Treatment of Associated Morbid Conditions
When dealing with the clinical account, it was pointed out that acute gout is frequently complicated by symptoms pointing to involvement of the fibrous tissues in muscles and nerve sheaths; moreover, that both during acute attacks and alike in the inter-paroxysmal periods gouty subjects are prone to two special varieties of fibrositis, viz., lumbago and sciatica. I may add, too, that in these individuals it is not uncommon for them to suffer with these local varieties of fibrositis from time to time prior to the advent of regular or articular gout.
Fibrositis.—As Bassett Jones and I in our work on fibrositis have dealt exhaustively with the treatment of its various forms, our remarks here must necessarily be devoted largely to the general principles of therapy, and for further details we would refer the reader to our treatise on the subject.
Whatever the type of fibrositis we are confronted with, the therapeutic indications are precisely similar to those advocated for articular gout. In other words, the indispensable preliminary measures are to control the production, absorption, and elimination of toxins. To this end, we must secure adequate evacuation of the bowels, free action of the skin, and diuresis. These ends will the more surely be attained if at the onset a temporary fast be enjoined, or a suitable dietary with copious drinking of bland, unirritating fluid. The general malaise and pyrexia indicate clearly that these cases of acute fibrositis must be treated in accordance with the general rules applicable to the febrile state.
Acute Lumbago.—Brisk purgatives are here our most efficient allies, for there is usually marked functional derangement, with high-coloured urine and dark, offensive fæces. In such cases it is well to give 3-4 grains of calomel at night, followed in the morning by a saline purge, and the same often has to be repeated once or twice during the acute stage. Also the following prescription, preferably rendered effervescent by adding a few grains of citric acid to each dose, may swiftly abate the intensity of the suffering:—
| ℞ | Pot. bicarb. | gr. 15 |
| Pot. nitrat. | gr. 10 | |
| Vin. colchici | ♏︎ 10-15 | |
| Aquæ ad unciam, quartis horis sumenda. | ||
Or, as in acute gout, we may give an initial large dose of 30-40 minims of colchicum wine, with subsequent attenuation of the same. It is in cases with scanty, high-coloured urine and costive bowels that colchicum succeeds best. On the other hand, in some cases of acute lumbago the urine is copious and light-coloured, and the bowels regular, and the fæces normal in appearance. Here the value of the initial purge is not so apparent, and a mixture containing salicylates and alkalies will be more likely to give relief, aided, if necessary, by nightly doses of Dover’s powder, followed by a morning draught of some aperient.
Where the case shows some disposition to linger on in a sub-acute form, and the urine still remains charged with lithates, a mixture of citrate or nitrate of potash, spirits of nitrous ether, and infusion of buchu should be given thrice daily. Sometimes, too, in broken-down subjects with sluggish circulation, we have found the addition of a few minims of tincture of digitalis most helpful in clearing up the condition.
Next to lumbago, pleurodynia is the most common muscular type of fibrositis to be met with in the trunk. I have seen its subsidence prove the signal for an outbreak of acute articular gout in the great toe. This significant sequence indicates the necessity of being alive to the possibility of a gouty basis in such cases and the advisability of combining colchicum with our remedies.
Sciatica.—This almost invariably is the outcome of a preceding attack of lumbago, of which, indeed, it is but an extension. If seen sufficiently early, and certainly when there are febrile symptoms, a mercurial purge, followed by an alkaline and diuretic mixture in combination with colchicum or salicylate of soda, should be resorted to vigorously, so as to abort, if possible, the attack.
If the underlying constitutional anomaly has been correctly diagnosed as gouty, the colchicum will exert its specific effect, and quickly, and the more speedily the sooner it is exhibited in the early stage. But even when seen later it is well worth trying the following combination:—
| ℞ | Quin. hydrochloratis | ½ drