are but weakly mineralised, and may be classed in the simple thermal group (81°-84° F.).

Respiratory Disorders.—While, as I have said, I deprecate any notion of specific gouty types of bronchitis, asthma, etc., there is no doubt that gouty subjects, like many others, are prone to bronchial affections, and for such mineral water treatment at a favourable season of the year, is equally beneficial. In gouty bronchitics of plethoric type, courses of sulphated alkaline waters will often do much to relieve the symptoms. Again, many sulphur, muriated alkaline, and muriated spas, have achieved a great reputation in the same sphere, e.g., Ems, Royat, Eaux-Bonnes, Baden-Baden, and Soden. Nor need we go outside our own country, for many of our mountain health resorts are in the summer months equally eligible for treatment of these disorders of the respiratory system.

Fibrositis.—Adequately to describe all the methods, internal and external, in vogue at spas for the treatment of, e.g., chronic lumbago and sciatica, would be quite futile in the space at my command. I have the less compunction in being unusually brief inasmuch as Bassett Jones and I have dealt exhaustively with the subject in our work on fibrositis.

The groundwork of successful treatment will rest on the application of the general principles in force for the treatment of the underlying gout. They will, of course, include internal and external treatment by simple thermal waters, the thermal muriated and thermal sulphurous waters, etc. Frequently, too, cold muriated and other waters artificially heated are invoked for this dual purpose.

The benefits of external treatment by douches of varying character will depend on the measure of discrimination exercised in adapting their application to suit the individual necessities of the case. But I would here lodge a plea against the far too great frequency with which such cases are sent to spas during the acute phases, whereas it is only the subacute or chronic forms that are eligible for treatment by hydrotherapy.

Gouty Eczema.—The climatic suitability of the spa is of primary importance, and while, as a rule, cold, damp and windy localities are to be avoided, still personal idiosyncrasy plays a large part in the decision, some cases of eczema being aggravated by cold, others by heat and sunlight.

The spa treatment of gouty eczema has for its aim the correction of the constitutional taint by the internal exhibition of mineral waters in conjunction with baths. To this end, the eliminative effects of courses of alkaline (Vichy, Vals), muriated (Llandrindod), sulphurous (Harrogate, Strathpeffer, Llanwyrtid), or muriated sulphurous waters (Uriage, Aix-la-Chapelle, etc.), are often invoked with marked benefit.

Again, the thermal muriated alkaline waters of Royat and the arsenical springs of La Bourboule have acquired a great reputation in gouty eczema, and in obstinate but non-pruriginous types the prolonged tepid baths in vogue at Loèche-les-Bains, in Switzerland.

In many instances of senile or atrophic type a course during the summer of simple thermal baths is often beneficial. Buxton is suitable, also Wildbad, Schlangenbad, Ragatz, etc. Lastly, in eczema of seborrhœic type thermal sulphurous waters, e.g., Schinznach, Aix-les-Bains, Bagnères-de-Luchon, etc., are highly commended.

Uric Acid Gravel.—Though, as before stated, there is no specific connection between this disorder and gout, still the gouty no more than others are immune therefrom. For the stout, plethoric, and constipated, sulphated and sulphated alkaline springs are indicated. But if, on the other hand, there is a tendency to diarrhœa, these aperient waters must be renounced in favour of simple alkaline springs. In those of less robust type the simple thermal or earthy waters, notably Contrexéville and Wildungen, are to be preferred, and failing these, the muriated waters.

Arterio-sclerosis.—It is hardly necessary to say that in all but the slightest forms high altitudes are contra-indicated. In these less advanced cases, if the subject be stout and plethoric, the sulphated alkaline waters (Karlsbad, Marienbad, etc.) are useful; while in thin persons the muriated waters are more suitable.

In more advanced cases we may during summer advocate a course of treatment at some simple thermal spa, such as Buxton, and many of these cases do well at Bath during the spring, or they may be sent to Bourbon Lancy, which has been termed the French rival to Nauheim, because of the excellent results obtained in cases of raised blood pressure.

Chronic Nephritis.—Clearly in these cases a quiet life, without mental worry, gentle and not excessive exercise, with residence in an equable climate, are the primary indications. In the early stage, when the patient’s condition is good, the tension not high, and the quantity of albumen small, the subjects derive much benefit from an annual visit to certain mineral springs. Not that mineral waters have any curative influence; they merely help the interstitial circulation and promote flushing.

Of mineral waters the simple thermal or the weak alkaline are generally considered the most eligible, e.g., Vichy, which is useful also in cases of combined albuminuria and glycosuria. In cases with cardiac dilatation care should be taken not to prescribe mineral waters in excessive amount. If complicated by anæmia, chalybeate waters, according to Weber, are “not rarely useful.”

Bain and Edgecombe, discussing gouty albuminuria, state that the magnesia water of Harrogate, in combination with the old sulphur, has a marked effect in reducing the absolute amount of albumen in the urine, e.g., from one-fourth by volume to a mere trace. They add, that if the specific gravity of the urine be low chalybeate water is indicated with, if necessary, a morning aperient draught. If glycosuria and albuminuria co-exist, the “sulphur waters may be tried tentatively” as the specific gravity does not help us in these cases. “When in doubt, it is safer to give an iron water and trust to diet and baths for a diminution in the excretion of these substances.” Not a few of these cases find their way to Bath and Buxton, often for relief of their increased arterial tension, and the experience of most is that in the more robust types a course of Aix massage is advantageous, while for others more advanced in years baths after the Bourbon Lancy method.

CONCLUDING REMARKS ON SPA TREATMENT

It is well that the potency and complexity of spa treatment be realised, involving as it does not only drinking or internal treatment, but also balneotherapy, electro-therapy, and all the other accessory therapeutic methods now at command. With all these powerful weapons to hand, it is obvious that their use demands a corresponding degree of discrimination, this even in cases otherwise suitable, and here a word as to the types of gout most suitable for the internal exhibition of mineral waters.

In this matter the rules laid down for hydrotherapy, or the external use of waters, are in the main applicable. In other words, acute cases of gout are always ineligible, as likewise those instances in which an attack appears imminent or those in which recovery from an acute paroxysm is barely accomplished. On the other hand, mineral waters are indicated in chronic gout and in the inter-paroxysmal periods that mark the early stages of the disorder. Indeed, I know of no other treatment that is as effectual, and, with Sir William Roberts, “I do not think, therefore, that gouty patients, if they can afford the time and expense, should forego the advantages of the time-honoured practice of a visit to a mineral spring.”

But, to attain the best results of spa treatment, not only should the cases be suitable, but they should be despatched at the right season. Even in spas that are open all the year round we should try to select the most congenial month. Thus, if the subject is intolerant of heat, we should not advise him, say, to go to Bath in July or August, or, for that matter, during the hottest summer months to Aix-les-Bains, Baden-Baden, Wiesbaden, Neuenahr, etc. If he has to take his course at this period of the year, and a thermal spring is indicated, Buxton will be more suitable than Bath, and we have a large choice of other spas in more bracing localities, such as Harrogate, Llandrindod, Strathpeffer. In short, some discrimination must be exercised. Again, if a course be indicated in the winter, we should favour those spas where the hotels are in proximity to the springs, so as to obviate unnecessary exposure, e.g., Bath, Wiesbaden, Helouan, etc.

As to duration of a course, there is, I think, in many spas a too great tendency to be dominated by tradition. Not only is the duration of the cure arbitrarily fixed, but, still worse, the drinking of the waters, the bathing, and even the dietaries are frequently in danger of becoming stereotyped, with, as a consequence, a lack of that eclecticism necessary in the best interests of individual cases. A certain amount of routine is unavoidable, and has this advantage, that persons find it easier to submit to irksome restrictions when they see others conforming thereto. But even so there is ample scope for such modifications as may be required, and upon their adoption the success of spa treatment mainly depends.

If arbitrary rules in respect of drinking, bathing, etc., are to be deprecated, the same applies with unvarying fixity to the duration of a cure for all cases. Generally speaking, three to four weeks is the average stay at spas. But obviously it should be varied to suit the patient’s condition, and in many instances of chronic gout it may with advantage be extended to six or eight weeks.

Again, I think perhaps in this country the advantages of an after-cure are insufficiently realised. In this respect our Continental brethren set us an example, attaching the greatest importance as they do to an after-cure, especially after a course of laxative waters, e.g., Karlsbad, Marienbad, and Kissingen. Certainly to plunge forthwith into work immediately after a cure leads but too often to another breakdown and the undoing of any advantages that may have been reaped. Of late I have noted, especially in business men, a tendency to interrupt even their course by travelling considerable distances on non-bathing days to attend to their affairs. The folly of this is obvious, and the results are almost invariably unsatisfactory. Indeed, in these all too strenuous days one almost despairs of after-cures, for it is difficult enough oftentimes to prevail on people to stay even for their course of three weeks, and frequently one is asked to conduct their treatment after a more intensive fashion, and so abridge it to a fortnight or even a week!

As to the nature and site of the resorts suitable for an after-cure it is impossible to lay down general rules, as individual peculiarities have to be considered. But the physician who prescribes such ought, as Sir Hermann Weber remarks, “to be acquainted with the nature of the locality recommended, if possible by personal visits, and the reports of thoroughly judicious people.” For, as he rightly says, there are numerous places in the British Isles perfectly suitable for an after-cure, to mention but a few in England, Ilkley, Ben Rhydding, Malvern, Haslemere, Church Stretton, Crowborough; in Scotland, Braemar, Ballater, etc.; and in Wales, Llanberis, Llangollen, etc.

SPAS FROM A NATIONAL ASPECT

But brief reflection on the foregoing considerations suffices to make it clear that the various spas and health resorts with which this country, through Nature’s beneficence, has been so bountifully endowed, are but members one of another, in short complementary, not antagonistic, as I fear is sometimes thought. This latter is a view to be discarded in favour of a more rational conception of these various centres from their collective aspect as integral parts of a therapeutic whole.

Now what, in a word, is the outstanding feature of our national life to-day? Co-operation—a veritable furore of national and international effort such as the world has never seen. Spas, too, must fall in line with the national trend, must organise and co-operate, if they would play their full rôle in the drama of reconstruction. Now, from the point of view of the State, the true objective in therapeutics is the achievement and maintenance of national efficiency—the production of healthy citizens, sound economic units. This then is the high purpose with which those responsible for spas must ever be animated—an aim only to be attained by their whole-hearted co-operation one with the other.

The lay custodians, too, of spas must increasingly realise that they do but hold in trust their healing springs to be safeguarded in the interests of the community. Mineral waters, like coal, issue from the bowels of the earth. Both are natural products; both are national assets. I doubt not that the growing movement for effectual popular control so rapidly obtaining a grip over the political and economic life of the nation will shortly be extended to our spas, with, as its outcome, their unification and co-ordination under the controlling influence of a central body of experts vested with plenary powers to inspect, control, and inspire the development of these hydrotherapeutic centres. “Salus populi suprema est lex.”

FOOTNOTES

Ewart, discussing the antiquity of gout, observes that it is “certainly as ancient as civilisation,” and as far as we can identify them in the accounts handed down from remote ages, the etiology, the leading symptoms, the outward characters of the articular gout of the ancients were practically the same as belong to gout in our own times! But of its relative prevalence in antiquity we have no means of judging. Continuing, he holds that “the ultimate lesions of gouty arthritis and its pathology are presumably as immutable as those of osteoarthritis.” This may be so, but such objective evidence as we possess certainly points to the greater antiquity of osteoarthritis as the following quotation from our work, “Arthritis Deformans,” testifies:—

“During the course of some excavations undertaken by the Survey Department of the Egyptian Government in that tract of Nubia lying immediately south of the First Cataract, over 6,000 bodies were brought to light, comprising among them representatives of all periods from early pre-dynastic times down to the fifth century after Christ. As the result of their examination of this vast accumulation of human débris, Professor Elliot Smith, in the Nubian Survey Bulletin, states that “The disease which shows itself with by far the greatest frequency in the bodies of all periods is rheumatoid arthritis” (Osteoarthritis).

920 (S. Eng. Leg.), “There cam a goute In is knee, of Anguische gret.... So longue, that is kneo to-swal.”

1310 (In Wright Lyric), “A goute me hath ygreythed so, Ant other eveles monye mo.”

1377 (Langl., P. Pl.), “He ... gyued me in goutes, I may noughte go at large.”

1400 (Lanfranc’s Cirurg.), “A man that hath arteticam, that is as myche to seie as a goute.”

1450 (M.E. Med. Bk., Heinrich), “Here wyth anoynte the goutes.”

1566 (J. Alday, tr. Baoystuau’s Theat. World), “Their legges full of gouts.”

1579 (Langham, Gard. Health, 1633), “For all goutes, seethe Leekes and Otemeale with sheepes tallow, and apply them hot.”

1590 (Spenser, F. Q.), “And eke in foote and hand A grievous gout tormented him full sore.”

1697 (Dryden, Virg. Georg.), “From Winter keep Well fodder’d in the Stalls, they tender Sheep.... That free from Gouts thou mayst preserve thy Care.”

1704 (Fuller, Med. Gymn.), “There have been some Gouts ... which nothing could remove but a very low Diet.”

1732 (Pope, Ess. Man.), “So, when small humours gather to a gout The Doctor fancies he has driv’n ’em out.”

1822 (Ld. Eldon, in Twiss Life), “I found the King in bed yesterday. He has had a pretty severe gout.”—New English Dictionary, Oxford, 1901. (Ed. Sir James Murrary.)

Pitt, in one of his last letters to the Marquess Wellesley, deplores his slow recovery from severe attacks of gout with which, by the bye, the statesman Fox was likewise affected.

Both Norman Moore and Bowlby subsequently upheld Ord’s view that uratic deposits only occur in tissues already degenerated. “Ebstein’s view has been modified by Von Noorden, who holds that a special ferment leads to the tissue change, to which the deposit of the urate is secondary.”

Physiognomy of the Goutily Disposed.—Taking the principles as laid down by Laycock, the peculiarities of those thus affected fall under the head of the sanguine arthritic diathesis. (That careful observer did not fail to note the modifying influences of gout upon struma and other cachexia.) Thus may be compared the physiognomy of the diathesis and its associated cachexia (developed in time):—

Blood-vessels numerous; heart large and powerful; blood-corpuscles numerous; skin over malar bones highly vascular (florid complexion); skin fair, firm, oleaginous, perspirable; eyes blue; hair thick, not falling easily; teeth massive, well-enamelled, regular, even, undecayed in advanced life; malar bones flattened; head symmetrical; nasal bones well-formed, nose aquiline or of mixed form; lower jaw massive; lips symmetrical.

Form.—Figure for the most part tall; thorax broad at the summit; ribs well-curved; abdomen full; muscles firm, large; limbs large, robust; gait erect, well-poised. Nutrition active; digestion vigorous; appetite great for animal food and alcoholic stimuli. Respiration deliberate, deep; circulation vigorous; animal heat abundant; locomotion active; aptitude for exercise and outdoor amusements. Reproductive powers active; innervation abundant, the mental powers vigorous and enduring.

Physiognomy of the Sanguine Gouty Cachexia.—Blood-vessels largely developed over the malar bones and varicose; skin oily, yellow from subcutaneous deposit of fat; hair thick and white; teeth numerous, discoloured, crusted with tartar; lips bluish, nose reddish, hypertrophied; arcus senilis; abdomen pendulous; limbs thick; joints nodose; nodosities on the ends of the fingers, lobes of ears, fascia of muscles, and tendons; respiration hurried, wheezing; pulse intermittent, irregular; stomach flatulent; digestion acid; urine loaded with lithates; temper irritable; mind sometimes enfeebled.

The local diseases of the arthritic cachexia are principally seen in adult males past the age of forty-five. They consist especially in chronic inflammation of the muscular and articular tissues; in calcification of the basilar and coronary arteries, and of the cardiac valves. These changes give rise to hæmorrhagic apoplexy, angina pectoris, cardiac hypertrophy and dilation; and to secondary pulmonary affections, as emphysema, pulmonary apoplexy, and asthma. Irritation of the mucous surfaces may give rise to nephritis, pharyngeal and laryngeal coughs, and diarrhœa.—Med. Observation and Research, 2nd edition, pp. 96-98.

According to Fischer the protein molecule can be split up into amino-acids, di-amino-acids, aromatic-amino-acids, nitrogenous derivatives of the benzene ring, pyrimidine bases, pyrrolidine derivatives, cystin, and ammonia. During proteolysis the amino-acids exist in groups, e.g., glycine and leucine (glycyl-leucine), two leucine radicles (alanyl-leucine), etc.—which combinations Fischer termed polypeptides, and some of which he has been able to produce synthetically. Furthermore, Fischer proved that nitrogen equilibrium can be maintained in animals by feeding them upon these polypeptide products of proteolytic digestion which no longer gives the biuret reaction. The derivation of amino-acids, etc., from peptone is the outcome of the action of a special intestinal ferment—erepsin. This enzyme is found not only in the alimentary tract, but in all tissues of the body, its action being especially developed in the renal tissues.

Glycocoll in solution dissociates more H-ions than OH-ions. In the presence of alkalies this acid character is more marked, so that it tends to throw the uric acid salts out of solution. The inhibitory influence of the urea upon the precipitation of uric acid from solutions is due to its basic nature.

Recent researches by S. R. Benedict show that uric acid, in the blood of most mammals, exists in combination, but not in that of the bird. Fresh ox-blood (Folin method) contains only 0·30005 gram, free uric acid per 100 grams of blood. But after boiling the protein-free blood filtrate with hydrochloric acid the uric acid content was about ten times as high. Moreover, this same augmented uric acid content was found to exist “in whole blood that had been allowed to stand for some time, indicating that the uric acid compound can be split by means of an enzyme.” The compound exists, not in the plasma, but in the corpuscles. MacLeod, to whose work on bio-chemistry we are indebted, remarks that “It is of some significance that after thus setting free the uric acid, there should be about 50 per cent. more of it present in the blood of the ox than in that of the bird, where most exists in a free state in the serum, although the urine of the ox contains only the smallest trace of uric acid, and that of the blood is loaded with it. Investigation of the condition of uric acid in human blood is at present in progress.”

According to Sir William Roberts, there are three compounds of uric acid (H₂U)—the neutral urate, M₂U, in which the metal replaces all the displaceable hydrogen, the biurate, MHU, in which half the displaceable hydrogen is replaced by the metal, and the quadriurate H₂UMHU, in which one-fourth of the displaceable hydrogen of two molecules is replaced by the metal.

Hutchison and Tidy suggest “that if Roberts’ salt be considered as NaHU. MH₂U instead of Na. HU, his hypothesis remains unaltered, whilst much of the criticism urged against it is nullified. The possibility of such a substance is shown by the existence of the compound LiHU₄HU. Roberts’ theory, or such a modification, is not inconsistent with Von Noorden’s views if these intermediate salts be regarded as within the tabernacle of organic combinations from which the kidneys can split off and excrete the uric acid.”

“If further investigations yield facts which sustain such an idea, it may be more easy to comprehend the types of the demands which are made upon the renal functions.... One of the next stages of research will be the determination of the behaviour of renal tissue to the various purin isomers. This may lead on to the identification of the types of nuclein derivations and their precise cellular origin. Perhaps this in turn may reveal whether there are any differences between the nucleotides of normal and gouty tissues. To this end progress in the technics of the cultivation of tissues in vitro may furnish a means for the elucidation of some of these questions.”—Walker Hall.

As a further illustration of the differences which may exist in the purin metabolism in different kinds of animals, in man and the anthropoid apes the quantity of purin bases in the urine is small in proportion to the quantity of uric acid. In the pig, which is included among the animals that form allantoin from uric acid, the purin bases exceed the uric acid in amount, whereas in the dog, which likewise excretes allantoin, the purin bases exist in very small amount compared with the uric acid.—Stewart’s “Manual of Physiology.”

The findings of Soetbeer and Ibrahim also indicate that 50 per cent. of the exogenous purin bodies undergo oxidation to uric acid, and 50 per cent. undergo further disruption and are excreted as urea or intermediate bodies.

The subject of the experiments—a healthy male (M. S. D.), 22 years of age and 58 kilos in weight—was placed for over six months upon a meat-free low protein diet, free also from purin-containing beverages. This with the exception of a few meals in the holidays, during which a small amount of meat was taken. “No attempt was made to secure a quantitative uniformity of the diet.” On the evening preceding the day of an experiment a light supper was eaten, and no further food was ingested until the completion of the day’s experiment, save the substance whose influence on uric acid excretion was to be studied. The urine was collected hourly, 200 c.c. of water being ingested hourly throughout the experimental period.—“Uric Add Metabolism,” 11—H. B. Lewis, M. S. Dunn, and E. A. Doisy, “Journal of Biological Chemistry,” 1918.

Two other men also served as subjects. Many of the experiments were duplicated, and similar results obtained with these other subjects, but inasmuch as the experiments with M. S. D. were more comprehensive and extended over a longer period of time, the data of these experiments alone are presented.

Quoting from the same article, Journal of Biological Chemistry, 1918, by Lewis, Dunn and Doisy, these authorities observe that—re glycocoll and alanine, Lusk concluded that “the chemical stimulation of protoplasm which is responsible for the phenomena of increased heat production (specific dynamic action) results from the action of their intermediary products, glycocollic and lactic acids, rather than from the amino-acids themselves. The phenomena of the stimulation of uric acid metabolism by amino-acids run parallel to those of the specific dynamic action of the amino-acids (except in the case of the dicarboxylic amino-acids), and it is possible that the same chemical factors are responsible for both.”

C₅H₄N₄O₃ + O + H₂O------>C₄H₆N₄O₃ + CO₂ Uric acid. Uricase. Allantoin.

Experimenting on a Dalmatian coach-hound, Gideon Wells was able to confirm Benedict’s observation that it excretes large quantities of uric acid. But inasmuch as the liver of this same dog was able to destroy uric acid in vitro, the inference is that the presence of uric acid in the urine of the Dalmatian is not attributable to the absence of uricase in its tissues. “The kidney did not exhibit uricolytic activity. Neither the liver nor spleen converted xanthine into uric acid, but the liver deaminised both guanine and adenine.”—Journal of Biological Chemistry, 1918.

Wells, in his “Chemical Pathology,” observes that the amount of uric acid that appears in the urine depends upon a variety of factors which may be summarised as follows:—

(1) The amount of purin bodies taken in the food upon which chiefly depends the amount of exogenous uric acid.

(2) The amount of destruction of tissue nucleo-proteins.

(3) The amount of purin bases formed in the muscle tissue.

(4) The amount of conversion of purin bases into the uric acid.

(5) The amount of destruction of uric acid, if any, occurring in the body.

(6) Possibly upon the capacity of the tissues to synthesize uric acid; and in case such power to synthesize uric acid exists upon the presence of the precursors of uric acid in the body.

(7) The retention of uric acid in the blood and tissues.

(8) The power of the kidney to excrete uric acid.

(9) The solubility of uric acid in urine—dependent upon the amount of neutral phosphates present, the temperature, reaction and concentration thereof.

EFFECT OF ATOPHAN ON EXOGENOUS PURINS. (McLester, in “Archives of Internal Medicine.”)

-----+--------------------------+--------+------------------------------ | | | Twenty-four Hour Urine. | | Blood +-------+-------+-------+------ Date.| R. E. |Mg. U in| Amt. | | NH. | | |100 Gm. | c.c. |U. Gm. |Gm. N. |N. Gm. -----+--------------------------+--------+-------+-------+-------+------ 5/28 | ---- | 2·9 | 1,150 | ·46 | ·58 |10·26 5/29 |7 a.m.: 500 grams thymus. | | | | | | 2 p.m.: Blood | 3·2 | 900 | ·66 | ·69 |10·96 5/31 |7 a.m.: 500 grams thymus. | | | | | | 9 a.m.: Atophan, 2 p.m.:| | | | | | Blood | 1·1 | 1,280 | ·75 | ·76 |11·16 -----+--------------------------+--------+-------+-------+-------+------

Walker Hall states that: “Taking the total volume of blood at three and a half litres, and the volume passing through the lungs as four and a half litres per minute, and through the kidneys as one litre per minute, and the solubility of lactim-urate as 0·1 grm. per 4,000 c.c. of blood, it would seem that the average daily output of 0·5 grm. could be suspended in the quantity of blood passing through the lungs in five minutes or through the kidneys in twenty minutes normal.”

Criticising the colorimetric method on the ground that “different workers obtain on the same blood samples results which vary considerably,” L. J. Curtman and A. Lehrman have devised a new volumetric method for the determination of uric acid in blood. The following is the summary of their researches:—

(1) An experimental study of a number of metallic salts as precipitants for uric acid in a solution alkaline with sodium carbonate was made. The results showed that nickel is the best of those tried.

(2) A 0·0004 N iodine solution was found suitable for the estimation of small amounts of uric acid provided certain conditions are adhered to.

(3) Based upon the above considerations, a new method has been developed for the determination of uric acid in blood, the chief features of which are (a) the precipitation of the uric acid by means of nickel acetate in a solution alkaline with sodium carbonate. (b) The estimation of the uric acid in the precipitate by means of a dilute solution of iodine.

(4) The method was applied with good results to aqueous solutions of uric acid as well as to blood serum to which known amounts of uric acid were added.

(5) Low and inconsistent results were obtained when the method was applied to sheep’s blood to which known amounts of uric acid were added. This was shown to be due to the inadequacy of the procedure generally employed, for the coagulation and preliminary treatment of the blood. The colorimetric method when used in the analysis of samples of the same blood also gave low and inconsistent results for the same reason.

(6) Comparison tests show that the volumetric method is fully as accurate as the colorimetric method, and possesses the advantage of requiring no special apparatus.

URIC ACID ESTIMATION IN NORMAL INDIVIDUALS

(McLester, “Archives of Internal Medicine.”)

Milligrams Uric Acid in 100 grams Blood.

J. C. 0·5 H. D. 0·6 M. D. 0·6 A. B. 0·8 R. C. 0·9 H. D. 0·9 J. G. 0·0 S. M. 1·1 R. D. 1·3 L. S. 1·4 L. H. 1·7 R. O. 2·1 H. H. 2·5 J. M. 2·5 R. E. 2·9

URIC ACID OF BLOOD IN DISEASE. (McLester, “Archives of Internal Medicine.”)

Milligrams in 100 grams Blood.

Mitral lesion 0·5 Rheumatic fever 0·6 Acute syphilis 0·8 Chronic tuberculous pleurisy 0·8 Pneumonia 1·2 Pneumonia 1·3 Sciatica 1·3 Typhoid fever 1·4 Ulcer of stomach 1·5 Pneumonia 1·6 Amœbic dysentery 1·6 Neurasthenia (?) 1·7 Acute tuberculous pleurisy 1·7 Chronic interstitial nephritis 1·8 Malaria 1·8 Pneumonia 1·9 Uremia 2·1 Polycythemia 2·2 Graves’ disease 2·5 Pneumonia 2·7 Gout 3·3 Arterial hypertension 3·3 Intermittent gastric supersecretion 3·7 Gout 4·5

However, as Walker Hall reminds us, Taylor, writing in 1912, stated, “That the margin of safety with regard to renal excretion is an exceedingly narrow one, that the kidney excretes uric acid slowly, and that its powers are soon overstepped.”

Magnus Levy and McClure have also noted that the excretion of exogenous purin is not invariably retarded or diminished.

When experimentally injected, the urates are absorbed slowly by phagocytic leucocytes and giant cells.—Gideon Wells.

Because the gouty tophi do not suppurate, even when ulcerated, through the skin, it has been suggested that the urates have antiseptic properties. Bendix (Zeit. klin. Med., 1902 (44), 165), however, could not demonstrate such antiseptic properties experimentally.—Gideon Wells.

Levinthal, in a personal experiment, injected half a gram of xanthin dissolved in piperazine into his cubital vein. A few days later, after a moderate strain upon the limbs through dancing, he was suddenly seized with a fairly acute painful attack in one of his knees, attended with some swelling and local heat.

“Tophi sometimes precede by some years ... the development of gouty attacks in joints. The same is true also of auricular tophi.”—Duckworth: “A Treatise on Gout.”

“While, however, tophaceous concretions generally show themselves after attacks of articular gout, cases occur, as I have already told you, in which the secretion of calcareous matter takes place irrespective of any arthritic attack. This sort of cutaneous gravel, if I may employ a comparison based on the great analogy between the composition of urinary gravel and tophaceous concretions, gravel of the skin, constitutes the sole manifestation of the diathesis, and is accompanied merely by a slight feeling of pain, of pricking unattended by any disturbance of the general health.”—Trousseau’s “Clinical Medicine.”

Redness of the skin overlying a developing tophus is not invariable. In a case recently under my care, the dorsum of the mid-phalangeal joints was the seat of small soft localised swellings. The superjacent skin was unchanged in colour. Aspiration of the contents by a hypodermic syringe disclosed the presence of a turbid white fluid, which, when microscopically examined, was found loaded with the acicular crystals of sodium biurate.

“Quod in omnibus podagricorum paroxysmis solemne est, insignior intumescentia venerum membro vexato intertextarum se in conspectu dat.”—Sydenham.

Sydenham’s classical description: “Towards the end of January or the beginning of February suddenly, and with scarcely any premonitory feelings, the disease breaks out. Its only forerunner is indigestion and crudity of the stomach, which troubles the patient for some weeks previous to the attack. His body also feels swollen, heavy, and windy—symptoms which increase from day to day until the fit breaks out. But a few days before this torpor comes on, and a feeling of flatus along the legs and thighs. Besides this, there is a spasmodic affection, whilst the day before the fit the appetite is unnaturally hearty. The victim goes to bed in good health and sleeps. About two o’clock in the morning he is awakened by a severe pain, generally in the great toe, more rarely in the heel, ankle, or instep. This pain is like that of a dislocation of the bones of these parts, and is accompanied by a sensation as of chilly water poured over the membranes of the suffering joint. Then follow chills and shivers and a little fever. The pain, which was at first moderate, becomes gradually more intense, and while it increases the chills and shivers die out. Every hour that passes finds it greater, until at length at night-time it reaches its worst intensity, and insinuates itself with most exquisite cruelty among the numerous small bones of the tarsus and metatarsus, in the ligaments of which it is lurking. Now it is a violent stretching and tearing of the ligaments, now it is gnawing pain, and now a pressure and tightening. So exquisite and lively meanwhile is the feeling of the part affected that it cannot bear the weight of the bedclothes nor the jar of a person walking in the room. Hence the night is passed in torture and a restless rolling first to one side, then to the other, of the suffering limb, with perpetual change of posture, the tossing about of the body being as incessant as the pain of the tortured joint, and being at its worst as the fit is coming on. Hence the vain efforts by change of posture, both in the body and the limb affected, to obtain an abatement of the pain.

“This comes only towards the second or third hour of the morning (a whole day and night after the first outbreak of the fit), such time being necessary for the moderate digestion and dispersion of the peccant matter. The patient then has a sudden respite, which he falsely attributes to the last change of position. A gentle perspiration is succeeded by sleep. He wakes freer from pain and finds the part recently swollen. Up to this time the only visible swelling has been that of the veins of the affected joint. Next day (perhaps for the next two or three days), if the generation of the gouty matter have been abundant, the part affected is painful, getting worse towards evening and better towards morning. A few days after the other foot swells, and suffers the same pains. The pain in the latter regulates the state of the one first attacked, for the more acutely it is tortured the more perfect is the abatement of suffering and the return of strength in the other. Nevertheless, there is a repetition in the second case of all the misery of the first both as regards intensity and duration. Sometimes during the first days of the disease the peccant matter is so exuberant that one foot is insufficient for its discharge. It then attacks both, and that with equal violence. Generally, however, it takes the feet in succession. After it has attacked each foot the fits become irregular both as to the time of their coming and as to their duration. One thing, however, is constant—the pain increases at night and abates in the morning. Now a series of lesser fits like these constitute a true attack of gout, long or short, according to the age of the patient. To suppose that an attack two or three months in length is all one fit is erroneous. It is rather a series of minor fits. Of these the latter are milder and more limited in their extent than the former, so that the peccant matter is discharged by degrees, and recovery follows. In strong constitutions, when the previous attacks have been few, a fortnight is the length of an attack. With age and impaired habits gout may last two months. With very advanced age, and in constitutions very much broken down by previous gout, the disease will hang on till the summer is far advanced. For the first fourteen days the urine is high-coloured, has a red sediment, and is loaded with gravel. Its amount is less than a third of what the patient drinks. During the same period the bowels are confined. Want of appetite, general chills towards evening, heaviness, and a troublesome feeling even in the parts which are free from the attack, attend the fit throughout. As it goes off the foot itches intolerably, mostly between the toes; the cuticle scales off, and the feet desquamate, as if venomed. The disease being disposed of, the vigour and appetite of the patient return, and this in proportion to the violence of the last fits. In the same proportion the next fit either comes on or keeps off. Where one attack has been sharp, the next will take place that time next year, not earlier.”—Sydenham.

“Pain is better borne by the poor man, as I have had opportunities of seeing, than by the man who acquired or promoted his gout with two or three bottles of port wine daily, with the surroundings which such luxury implies.”—Longstreth, “On Gout.”

“The pain is altogether disproportionate to the other signs of inflammation, and, even more, to the consequent structural changes in the inflamed part.”—Paget.

As to the peculiar character of the pain, Duckworth states: “Nothing at all like it occurs in any other joint disease.”

Sydenham noted that “sometimes the morbific matter is thrown upon the elbows and occasions a whitish swelling, almost as large as an egg, which becomes gradually inflamed and red.”

“Regular gout may supervene suddenly, and be chronic; that is to say, its outbreak need not have been preceded by paroxysms in any way characteristic of acute gout.”—Trousseau, “On Gout.”

As Trousseau puts it: “Regular chronic gout, in respect of the frequency of the recurrence of the paroxysms, resembles acute gout with successive paroxysms, there being this capital difference, however, that its attacks are longer and during the intervals are not entirely absent.”

Mr. James Moore, surgeon to the Second Regiment of Life Guards (Medico-Chirurgical Transactions, 1809, Vol. I.):—

“This effusion” (meaning the milky fluid containing the urate of soda) “occurs not only during fits of gout, but likewise in the intervals; and as the extremities, particularly the hands and feet, are the principal seat of gout, it is there the greatest accumulation of chalk takes place. Though this process is usually preceded and accompanied by inflammation, the chalk is never inclosed in a cyst, like pus in an abscess. It lies usually in the cellular membrane, in the bursæ mucosæ, or in the cavities of the joints. I have even seen it thrown out between the cutis and the cuticle. But, as the gouty inflammation is of the erythematous kind, there is no extravasation of coagulable lymph, and no new-formed covering surrounding the chalk. This point is of the first importance, and explains many of the peculiarities of gout, which is generally considered as a phlegmon. But the absence of coagulable lymph in the inflamed parts I consider as full evidence of the inflammation being erythematous.

“The chalky liquid when first secreted gives to the finger the feeling of fluctuation, and cannot be distinguished from the ordinary serous effusion of gout. But unfortunately the absorbents cannot suck up the chalky particles. The consistence of the liquid therefore becomes thicker and thicker, till at last nothing remains but a hard mass. When even a considerable effusion of this kind occurs, the quantity of chalk which ultimately remains is comparatively small, as by far the greater quantity is merely serum. It therefore usually requires repeated effusions to form any great mass of chalk, and the consistency depends upon its age and the activity of the absorbents. The quantity at last accumulated by repeated paroxysms is in some instances immense, which augments very seriously the sufferings of the gouty. The distress, however, is not owing to any irritating quality in the chalk, but to its obstructing the motion of the tendons and joints, occasioning often complete anchylosis, and pressing and distending the surrounding parts by its bulk. It acts, therefore, by mechanically embarrassing the machine of the body, and not upon the living principle, for it will often remain for years in parts highly sensible without exciting the slightest pain or inflammation. Although these concretions are of so mild a nature, they often are the cause of extensive mischief, bursting externally, occasioning ulcers very difficult to heal. When a violent fit of the gout attacks a chalky tumour, the appearance is frequently very alarming, the new paroxysm being accompanied with a fresh serous and chalky effusion, which, added to the old deposit of chalk, occasions a prodigious swelling; the cutis when distended to the utmost opens, yet sometimes the cuticle remains entire. The chalky or serous liquid may then be seen through the semi-transparent epidermis. The surrounding integuments appear of a deep red, or of a purple hue, threatening mortification, while the pain is excruciating.

“At length the cuticle gives way, a discharge of serum and chalk takes place, and a remission of all the symptoms usually follows. During the whole of this alarming process suppuration never occurs; but soon after the opening has taken place suppuration commences, and pus and chalk are then discharged from the ulcer. There are several unexpected occurrences in the progress of such ulcerations. When an opening is formed, the whole of the chalk never escapes, and its complete evacuation is often a very tedious process; this is owing to its being diffused through the cellular membrane, as in the cells of a sponge. One cell must sometimes give way after another, and small portions of chalk are successively thrown out, so that months and even years pass away before the whole is discharged. It also frequently happens that the orifice contracts and closes over, leaving portions of chalk underneath. This kind of cicatrix sometimes stands its ground, but more commonly breaks out again and again to discharge chalk. Even openings into joints, which are so dangerous when occasioned by other extraneous bodies, are often attended with no serious symptoms when the joint is filled with chalk. On such an accident happening a surgeon unacquainted with these peculiarities might be tempted to propose large openings, or even amputation, as the only resource for hindering extensive inflammation and carious bones. But if he treats the disease mildly, he will find that no such severe plans are requisite, for the parts will probably fall into a very tranquil or indolent state; a sore will continue for a certain period, discharging pus, and occasionally a bit of chalk, till at last the orifice will close up. Independent of the opening formed by a fit of the gout, the skin, stretched over a mass of chalk, is sometimes thinned, absorbed, and pierced by mere pressure. At other times this is effected by common inflammation and suppuration. When openings take place in these milder ways, a less quantity of chalk is usually evacuated; but this depends entirely upon the degree of inflammation. When the suppuration is great, it naturally detaches and washes out a greater quantity of chalk.

“The last peculiarity is the rarest, namely, that a dry, hard piece of chalk shall pierce the skin, and remain like an excrescence, without exciting either inflammation or suppuration.”

According to Adler, about one-tenth as much uric acid is excreted in the sweat as in the urine, sweat containing 0·1 mg. per cubic centimetre.

In this connection the tendency of gouty glycosurics to exhibit boils and sometimes carbuncles should not be forgotten.

Max Strunsky, of New York, discussing the frequency with which by the older physicians gouty forms of arthritis were confused with gonorrhœal, syphilitic, and other undifferentiated forms of infective arthritis, makes the following observation: “Also flatfeet must have added herds of cases, for this pathological entity was as yet unknown. The rich man in pursuit of his pleasure and the poor man from prolonged standing at his labour strained their arches then as they do now, and women by their ultra-fashionable shoes, which fashion decreed upon them in certain periods of history, produced painful feet which were undoubtedly mistaken for gout. That patients with local foot trouble were treated for gout the writer can speak from experience. A typical case is of a woman who came to his office two years ago. She had broken-down anterior arches. Hallux valgus, hammer-toes, and bunions were present, and the heels were small and undeveloped. Her feet were one mass of pain, and they looked infantile, reminding one of a Chinese woman. All her adult life she wore high-heeled, narrow, pointed, tight shoes. She said that for twenty years she had been treated for gout.”

In support of this contention, I would note that Charcot, while he gives us an inimitable account of the tophaceous variety of gout, introduces also another variant, as he deems it, of chronic articular gout. The joint changes in this latter are marked by what he terms “a thorough atrophy,” including the superjacent skin, which “is pale, shining and polished.” With this are associated ankyloses, angular deflections, and partial dislocations. The joints, he states, “may be absolutely free from swelling, for example when the extra-articular urate deposits either do not exist at all, or only mere traces of them, or when only the articular cartilages are invaded by the urate of soda.” It cannot, we think, be doubted that the clinical content of this group is largely made up of rheumatoid or atrophic arthritis. The evidence that these examples, quâ uratic deposits, are of “gouty” nature, is obviously very slender.

Reverting to Sir Dyce Duckworth, this authority also recognises two varieties of chronic articular gout: (a) tophaceous gout; (b) chronic deforming gout, with as its synonym arthritis deformans uratica. As to the clinical content of this latter group he writes: “The fingers, hands, and wrists show various deformities depending on over-growth of articulating ends of bone, cartilage, ligaments, and bursæ. These may be complicated with visible or invisible tophaceous deposits.” As to these anatomical alterations, Duckworth regards them as “similar to, but not the same as, those induced by rheumatic disease.” But he adds: “It is very rare for the deformities of true gout to attain the gross characters peculiar to chronic rheumatic arthritis; they are altogether of lesser degree in the majority of the worst instances.” From a careful study of their anatomical characters, I cannot avoid the conclusion that they were in the main examples of the hypertrophic variety of arthritis deformans, viz., osteoarthritis.

As Sir W. Hale White has pointed out, “pads” not uncommonly develop on the dorsal aspects of the mid-phalangeal joints. They range in size from a split pea to a hazel nut. Histologically they are the outcome of an excessive overgrowth of fibrous tissue beneath the corium. They in no way involve the joints, but, according to Hale White, they have been confused with osteoarthritis. Their frequent association with Dupuytren’s contracture might conceivably lead to their confusion with gout also, inasmuch as that deformity is so widely attributed to a “gouty” habit.

Sir Spencer Wells in his “Practical Observations on Gout and its Complications and on the Treatment of Joints stiffened by Gouty Deposits.”

“Of the many cases related by authors as anonymous disease by far the greater portion were connected with a gouty diathesis, as indicated both by the formation of calculi, by the occurrence of regular paroxysms of gout, and by the descent of the individual from gouty ancestors; they are cases, in fact, which would have been better understood and better treated if they had been termed ‘anomalous gout’; but as the subjects are young females, they are of course set down as ‘anomalous hysteria.’”—Laycock: “Nervous Diseases of Women.”

“Diseases of the Eye” (1918), p. 258.

“Diseases of the Eye” (1919).

“Diseases and Injuries of the Eye” (1913).

Kruckmann, Med. Klinik., 1910, No. 38.

Proc. Roy. Soc. Med., Ophth. Section, 1914, p. 66.

Ophth. Hosp. Reps., VII., p. 287, 1873.

“Diseases of the Eye” (1854), p. 558.

Brit. Med. Journ., 1885, R. Clement Lucas.

Lancet, 1920, Vol. I., p. 500, Browning.

Archives d’Ophtalmologie, Vol. XII., p. 623.

A very rare form of iritis was described by the late Mr. Doyne as guttate iritis (Trans. Ophth. Soc., Vol. XXX., p. 91) because the appearances resembled drops of lymph on the margin of the pupil. In his view it was a true form of gouty iritis, but the diagnosis does not seem to have been confirmed by other observers. Even if we grant that his view is possibly correct, we must beware how we generalise on a basis of exceptions and freaks.

Brit. Med. Journ., 1903, Vol. II., p. 138.

“Gout” (1876), p. 450.

Clin. Soc. Trans., Vol. XI., p. 132, 1898.

“Medical Ophthalmoscopy,” 3rd edition, p. 267.

Practitioner, 1909, Vol. II., p. 61.

Sydenham, discussing a milk diet, observes that “it has done good as long as it has been rigidly attended to. The moment, however, that the patient swerves from it a hair’s breadth, and the moment he betakes himself to the diet of a healthy man (no matter how mild and simple), the gout returns worse than ever.”

“The lighter beers of Germany, Austria, and Scandinavia, appear to be harmless for the gouty unless taken immoderately. Residents in towns goutily disposed, leading sedentary lives, are seldom long tolerant even of light laager beer.”

Sir Archibald Garrod has suggested that guaiacum has a distinct effect in reducing the amount of uric acid excreted, i.e., it was thought that the uric acid is eliminated in some other form, possibly hippuric acid. Accordingly Martindale and Westcott conducted investigations to determine whether this resin increases or decreases the elimination of uric acid from the human body.

A normal individual took guaiacum resin in 5-grain doses daily in the morning, and the uric acid was estimated in the urine the same afternoon. Hippuric acid was also estimated in specimens of the same urine by the method given by Allen, “Chemistry of Urine,” p. 186. After a day’s interval the acids were estimated on several days without administration of the drug. The two series were then repeated on the same lines after an interval. Seeing that the diet of the individual could not well be controlled in weighed amounts of food, as would strictly be necessary for an investigation of this kind, it was thought that to express the results in percentage ratios of uric acid to excess of solids (R.U.A.) over water might yield more comparable results.

Joulie employs this method of indicating the constituents of urine by ratios; cf. Vol. I., p. 736. Thus, taking a specimen of urine with the following “normal” factors in grams per litre:—

Specific gravity 1017·8 Excess of solids over water 17·8 Physiological acidity in terms of H₂SO₄ 0·849 Total P₂O₄ 2·083 Cl 6·865 Urea 18·75 Uric acid 0·416 Hippuric acid 1·3 (mean).

One may express the constituents as the following percentage ratios:—

Normal.

“R.A.”—Ratio of physiological acidity to excess of solids over water 4·77 0·849 × 100 ----------- 17·8

“R.P.”—Ratio of total P₂O₄ to excess of solids over water 11·17 “R.U.”—Ratio of urea to excess of solids over water 100·53 “R.U.A.”—Ratio of uric acid to excess of solids over water 2·33 “R.H.A.”—Ratio of hippuric acid to excess of solids over water 7·3 “R.P./R.A.”—Ratio of phosphoric acid to ratio of acidity (Joulie’s factor, cf. Vol. I., p. 737) 2·45

Ratio of uric acid, for example, is arrived at thus 0·416 × 100 ----------- = 2·33 17·8

The results which we obtained are given in the following table:—

Effects of Guaiacum Resin on the Urine of a Normal Individual.

-----------------+---------+-------+-----+------+------+--------+-------- | Date. | Sp. |Urea.| Uric | Hip- |“R.U.A.”|“R.H.A.” | | Gr. | | Acid.| puric| | | | | | | Acid.| | -----------------+---------+-------+-----+------+------+--------+-------- With guaiacum | 28/12/11| 1·0107| 2·29| 0·09 | 0·09 | 4·43 | 4·34 With guaiacum | 29/12/11| 1·0247| 1·29| 0·08 | 0·1 | 3·34 | 4·04 With guaiacum | 1/1/12| 1·0215| 2·56| 0·015| 0·15 | 4·88 | 6·97 With guaiacum | 2/1/12| 1·0141| 2·82| 0·10 | 0·2 | 4·2 | 8·20 Without guaiacum | 4/1/12| 1·0229| 2·42| 0·06 | 0·1 | 2·62 | 4·36 Without guaiacum | 5/1/12| 1·0249| 2·42| 0·08 | 0·2 | 3·16 | 8·03 Without guaiacum | 8/1/12| 1·0255| 3·09| 0·10 | 0·225| 4·11 | 8·12 With guaiacum | 11/1/12| 1·0233| 2·56| 0·09 | 0·1 | 3·7 | 4·29 With guaiacum | 12/1/12| 1·0213| 1·88| 0·075| 0·1 | 3·05 | 4·69 Without guaiacum | 24/1/12| 1·0239| 2·42| 0·08 | 0·038| 3·45 | 1·57 Without guaiacum | 25/1/12| 1·0229| 2·15| 0·06 | 0·05 | 2·61 | 2·18 -----------------+---------+-------+-----+------+------+--------+-------

Average uric acid ratio under guaiacum resin = 3·39 Average uric acid ratio without guaiacum resin = 3·19 Average hippuric acid ratio under guaiacum resin = 5·43 Average hippuric acid ratio without guaiacum resin = 4·49

The quantity of hippuric acid normally found is known to vary enormously, e.g., between 0·02 and 0·25 per cent. From this we deduced, for purpose of this investigation, a mean normal R.H.A. of 7·3. A number of other investigations were conducted on analogous lines, but need not be recorded.

From the results of these experiments one notices an average increase of uric and hippuric acids during the “+ guaiacum” periods. It is not possible to draw a conclusion without further corroboration. The amount of each acid from day to day is seen to be erratic, and the process of estimation of hippuric acid is not accurate.

“Weakly mineralised thermal muriated waters, such as those of Baden-Baden in Germany, and Bourbon-Lancy in France, which in character and action approach the simple thermal group, may also show great radio-activity. In fact, the Büttquelle of Baden-Baden in this respect rivals some of the most radio-active springs of Gastein. Of Bourbon-Lancy springs, according to A. Piatot, the least mineralised are the most radio-active.”—“Climato-therapy and Balneo-therapy,” by Sir Hermann Weber.

SIR WILLIAM RAMSAY’S ANALYSIS OF THE BATH WATERS.

Density of the water from King’s Well 1·0166

Osmotic pressure equivalent to that of a salt solution containing per litre 1·09 grams NaCl.

Volume of gas in twenty-four hours from—

Litres. King’s Well 4,927 Cross Spring 218 Hetling Spring 218 (estimated). ----- 5,363 -----

Analysis of gas (King’s Well)—

Parts per 10,000. Carbon dioxide 360 Nitrogen, etc. 9,640 No oxygen, no hydrogen, no marsh gas.

The nitrogen contains—

Argon 73·63 Neon 23·34 Helium 2·97

From all three wells in twenty-four hours—

Litres. Argon 39 Neon 12½ Helium 1½

Gases dissolved in Pump-room Water.—This water contains 18·5 volumes of gas per 1,000 of water. Its composition is—

Carbon dioxide 6·9 Nitrogen 11·6

It had become somewhat aerated on drawing, but allowance has been made for that.

Milligrams per million litres.

Radium in the water of the King’s Well 0·1387 Niton (radium emanation) in the water of King’s Well 1·73 ” ” ” ” of Cross Bath 1·19 ” ” ” ” of Hetling Bath 1·70 ” ” ” in the gas from King’s Well 33·65

Bickel in a series of experiments in which the acid contents as well as the total amount of gastric juice were considered obtained the following results: simple gaseous waters (Apollinaris, Giesshübl), muriated waters (Rakoczy spring of Kissingen, Wiesbaden, Kochbrunnen), and muriated alkaline waters (Ems, Selters), all of them, as compared to distilled water and ordinary tap water, rather increased than decreased the specific secretory activity of the gastric mucous membrane, whereas simple alkaline waters (Vichy) and sulphated alkaline waters (Karlsbad) had a slight tendency to diminish, and the sulphated “bitter” waters (Hunyadi Janos water) decidedly diminished, the gastric secretory activity, although “bitter” waters sometimes induced a watery flow from the gastric mucosa, which increased the fluid contents of the stomach.

Bain, of Harrogate, from his observations on a man with permanent cutaneous biliary fistula, found that the old sulphur spring of Harrogate increased both the quantity of bile and the bile solids. This, he thinks, may “fairly be taken as an index of the degree to which it stimulates the liver, and is, in fact, the most reliable indication of the value of a cholagogue.”

INDEX

=A-amino-acids=, 61

=Aborigines=, gout unknown among, 2

=Abscess= formation in peri-tophal tissues, 234 skin resembling, in acute gout, 212

“=Accessory= food factors” in diet of gouty, 339

=Adenase=, 100, 101

=Adenine=, 73, 75, 77, 98

=Aetius’s= views on gout, 6

=Age= factor in gout, 40 influence of, on diet, in acute stage of gout, 333

=Agotan= in treatment of acute gout, 379

=Aix= massage baths, 427

=Alanine=, uric acid excretion augmented by, 89

=Albuminuria=, diet in, 358

=Alcohol= and gout, 48 hypersensitiveness of gouty to, 365 in febrile stage of sthenic gout, 333 in gout, 361 in subjects of gouty glycosuria, 237 modus operandi of, in induction of gout, 49 plus overeating, cause of gout, 49

=Alcoholism=, chronic, purin metabolism in, 115

=Alexander= of Tralles’s views on gout, 5

=Alimentary= canal, condition of, and gout, 174 disorders, effects of radio-active waters on, 439 tract, functional derangements of, in diagnosis of articular gout, 249 X-ray examination of, in treatment of gout, 336

=Alkalies= in inter-paroxysmal periods of gout, 392 in treatment of acute gout, 383 in treatment of chronic gout, 399

=Alkaline= waters, simple, spas for, 441

=Alkapton= in urine, 59

=Alkaptonuria=, 69

=Allantoin=, 104

=Alternatives= in treatment of chronic gout, 401

=Alveolus=, senile atrophy of, 329

=Amberg= and Jones’ scheme of formation of uric acid, 104

=America=, United States of, gout in, 47

=Amino-acetic-acid=, 64

=Amino-acids= and dicarboxylic amino-acids, 89 deaminisation of, 62, 63 fate of, 62 in portal blood, 62 in relation to gout, 64

=Amino-purins=, as source of uric acid, 84

=Amylaceous= dyspepsia, diet in, 351, 352

=Anacritical= stage of depression, 211

=Anæmia= in cases of long-standing gout, treatment of, 406 retention capacity of tissues for uric acid in, 158

=Anatomical= alterations in articulations, 54

=Anglo-Saxon= period, prevalence of gout in, 2

=Animal= cells, nucleic acid derived from, 98

=Animals=, various, uric acid blood content of, 135

=Ankylosis= in chronic gout, 287

=Anodyne= preparations in treatment of acute gout, 384, 385

=Anodynes= in acute gout, 383

=Antiquity= of gout, 1

=Anuria=, hysteria in, 126

=Aponeuroses=, gouty polyarthritis in, 214

=Appendicitis=, septic foci of, 184

=Appendix-dyspepsia=, 184

=Arab= physicians’ views on gout, 6

=Aretæus= the Cappadocian’s views on gout, 4, 5

=Arterio-sclerosis=, associated with gout, 245 blood-content in, 127 spa treatment of, 451

=Arthralgia=, fleeting, 193

=Arthritic= attacks, tophi formation preceding, 164 iritis, 315

=Arthritides=, specific infective, and gout, analogies between, 194

=Arthritis= deformans, cleavage into two types, 18 differentiation of, from chronic gout, 16 rheumatoid, and osteoarthritis, 20

=Arthritis=, gonococcal, acute, differential diagnosis from acute gouty polyarthritis, 270 from gout, 259 of tarsus and metatarsus, differential diagnosis from gout, 263 gouty, 39 definition of, 20 frequency of tophi in, 255 relation to local foci of infection, 185 Greek designation, 3 hæmophilia, differential diagnosis from chronic gout, 285 infective, of undifferentiated type, differential diagnosis from acute polyarticular gout, 272 skiagraphy in differential diagnosis of, 290 non-gouty, hyper-uricæmia in, 140 rheumatoid, 17 differential diagnosis from chronic gout, 284 local character of joint swellings, 284 or atrophic, acute, differential diagnosis from acute gouty polyarthritis, 272 skiagraphy in differential diagnosis of, 291 syphilitic, differential diagnosis from chronic articular gout, 277 secondary, differential diagnosis from acute gouty polyarthritis, 271 tophi in relation to, 254

=Arthropathies=, nerve, differential diagnosis from chronic gout, 284

=Articular= gout, chronic, medicinal and other modes of therapy, 397 etiological diagnosis, 247

=Articular= lesions in chronic gout, distribution of, 226

=Asphyxias=, local, of hands, in gout, 45

=Atophan=, effect of, on exogenous purins, 110 on uric acid excretion, 119 indicated when gout attack imminent, 395 in treatment of acute gout, 379 in treatment of chronic gout, 403

=Auricular= tophi, 202

=Auto-intoxication= theory of gout, 182

=Auto-toxæmia= theory of gout, 182

=Avicenna’s= views on gout, 6

=Bacillus coli communis= as causative agent in gout, 175

=Bacterial= flora, intestinal, modifications in, 182

=Bacteriological= examination in diagnosis of articular gout, 251

=Baillon’s= dissociation of rheumatism from gout, 15

=Banting= method in reduction of obesity, 357

=Barclay’s= theories of ætiology of gout, 23

=Bath= as residence for gouty, 419

=Bath= waters, Sir W. Ramsay’s analysis of, 435

=Baths= in treatment of gout, method of application, 427

=Beaumont, W. M.=, ocular disease in the gouty, 308

=Beauvais’s= work on gout, 17

=Beer= as beverage in gout, 362

=Benzoates= in treatment of chronic gout, 401

=Berkart’s= theory of ætiology of gout, 27 views on gout, 56

=Beverages= in gout, 359

=Bismuth= carbonate in inter-paroxysmal periods of gout, 392

=Biurate= of soda in gouty tophi, 151

=Blisters= in treatment of acute gout, 386

=Blood=, changes in, in acute gout, 210 in chronic articular gout, 226 in gouty polyarthritis, 216 content in gout, 189 count in acute gout, 211

=Blood=, examination of, in diagnosis of articular gout, 251

=Blood=, human, relationship between amounts of uric acid, urea and non-protein nitrogen in, 122 in chronic interstitial nephritis, urates in, 120 in disease, uric acid of, 137 portal, amino-acids in, 62 routine examination of, in diagnosis of articular gout, 249 uric acid as normal constituent of, 135 uric acid content of, and gout, relation between, 143 effect of diet upon, 141 effect of exogenous purins on, 137 estimation of sources of fallacy, 145 in gout, 133, 139 uric acid in, 24, 34, 78 discovery of, 21 Folin and Denis’s method of determination, 133 forms of, 145 Gudzent and Schade’s theories, 79 non-protein nitrogen and urea nitrogen in (table), 136 variations in uric acid content independently of diet, 142

=Bodily= conformation, and gout, 44

=Boils=, gout following, 53, 178

=Bone=, conditions of, revealed by skiagraphy, in diagnosis of gout, 286

=Bones=, changes in, in gout, 53 focal areas of rarefaction in, revealed by skiagraphy, 286, 287

=Brandy= in gout, 371

=Bruce’s= modes, 286

=Bunion=, inflamed, differential diagnosis from gout, 261

=Burian= and Schur’s researches on sources of uric acid, 83

=Bursæ=, involved in gout, 195 tophi in, 233

=Bursitis=, olecranon, gouty, 215 post-calcaneal, in referred pain in heel, 265

=Cælius Aurelianus’s= views on gout, 5

=Caffeine=, 85

=Calcium= carbonate in inter-paroxysmal periods of gout, 392 salts in gouty tophi, 151

=Calculus=, urinary, 29

=Carbohydrates= in diet of gouty, 347

=Carbuncles=, gout following, 53, 178

=Cartilage=, morbid changes in, 53 uratic deposits in, 52, 153 in nephritis, 128

=Cataphoresis= in treatment of chronic articular gout, 407

=Cell= protoplasm, chemistry of, 176

=Celsus’s= views on gout, 4

“=Chalk-stones=,” 150

=Chalybeate= waters, spas for, 442

=Champagne= in gout, 368

=Charcot’s= discovery of nerve arthropathies, 18 joint, differential diagnosis from chronic articular gout, 277

=Chemistry= of uric acid and purin bodies, 75

=Chilblains= confused with early stages of tophi formation, 164

=Chirargra=, Greek designation, 3

=Cholecystitis=, 184

=Cider= as beverage in gout, 363

=Claret= in gout, 369

=Climate= and gout, 45 and residence in treatment of gout, 418

=Climato-therapy= in gout, 418

=Clothing=, importance of, 421

=Cocoa= as beverage in gout, 361

=Coffee= as beverage in gout, 361

=Colchicine= in treatment of acute gout, 378

=Colchicum= in acute gout, 192, 374, 375, 378 contra-indicated, alkalies as substitute, 383 method of administration, 376 preparations and dosage of, 376 used by Aetius, 6

=Colitis=, mucous, initial manifestations of gout, 175

=Colloids= in gouty tophi, 152

=Collosol= iodine in treatment of chronic gout, 402

=Colorimetric= method of determining uric acid in blood, 133

=Colour= reaction test in blood analysis, 133

=Condiments= in diet of gouty, 350

=Constipation=, effect in gout, 337 in acute gout, treatment of, 373 in chronic gout, treatment of, 400 in inter-paroxysmal periods of gout, treatment of, 393

=Constitutional= disturbance in gout, 188 influences in formation of tophi, 161

=Corpora= cavernosa of penis, tophi in, 235

=Cramps= in acute gout, 210

=Cream=, effect of, on uric acid output, 348

=Creatine=, 63, 67 in urine of children, 68

=Creatinine=, 61, 63, 67, 68 in blood in gout and nephritis (table), 121

=Crystalline= deposits in synovial fluid, 54

=Crystalloids= in gouty tophi, 152

=Cytosine=, 98

=Cullen’s= differentiation of varieties of rheumatism, 16 theory of ætiology of gout, 21

=Cutaneous= disorders in gout, 240 gravel, 203

=Cuticule=, desquamation of, typical of gout, 191

=Cystin= in urine, 59

=Cystinuria=, 69

=Cystoid= degeneration in gout, 56

=Deaminisation= of amino-acids, 62, 63

=Deficiency= diseases and accessory food factors, 340

=Degeneration=, theories of, 25, 27

=Desquamation= in acute gout, 212

=Diabetes=, glycosuria and, 60

=Dicarboxylic= amino-acids, 89

=Diet=, effect of, on blood content of uric acid, 141

=Diet= on excretion of uric acid, 83

=Diet= in acute paroxysms of gout, 332 in albuminuria, 358 in amylaceous dyspepsia, 351, 352 in chronic gout, 334 in glycosuria, 357 in hyperchlorhydria, 353 in hyperuricæmia, 354 in hypochlorhydria, 354 in inter-paroxysmal periods of gout, 391 in reduction of obesity, 357 in treatment of gout, 332 “accessory food factors,” 339 carbohydrates, 347 collaboration of clinician and bio-chemist, need for, 337 condiments, 350 fats, 347 fish, 346 fruits, 349 idiosyncrasies of, 343 physical examination necessary before, 336 proteins, 345 regulations of, 342 vegetables, 348 variations of blood content of uric acid independently of, 142

=Dietaries=, fixed, fallacy of, in treatment of gout, 335

=Digestion=, disturbances of, prevention of, in treatment of gout, 335

=Digestive= glands, rôle of, in uric acid excretion, 88

=Diocletian=, edict by, re gout, 5

=Dislocations=, signalising attack of gout, 53

=Douches=, 428

=Dover’s= powder, with aspirin and phenacetin, in treatment of acute gout, 383

=Drink= and gout, 48

“=Drug= dyspepsia,” 391

=Drugs= influencing excretion of endogenous uric acid, 96

=Duckworth’s= classification of arthritic type of gout, 36 theory of ætiology of gout, 33

=Dyschezia= and gout, 337

=Dysenteric= arthritis, differential diagnosis from acute gouty polyarthritis, 272

=Dysentery=, complicated by arthritis and myalgias, 194

=Dyspepsia=, amylaceous, diet in, 351, 352 atonic, muriated waters in treatment of, 444 chronic, gout associated with, 178 “drug,” 391 gouty, no specific form of, 350 intestinal, preceding gout, 182 mineral waters in treatment of, 443 spas in treatment of, 442

=Dyspeptic= symptoms of acute localised gout, 201

=Ear=, pricking or tenderness in, 203 tophus in, 202

=Ears=, tophi in, antedating articular outbreaks, 203

=Ebstein= and Sprague’s analysis of tophi, 150

=Ebstein’s= theory of ætiology of gout, 25

=Ecchymoses=, local, in acute gout, 212

=Eczema=, gouty, spa treatment of, 451 treatment of, 416 in gout, 241

=Egypt=, osteoarthritis in, in ancient times, 1

=Endemic= areas of gout, 46

=Endogenous= purins, 87 origin of, 83 source of, 88 uric acid excretion, 91 factors influencing, 93 increased by purin-free proteid food, 89 pathological states influencing, 94 periodic variations of, 94 physiological conditions, 93

=Environment= in gout, 40

=Enzymes=, distribution of, 99 in intestinal juices and wall, 100

=Epistaxis=, gout following, 178

=Epithelial= cells, nucleus in gouty tophi, 151

=Erysipelas=, gouty arthritis simulating, 215

=Erythromelalgia=, differential diagnosis from gout, 266

=Etiological= diagnosis of articular gout, 247

=Exercise= in gout, importance of, 421 relation of, to gout, 337

=Exogenous= origin of purins, 83 purins as source of uric acid, 84 uric acid excretion, 85

=Exudative= diathesis, 116

=Eye=, deposition of urates in, 309 gout in, evidence of, 309 gouty diathesis in regard to, 310

=Eyelids=, uratic deposits in, 235

=Fæces=, examination of, in diagnosis of articular gout, 250 in treatment of gout, 337

=Fasciæ=, involved in gout, 195

“=Fat= soluble A,” 340

=Fats= in diet of gouty, 347

=Feet=, incidence of tophi in, 162 plantar surface of, tophi in, 235

=Fibrosis=, interstitial, chronic, 186 of visceral organs in gout, tendency to, 186

=Fibrositis= associated with acute articular gout, 195 associated with gout, treatment of, 411 gouty, acute brachial, treatment of, 412 incidence of gouty stigmata in types of, 221, 222 muscular, in gouty, massage in, 423 spa treatment of, 450

=Fingers=, deformed, in chronic gout, 230 pulps of, tophi in, 235

=Fischer’s= researches on protein molecule, 61

=Fish= in diet of gouty, 346

=Flatfoot=, pains in, differential diagnosis from gout, 263

“=Flying= gout,” 193

=Foci= of infection in gouty, 53 local, in gout, 177

=Foci=, relation to gouty synovitis and arthritis, 185

=Folin= and Denis’s method of determination of uric acid in blood, 133 researches into urea formation, 63

=Food=, cooking of, in diet of gouty, 344 influence on gout, 48

=Foods=, various, exogenous urinary purin in, amount of, 85

=Foot= deformities, static, differential diagnosis from gout, 261

“=Fot-adl=,” Anglo-Saxon name for gout, 3

=Fractures=, signalising attack of gout, 53

=Fruits= in diet of gouty, 349

=Function=, gout a disorder of, 200

=Functional= disturbances in gout, 201

=Galen’s= views on gout, 2, 4

=Gall-stones=, gout associated with, 184

=Gall-bladder dyspepsia=, 184

=Garrod’s= discovery of uric acid in blood of gouty persons, 21 pathogeny of gout, growing scepticism as to, 32 theory of ætiology of gout, 22 views on gout in the eye, 320

=Gastralgias= in gouty, 351

=Gastric= catarrh, chronic, gout associated with, 351 chronic, mineral waters suitable for, 445 glands, diseased conditions of, and gout, 173 insufficiency, muriated waters in treatment of, 444

=Gastro-intestinal= asepsis, importance of, in gout, 332 derangements in acute paroxysms of gout, 333 disorders and gout, 180 attributed to gout, 299-302 chronic, spas in treatment of, 442 mineral waters in treatment of, 443 tract, derangement of, cause of gout, 170

=Genito-urinary= passages, infection of, examination for, in diagnosis of articular gout, 249 tract, examination of, in treatment of gout, 331

=Geographical= distribution of gout, 45-48

=Gin= in gout, 371

=Glandular= affections in gouty subjects, 179

=Glaucoma=, gout and, 324

=Glycocine= and urea, interaction between, 84

=Glycocoll=, rôle of, 64 theory of gout, 65 uric acid excretion augmented by, 89

=Glycosuria= and diabetes, 60 associated with gout, treatment of, 414 diet in, 357 examination for, in treatment of gout, 337 gout and, co-existence of, 185 gout in relation to, 236 “gouty,” 182 spa treatment of, 449

=Glyoxylic= acid in gouty urine, 65

=Gonococcal= arthritis of tarsus and metatarsus, differential diagnosis from gout, 263 infection, articular involvement, with muscular and nervous lesions, 194 differential diagnosis from gout, 259 exclusion of, in diagnosis of articular gout, 248

=Gore=, Ringrose, theory of pathology of gout, 173

=Gout=, acute, colchicum in, 375 definitely paroxysmal, 191 general phenomena of, 210 ionisation in treatment of, 387 local phenomena, 211 localised, clinical account, 200 dyspeptic symptoms of, 201 premonitory articular pains, 204 prodromal symptoms, 200 locality of, 208 medicinal treatment of, 372 onset of, 207 pain in, 208 paroxysm of, analysis of, 188 diet in, 332 symptoms of, 205 uric acid variations in, 117 surgical methods considered, 388 treatment of, alternative remedies in, 381 local measures, 384 uric acid excretion in, 117, 211 uric acid variations in, 108, 117 ætiology of, histogenous theories of, 23 nervous theories, 31 summary of, 44 theory of antecedent structural changes, 25 age factor in, 40 alcohol in, 361 amino-acids in relation to, 64 and fibrositis, incidence of, 221 and granular kidney, clinical associations of, 130 and immunity, early fallacies regarding, 10 and nephritis, 242 and other diseases, affinities between, 236 and rheumatoid arthritis, resemblance between, 113 and specific infective arthritides, analogies between, 194 antiquity of, 1 arterio-sclerosis associated with, 245 articular, acute, differential diagnosis, 259 localised, clinical diagnosis, 258 chronic, 225 alkalies in treatment of, 399 blood changes in, 226 clinical diagnosis of, 275 distribution of, 226 local measures in, 407 medicinal and other modes of therapy, 397 progress of disease, 228 surgical treatment, 409 classification of, author’s division, 38 clinical diagnosis of, 252 etiological diagnosis, 247 manifestations of, 195 as an infection, 177 auto-intoxication theory, summary, 182 beverages in, 359 blood content in, 127 uric acid and, relation between, 143 choice of spa in treatment of, 440 chronic, ankylosis in, 287 confusion with chronic villous synovitis, 279 diet in, 334 differentiation of, from arthritis deformans, 16 joint deformities of, 229 of oligo-articular distribution, 278 polyarticular, clinical features, 282 polyarticular, differential diagnosis, 282 tardy dissociation of, from chronic rheumatism, 15 uric acid variations in, 109 classification of, 35, 36 climate and residence in treatment of, 418 climato-therapy in, 418 clinical account of, 200 clothing and, 421 collateral phenomena of, 219 constipation and, 337 cutaneous disorders in, 240 definition of, 35 author’s, 36 derangement of gastro-intestinal tract as cause of, 171 elimination of infective arthritides from domain of, 19 endemic areas in, 46 etiology of, 39 evolution and life history of, 193 excretion in, anomalies of, 112 exercise in, importance of, 421 false, ocular symptoms, 322 glycocoll theory of, 65 Greek physicians’ views of pathology of, 3 growing infrequency and attenuation of, 12 guanine, in swine, 100 heredity and, 41 hydrotherapy, general, in treatment of, 424 local, in treatment of, methods of, 428 hyperpyræmia in ætiology of, 30 in big toe, differential diagnosis, 259 infantile, 116, 305 infective theory of, rise of, 171 summary, 182, 183 inflammatory phenomena in, cause of, 165 initial attacks usually monarticular, 207 initial outbreaks of, anomalous sites for, 267 sites of, 37 in relation to glycosuria, 236 in relation to phlebitis, 239 in the heel, 264 in the instep, 262 in the sole, 265 inter-paroxysmal period, treatment in, prophylactic measures, 389 introduction of word, 6 irregular, 293 conclusions regarding, 304 isolation of acute articular rheumatism from, 15 lead workers predisposed to, 50 leanness in, 337 leucocytosis in, 172, 189 life history of, 193 local foci of infection, 177 treatment of, radical, 327 local syncopes and asphyxias of hands in, 45 long-continued, favouring onset of pre-senilism, 398 lumbago associated with, 221 massage, general, in treatment, 423 metabolic phenomena correlated with postulated infective element, 195 mineral springs in treatment of, 431 monarticular, chronic, differential diagnosis of, 276, 277 morbid anatomy of, 39, 53 morbid conditions associated with, treatment of, 411 obesity in, reduction of, 356 ocular disease in, 308 frequency a factor in diagnosis, 316 onset of, symptoms, 188 organic predisposition to, 43 other conditions classified as, in early times, 12 pathogenesis of, earlier theories of, 21 pedigree of, 14 periodicity of, 191 phenomena of, detailed account of, 207 predisposing causes of, summary of, 52 prevalence of, in Anglo-Saxon period, 2 prognosis in, 244 renal theory of, 117 restriction of, by elimination of other disorders, 19 retarded purin elimination in, 118 retention capacity of tissues for uric acid in, 158 retrocedent, 39, 296 irregular manifestations of, 299 sex incidence of, 41 skiagraphy in diagnosis of, 286 specific organism suggested, 175 sthenic, febrile stage of, alcohol and, 333 structural changes, 54 sub-infection theory, summary, 182, 183 subjective phenomena of, in relation to blood content and excretion of uric acid, radium emanations and, 438 “the honour of,” 8 theory of hepatic inadequacy, 28 tophaceous, 39 treatment of, 327 diet in, 332, 342 fallacy of fixed dietaries, 335 gastro-intestinal asepsis in, 332 hyperæmia, 429 physical examination necessary before dieting, 336 prevention of digestive disturbances, 335 uratic deposits in, 54 differentiation from nephritis, 129 localisation of, 153 uratosis in relation to, 149 urea excretion in, 66 uric acid content of blood in, 139 uric acid excretion in, 108 anomalies in, 117 uric acid in relation to, 107 uric acid theory of, 21 uric acid, urea and creatine in blood in (table), 211 uricæmia in, 125, 133 not cause, but result, of, 148 variations in excretion in, diagnosis of, 60

=Gouty= arthritis, definition of, 20 phlebitis, 240 polyarthritis, acute, 214 stigmata in types of fibrositis, 222

“=Gravel=, cutaneous,” 203 immunity from, 29

=Greek= physicians, terms used for forms of gout, 3 views of pathology of gout, 3

=Guaiacum= in treatment of chronic gout, 403 resin, effects on urine, 405

=Guanase=, 100, 101

=Guanine=, 73, 75, 77, 98 gout in swine, 100

=Gudzent= and Schade’s theories of uric acid in blood, 79

=Gummata=, peri-bursal, 281 peri-synovial, 281

=Gums=, recession of, early, 45

=Hæmatemesis=, gout following, 178

=Hæmo-analysis=, 147

=Hæmophilic= arthritis, differential diagnosis from chronic gout, 285

=Hæmorrhage=, retinal, and gout, 322

=Hair=, premature whitening of, 45

=Hallux= rigidus, differential diagnosis from gout, 262 valgus with inflamed bunion, differential diagnosis from gout, 261

=Haly Abbas’s= views on gout, 6

=Hand=, gouty polyarthritis in, 214

=Hands=, deformed, in chronic gout, 230 incidence of tophi in, 162 local syncopes and asphyxias in gout, 45 palms of, tophi in, 235

=Hare’s= theory of ætiology of gout, 30

=Heart= affections in gouty subjects, 302

=Heberden’s= differentiation of rheumatoid arthritis from gout, 17 nodes, 41, 283

=Heel=, gout in, 264 referred pain in, differential diagnosis in, 264 local sources of fallacy, 265

=Hepatic= derangement in acute paroxysms of gout, 333 inadequacy theory of ætiology of gout, 28

=Heredity= in gout, 8, 28, 40, 41, 214

=Herpes= in acute gout, 241

=Hexose= group in vegetable nucleic acids, 98

=Hippocrates=, aphorisms of, on gout, 4

=Histogenous= theories of ætiology of gout, 23

=Historical= survey, 1

=Horbaczewski’s= experiments on uric acid, 73

=Hot-air= baths, 429 contra-indications to use of, 429

=Hutchinson= on gout and rheumatism, 15

=Hydrarthrosis=, bilateral, 281 in chronic articular gout, 278

=Hydrochloric= acid, secretion of, and gout, 173 strong or fuming, in inter-paroxysmal periods of gout, 393 variations in, and gout, 181

=Hydro-therapy=, general, in treatment of gout, 424 in acute gout, 385 in treatment of gout, contra-indications and untoward complications, 425 methods of application, 427 prophylactic measures, 424 local, in treatment of gout, 428

=Hyperacidity= due to organic acids, 351 in inter-paroxysmal periods of gout, 393

=Hyperæmia=, treatment of gout by, 429

=Hyperchlorhydria=, 181, 351 associated with gout, treatment of, 415 complicating gout, salt in diet contra-indicated, 350 diet in, 353 mineral waters suitable in treatment of, 446

=Hyperpyræmia= in ætiology of gout, 30

=Hyperuricæmia=, diet in, 354 in gout, 140 in non-gouty arthritis, 140 ocular symptoms in, 321

=Hypochlorhydria=, 351 diet in, 354

=Hypoxanthine=, 73, 75, 77

=Indigestion=, intestinal, in gouty subjects, 181

=Infantile= gout, 116, 305

=Infection= in gout, local foci of, 177 examination for in diagnosis of articular gout, 248 theory of gout, 182, 183

=Infections=, differential diagnosis from acute localised articular gout, 259 specific, arthritic muscular and nerve lesions associated with, 195 diagnosis of, 19

=Infective= element in gout, correlated with metabolic phenomena, 195

=Inflammation= and tophi formation, 164 gouty, pus formation and, 191

=Inflammatory= phenomena in gout, cause of, 165

=Influenzal= arthritis, differential diagnosis from acute gouty polyarthritis, 272

=Immunity= conferred by gout, early fallacies regarding, 10

=Inosinic= acid, 93

=Instep=, gout in the, 262

=Intestinal= canal, source of microbe or toxin in gout, 181 derangements, mineral waters suitable in treatment of, 448 dyspepsia preceding gout, 182 indigestion in gouty subjects, 181 irrigation with radio-active waters, 439 juices and wall, enzymes in, 100

=Iodides= in treatment of chronic gout, 401 value of, in renal and vascular changes, 403

=Iodine-albumen= compounds in treatment of chronic gout, 402

=Iodo-glidine= in treatment of chronic gout, 402

=Iodo-protein= in treatment of chronic gout, 402

=Ionisation= in treatment of acute gout, 387 in treatment of chronic articular gout, 407

=Iritis=, “arthritic,” 315 diseases commonly associated with, 313 gouty, “not” a clinical entity, 316 in gout, 308 relative incidence of, 313

=Irregular= gout, 293

=Isomeric= forms of uric acid, 81

=Isomers= of purins, 81 of pyrimidins, 81

=Jaw=, formation of, 45

=Jaws=, radiographs of, in treatment of gout, 328

=Joint= cartilage, murexide reaction in, 153 deformities of, chronic gout, 229

=Joints=, diaphyses of, cystic changes in, 56 rheumatism of, 14 stiffness of, after acute attacks of gout, 212 swellings, local character of, in osteo-arthritis, 283 local character of, in rheumatoid arthritis, 284 tophi in, 233

=Juices=, gastric and intestinal, gout and, 173

=Kidney= and kidneys, capacity of for eliminating uric acid, 125 condition of, effect in blood content of uric acid, 138 disease of, granular, and gout, clinical, association, 130 joint examination in, results of, 129 disease of, and gout, 242 functionally deficient in late stage of gout, 119 functional disorders of, 27, 28 functional efficiency of, tests for, 338 gouty, histological changes in, 127 guanase in, 100 uric acid elimination in, 119

=Knee=, gouty polyarthritis in, 214 site of primary attack of gout, 267

=Kossel’s= discovery of purin bases, 73

=Labile= protein, 59

=Latham’s= theory of hepatic origin of gout, 29

“=Lead= gout,” 50

=Lead=, elimination by iodides, 403 poisoning, blood content in, 122, 123, 127 ocular symptoms in, 321 purin metabolism in, 115 workers, predisposed to gout, 50

=Leanness= in gout, 337

=Lehmann’s= analysis of tophi, 150

=Leucocytosis=, 24, 27 during acute attacks of gout, 172 in gout, 189 in gouty polyarthritis, 216 relation to uric acid excretion, 95

=Leucopenia=, 96 in gout, 189

=Leukæmia=, blood content in, 122, 123 ocular symptoms in, 321 uric acid in urine in, 95

=Levy’s= (Magnus) researches on gout, 107

=Limbs=, integument of tophi in, 235

=Lime= salts, focal absorption of, in bones, 288

=Liniments= in treatment of acute gout, 386

=Literature= of various periods, references to gout in, 3

=Lithæmia=, 294 tendency to, 28, 33

=Lithiasis=, 29

=Lithium= salts in treatment of chronic gout, 400

=Lithuria=, 29

=Liveing’s= theory of ætiology of gout, 31

=Liver=, diseases of, amino-acids in, 59 disorders of, functional, mineral waters suitable in treatment of, 447 enzymes in, 99 functional efficiency of, tests for, 338 glycogenic distension of, 31 guanase in, 100 main centre of production of urea, 63

=Living=, style of, effect on incidence of gout, 2

=Locality=, factor in gout, 45 incidence of, in acute gout, 208

=Lucian= of Saramosta’s views on gout, 4

=Lumbago=, associated with gout, 221 treatment of, 411

=Lung=, guanase in, 100

=Lymph= spaces, purins in, 146 stream, sodium ions in, 146

=Lymphangitis=, co-existent with gout, 58 in gout, 190

=Lymphatic= gland, enlargement of, in gout, 190

=Lymphatics=, purins in, 146

=Malt= liquors in gout, 362

=Marchand’s= analysis of tophi, 150

=Massage=, general, in treatment of gout, 423 in after-treatment of acute gout, 385, 387

=McCarrison’s= views on effect of absence of vitamines on functional efficiency, 340

=McClure and McCarty’s= researches on bone conditions as revealed by skiagraphy, 288, 289

=Meat=, over-eating of, functional damage resulting from, 65

=Meningococcal= arthritis, differential diagnosis from acute gouty polyarthritis, 272

=Menstruation=, effect of, on incidence of gout, 41

=Mental= over-exertion and gout, 51

=Metabolic= phenomena of gout correlated with postulated infective element, 195

=Metabolism=, alterations in, 30 inborn errors of, 69 nuclein, 71 protein, 59, 61

=Metastasis= in relation to ocular gout, 314 gouty, 297

=Metatarsalgia=, differential diagnosis from gout, 262

=Methyl-purins= as source of uric acid, 85

=Microbic= theory of gout, 175

=Miescher’s= researches on spermatozoa, 72 on the nucleus, 71

=Milk= diet in acute paroxysms of gout, 332

=Mineral= springs, 431 waters as beverage in gout, 360

=Monarticular= gout, differential diagnosis of, 276, 277

=Morphia=, hypodermic injections of, in acute gout, 383

=Mouth=, examination of, in diagnosis of articular gout, 248 in treatment of gout, 328 local foci of infection, results of, 184

=Murchison’s= theory of ætiology of gout, 28

=Murexide= reaction in joint cartilage, 153

=Muriated= chloride waters, spas for, 441 sulphated waters, spas for, 442

=Muscles=, affections of, in gout, 195 voluntary, relation of creatinine to, 68

=Muscular= exercise, uric acid excretion increased by, 93

=Myeloma=, waste of albumoses in, 59

=Nails=, striated, fluted and brittle, 45

=Nasal= affections, radium emanations for, 438 disorders, gout and, 178

=Naso-pharynx=, examination of, in treatment of gout, 328 foci of infection, 53

=Necrosis=, local, in uratic deposition, 152 relationship to gout, 25

=Nephritis=, acute and chronic, blood content in, 127 chronic, spa treatment of, 452 complicating gouty polyarthritis, 219 early, blood content of uric acid, urea and creatine, similarity to gout, 120 gout and, 242 gouty, treatment of, 416 uratic deposits in, 128 differentiation from gout, 129 uric acid, urea and creatine in blood in (table), 121 uricæmia in, 120 uricæmia not peculiar to, 124

=Nerve= arthropathies, differential diagnosis from chronic gout, 284 Charcot’s discovery of, 18

=Nervous= phenomena of gout, 188, 304 system, effect of gout on, 219 theories of ætiology of gout, 31

=Neuralgia=, plantar, differential diagnosis from gout, 266

=Neuritis=, alcoholic peripheral, 238 glycosuric peripheral, 238

=Neuro-lymphatismus=, 116

=Neuro-retinitis= in the gouty, 324

=Neurosis=, gouty, 31

=Neuroses=, paroxysmal, of gout, 188

=Nose=, alæ of, tophi in, 235

=Nuclease=, 100

=Nucleic= acid, 72, 77 characteristic constituents of, 78 disruption of, 100 in body, 74 formation of uric acid from, 98 isolation of, 71 metabolism of, in gout, 69 molecules, 101 of animal origin, structural formula of, 99 physiological derivation of uric acid from, 73 uric acid a derivative of, 73

=Nucleic-acidase=, 100

=Nuclein=, discovery of, 72 metabolism, 71 chemistry of, 60

=Nucleins=, 77 phosphoric acid group in, 112

=Nucleo-proteins=, 77

=Nucleosidases=, 101

=Nucleosides=, 87, 100

=Nucleotidase=, 100

=Nucleotides=, 100

=Numbness= after acute attacks of gout, 212

=Obesity= and gout, 245 Ebstein’s views of affinity, 280 in gout, 337 reduction of, 356

=Occupation= and gout, 48

=Occupations= predisposing to gout, 50

=Ocular= disease in gout, 308

=Œdema= in acute gout, 212 in gouty conditions, 191

=Olecranon= bursa, involved in gout, 215 tophi in, 233, 235

=Oligo-articular= distribution of chronic gout, 278

=Oral= sepsis in gouty subjects, 179 radium emanations and, 438 treatment of, in gout, 330

=Ord’s= theory of ætiology of gout, 25

=Osler’s= views on gout, 36

=Osteoarthritis=, acute, differential diagnosis from gout, 261 and chronic articular gout, 275, 276 co-existing with gout, 19 differential diagnosis from chronic articular gout, 278 differential diagnosis from chronic gout, 283 in ancient civilisations, 1 local characters of joint swellings, 283 of hip, with auricular tophi, 226 skiagraphy in differential diagnosis of, 291

=Overeating= and gout, 48 plus alcohol, cause of gout, 49

=Oxaluria= associated with gout, treatment of, 413 examination for, in treatment of gout, 337 spa treatment of, 449

=Oxidation= of purin, products of, 77

=Oxy-purins= as source of uric acid, 84 formation of, 102

=Pain= and tophi formation, 164 in acute gout, 208 in auricular tophi, 233 referred, in heel, differential diagnosis of, 264

=Pains=, premonitory articular, in acute localised gout, 204

=Painters=, predisposed to gout, 50

=Pancreas=, enzymes in, 99

=Pancreatic= inefficiency, evidence of, in diagnosis of articular gout, 250

=Pancretin=, 392

=Papain=, 392

=Parke’s= theories of ætiology of gout, 23

=Parotitis=, acute, gout following, 53 in gout, 179

=Patella=, tophi in, 235

=Pathological= states influencing endogenous uric acid excretions, 94

=Paulus Ægineta’s= views on gout, 6

=Pedigree= of gout, 14

=Pentosuria=, 69

=Peri-bursal= gummata, 281

=Perineum=, uratic deposits in, 235

=Periodic= variations in excretion of endogenous uric acid, 94

=Periodontitis=, chronic, 329

=Peri-synovial= gummata, 281

=Pes planus=, differential diagnosis from gout, 263

=Pharyngeal= affections, radium emanations for, 438

=Pharyngitis=, acute and chronic, in gouty subjects, 179 acute, gout following, 53

=Pharynx=, examination of, in diagnosis of articular gout, 249

=Phlebitis=, gout in relation to, 239 gouty, treatment of, 415 in limb in articular gout, 190 spa treatment of, 450 treatment of gout and, 328

=Phospho-nuclease=, 102

=Physical= examination, necessity for, before dieting, in treatment of gout, 336 over-exertion and gout, 51

=Physiognomy= of the goutily disposed, 44

=Pinna=, small red swellings on, 204

=Planchon’s= views on gout, 6

=Plantar= neuralgia, differential diagnosis from gout, 266

=Pleurodynia= associated with gout, treatment of, 412

=Plumbers=, predisposed to gout, 50

=Plumbism= and gout, 60 purin metabolism in, 115

=Pneumococcal= arthritis, differential diagnosis from acute gouty polyarthritis, 272

=Podagra=, 12 Greek designation, 3

=Polyarthritis=, articular, acute, differential diagnosis of, 269, 270 gouty, acute, 214 clinical diagnosis of, 268 diet in, 334 blood changes in, 216 distribution of, 214 effect on nervous system, 219 simulating erysipelas, 215 non-gouty, uric acid blood content in, 141

=Polyarticular= distribution of gout, 214

=Poly-nucleotides=, 100

=Port= wine in gout, 364, 368

=Portal= blood, amino-acids in, 62

=Post-critical= stage of depression, 211

=Potash= compounds in treatment of chronic gout, 400

=Potassium= in gouty tophi, 151

=Prescriptions= for use in acute gout, 375, 377, 378, 379, 380, 386, 391 for use in chronic gout, 401, 405, 406 for use in inter-paroxysmal periods of gout, 391, 392, 393, 394

=Pre-senilism=, long-continued gout favouring, 398

=Protamine=, 72

=Protein=, amino-acids in, number of, 64 chemistry of, 60 labile, 59 metabolism, 59, 61 urine content of urea, etc., in, 59 tissue, 59

=Proteins= and their derivatives, 88 in diet of gouty, 345

=Pulse= quickened in gout, 189

=Purgatives= in treatment of acute gout, 374

=Purin= bases, toxicity of, discussed, 168 bodies, 34, 48, 63 chemistry of, 75 diet, uric acid excretion in, 86 “free” diet, 355 uric acid blood content in, 137 uric acid excretion in, 86 elimination, retarded, in gout, 118 metabolism, chemistry of, 60 in chronic alcoholism, 115 in other disorders, 113 in plumbism, 115 nuclease, 102 nucleus, arrangement of atoms, 76 oxidation of, products of, 77 scheme illustrating probable stages in passage through body, 101 synthesis in mammals, 97 unexcreted, fate of, 87

=Purins=, discovery of, 72 endogenous, 83, 87 source of, 88 exogenous, 83 as source of uric acid, 84 effect of atophan on, 110 effect on uric acid blood content, 137 isomers of, 81 of vegetable origin, 77

=Pus= formation, non-existence of, in gouty inflammation, 186, 191

=Pyæmia=, differential diagnosis from gout, 259

=Pyæmic= conditions confounded with gout, 191

=Pyorrhœa= alveolaris, and gout, 178 and treatment of gout, 329 exclusion of, in diagnosis of articular gout, 248

=Pyrexia= in acute gout, 210 in gout, 189

=Pyrimidine= bases, 77

=Pyrimidins=, isomers of, 81

=Quadriurate= in blood, 78, 79

=Quinic= acid in treatment of acute gout, 383

=Quinine= in treatment of acute gout, 383

=Race= incidence of gout, 45-48

=Radio-active= properties of thermal waters, 427 waters, physical properties of, 434

=Radium= emanation, increased excretion of uric acid through, 437 influence on uric acid metabolism, 436 physiological action of, 435 subjective phenomena of gout in relation to blood content and excretion of uric acid and, 438 therapeutic action and application, 438

=Regular= gout, 13

=Renal= changes in gout, 54 defect, uricæmia not necessarily due to, 123 depression, functional, 119 disease, abnormal protein loss in, 59 theory of gout, 117 uric acid infarcts, 151

=Residence=, choice of, 420

=Respiratory= disorders, spa treatment of, 450 organs, affections of, in gout, 303

=Retinitis=, nephritic, 324

=Retrocedent= gout, 39, 296

=Rhazes’s= views on gout, 6

=Rheumatism=, acute articular, differential diagnosis from acute gouty polyarthritis, 269, 270 isolation from gout, 15 muscular and nervous lesions associated with, 194 confused with gout, 215 chronic, tardy dissociation of, from chronic gout, 15 differential diagnosis from gout, 259 early use of term, 14 muscular, identification of, 16

=Rheumatoid= arthritis, 17 and gout, resemblance between, 113 differential diagnosis from chronic gout, 284 disturbance of purin metabolism in, 112 or atrophic arthritis, differential diagnosis from acute polyarticular gout, 272

=Roberts’, Sir William=, views on gout, 36

=Salicylate= group as alternative remedy in treatment of acute gout, 381 of colchicine in treatment of acute gout, 379

=Salicylates= in treatment of acute gout, contra-indicated, alkalies as substitute, 383 in treatment of chronic gout, 401

=Salisbury= diet in hyperchlorhydria, 353 method in reduction of obesity, 357

=Salt= in diet of gouty, 350

=Scapular= region, uratic deposits in, 235

=Scheele’s= discovery of uric acid, 8

=Schnee= four-cell bath in ionisation, 408

=Sciatica= associated with gout, treatment of, 411, 412

=Scudamore’s= definition of gout, 35

=Seneca’s= views on gout, 5

=Septic= conditions confounded with gout, 191

=Serapion’s= views on gout, 6

=Serous= membranes, uratic deposits in, in nephritis, 128

=Sex= incidence in gout, 41

=Shivering= at onset of acute paroxysm of gout, 188

=Sidonal= in treatment of acute gout, 383

=Silk= as underwear, 421

=Sinusitis=, latent, cause of systemic infections, 331

=Skiagraphy= in diagnosis of gout, 286 in diagnosis of villous synovitis, 281 in differential diagnosis of hypertrophic or osteo-arthritis, 291 in differential diagnosis of infective arthritis, 290 in differential diagnosis of rheumatoid or atrophic gout, 291

=Skin=, action of, consideration of, in treatment of gout, 337 appearances of, and gout, 45 defective elimination by, in chronic gout, treatment of, 400

=Sodium= biurate crystals in synovia, 52 ions in lymph stream, 146 mono-urate compound, 81 salicylates of, in treatment of acute gout, 382

=Sole=, gout in, 265

=Solubilities= of uric acid and urates in gouty blood, 82

=Sool-Bader= baths, 427

=Spa=, choice of, in treatment of gout, 440 treatment, duration of course of, 453 in acute gout, 385 of gout, principles of, 434 remarks on, 452

=Spas= from a national aspect, 454

=Spermatozoa=, Miescher’s researches in, 72

=Spirits= in gout, 370

=Spleen=, enlargement of, in gout, 190 enzymes in, 99 functional efficiency of, tests for, 338

=Starchy= foods in diet of gouty, 347

=Static= foot deformities, differential diagnosis from gout, 261

=Stone= in Norfolk, 29

=Streptococci= in tonsils, 183

=Sub-infection= theory of gout, 182, 183

=Sub-thermal= baths, 428

=Succus= entericus, action on nucleic acid, 100

=Sugar= in diet of gouty, 347

=Sulphated= alkaline waters, spas for, 442 waters, 441, 442

=Sweetbreads= in diet of gouty, effect of, 345, 346

=Swine=, guanine gout in, 100

=Sydenham’s= differentiation of rheumatism from gout, 15 views on gout, 7

=Syncopes=, local, of hand, in gout, 45

=Synovia=, appearance in, in acute gout, 52

=Synovial= fluid, reaction of, 52

=Synovitis=, gouty, relation to local foci of infection, 185 gummatous, differential diagnosis from chronic articular gout, 277 of knees, differential diagnosis from gout, 264 of tendo Achilles in referred pain in heel, 265 perforative, 57 villous, chronic, confusion with chronic gout, 279 clinical symptoms of, 280 static and non-gouty in origin, 280

=Synthetic= formation as source of uric acid, 84 of uric acid, 96

=Syphilis=, articular, muscular and nerve lesions associated with, 194

=Syphilitic= arthritis, secondary, differential diagnosis from acute gouty polyarthritis, 271 disease of tarsal joints, differential diagnosis from gout, 263

=Taka-diastase=, 392

=Tarsal= joints, gonococcal arthritis of, differential diagnosis from gout, 263 involved in gouty polyarthritis, 214 tuberculous and syphilitic disease of, differential diagnosis from gout, 263

=Tartareous= nature of tophi, views on, 8

=Tea= as beverage in gout, 361

=Teeth=, characteristic, in gout, 45 conditions in gout, 178 devitalised, examination of, in treatment of gout, 328 foci of infection, 53

=Temperament=, and gout, 44

=Temperature= curve of gout, 188

=Tendo= Achilles, involved in gout, 215

=Tendon= sheaths, involved in gout, 195

=Tendons=, gouty polyarthritis in, 214 uratic deposits in, 153

=Test= meals for HCL variations, 336

=Tests=, modern, for uric acid determination, disabilities of, 147

=Theobromine=, 85

=Theophyllin=, 85

=Throat=, gouty, 45

=Thymine=, 98

=Thyminic= acid, 80 in treatment of acute gout, 383

=Thymus=, enzymes in, 99 gland, nucleic acid derived from, 98 in diet of gouty patients, effect of, 345, 346

=Tibia=, tophi in skin over, 235

=Tissue= affinities for uric acid, 157 protein, 59

=Tissues=, human, concentrations of uric acid in, 159 retention capacity of, for uric acid, 158 effect on blood content, 138

=Toe=, big, gout in, differential diagnosis of, 259 initial outbreak of gout in, 37, 188

=Tonsil=, site of infection in gout, 180

=Tonsillar= sepsis, gout and, 178

=Tonsillitis=, acute, gout following, 53 in gouty subjects, 179 treatment of, in gout, 330

=Tonsils=, examination of, in diagnosis of articular gout, 249 foci of infection, 53 streptococci in, 183

=Tophaceous= deposits in chronic articular gout, 227 gout, 39

=Tophi=, analysis of, 150 antedating articular attacks, 202 auricular, 202 pain in, 233 clinical evolution of, 162 constitution of, 149 constitutional influences in, 161 diagnostic status of, 252 difficulty in detecting, 256 early stages of, confused with chilblains, 164 early views as to nature of, 7 evolution and distribution of, 231 formation preceding arthritic attacks, 164 frequency of, in gouty arthritis, 255 gouty, causation of, 154 formation of, 151 localisation of, 153 radiating, concentric and laminated structure of, 152 urate of soda, 150 importance of, in diagnosis of acute gouty polyarthritis, 269 in diagnosis of gout, 38 in eyes, significance of, 311 inflammatory nature of swellings in, 163 in relation to arthritis, 254 in relation to uricæmia, 155 sites of, 233 stage of small red swellings, 163 treatment of, in chronic articular gout, 407

=Tophus= formation in acute gout, 212 premonitory symptoms of, 203 in ear, sign of gout, 202

=Trauma=, local, effect on gout, 53

=Traumatic= lesions, differential diagnosis from gout, 260

=Trousseau’s= views on gout, 36

=Tuberculous= disease of tarsal joints, differential diagnosis from gout, 263 joint disease, differential diagnosis from chronic articular gout, 277

=Toxæmia=, alimentary, hydrochloric acid, 394 chronic, 182

=Toxicity=, low, of chemical products, in gout, 69 non-, of uric acid, 166

=Ulna=, tophi in skin over, 235

=Uracil=, 98

=Urate= of soda in gouty tophi, 150

=Urates=, deposition of, in eye, 309

=Uratic= depositions as criterion of gout, 37 deposits in gout, 54 in gout and nephritis, differentiation of, 129 in gout, localisation of, 153 in nephritis, 128

=Uratosis= in gout, 149

=Urea= and glycocine, interaction between, 84 end-product of protein metabolism, 63 excretion in gout, 66 excretion of ammonia as, 63 formation of, 62 Folin and Denis’s deductions, 64 seat of, 63 in blood in gout and nephritis (table), 121

=Ureters=, ligature of, 26

=Uric= acid, 75, 77 a normal constituent in blood, 135 an end-product, 70 as a derivative of nucleic acid, 73 blood content of, in various animals, 135 variations independently of diet, 142 chemical constitution of, 75 concentrations in human tissues, 159 content of blood and attacks of gout, relation between, 143 in gout, 139 deposition of, 22, 34 destruction of, 98, 104 determination of, disabilities of modern tests, 147 diathesis, 294, 295 discovery of, by Scheele, 8 estimation of, sources of fallacy, 145 excretions of, amount of, 75 exogenous, 85 in acute gout, 211 in gout, 108 anomalies in, 117 increased by radium emanation, 437 relation of leucocytosis to, 95 exogenous purins as source of, 84 formation of, Amberg and Jones’s scheme of, 103, 104 from nucleic acid, 98 gravel, spa treatment of, 451 in the blood, 78 forms of, 145 in gout and nephritis (table), 121 of gouty patients, discovery of, 21 organic combinations of, 79 infarcts, renal, 151 in relation to gout, 107 isomeric forms of, 81 kidney capacity for eliminating, 125 metabolism, influence of radium emanations on, 436 non-toxicity of, 166 of blood in disease (table), 137 output, endogenous, lowered, 111 exogenous, retarded, 109 physical properties of, 78 retention, capacity of tissues for, 158 solubilities of, 154 sources of, 83 synthetic formation of, 84, 96 theory of gout, 21 tissue affinities for, 157 variations in acute gout, 108 variations in chronic gout, 109 Wollaston’s researches on, 8

=Uric-acidæmia=, 295

=Uricæmia= and gout, 125 in gout, 133 in nephritis, 120 not cause, but result, of gout, 148 not necessarily due to renal defect, 123 not peculiar to nephritis, 124 significance of, 145 tophi in relation to, 155

=Uricase=, 87, 104 absence of, in man, 104

=Uricolysis=, 104

=Uricolytic= enzyme, 105 ferment, absence or diminution of, 106

=Urine=, alkapton in, 59 analysis of, in metabolism of gout, 113 in treatment of gout, 337 children’s, creatine in, 68 cystin in, 59 effects of guaiacum resin on, 405 examination of, in diagnosis of articular gout, 250 gouty, glyoxylic acid in, 65 human, daily excretion of uric acid, amount of, 83 scanty, before paroxysm of gout, 205

=Urosin= in treatment of acute gout, 383

=Vaccine= therapy in treatment of gout, 331

=Vapour= baths, 428

=Vegetable= cells, nucleic acid derived from, 98

=Vegetables= in diet of gouty, 348

=Veins=, engorged, before paroxysm of gout, 205

=Venesection=, 4 gout following, 178

=Vichy= bath, 428

=Vidal’s= atrophic form of arthritis deformans, 18

=Vinegar= in diet of gouty, 350

=Viscera=, functional capacity of, tests of, 338

=Visceral= organs, tendency to fibrosis in gout, 186

=Vitamines=, 340

=Volumetric= method of determination of uric acid in blood (Curtman and Lehrman), 134

=Vomiting= in acute paroxysms of gout, 333

=Wade’s= theory of nervous origin of gout, 32

=Water=, hot, advantages of, 360 value of, as beverage in gout, 359

“=Water-soluble B=,” 340

“=Water-soluble C=,” 340

=Watson’s= (Chalmers) researches on gout, 107, 172

=Weir-Mitchell= method in reduction of obesity, 357

=Whisky= in gout, 364, 370

=Wines= as beverages in gout, 364 general rules, 367 individual and, 365 importance of quality of, 366

=Wollaston’s= researches on uric acid, 8

=Wrist=, site of primary attack of gout, 267

=Xanthine=, 75, 77

=Xanthine-oxidase=, 99

=Xanthosine-hydrolase=, 102

=X-ray= examination of alimentary tract in treatment of gout, 336

=Yeast=, nucleic acid derived from, 98

THE WHITEFRIARS PRESS, LTD., PRINTERS, LONDON AND TONBRIDGE.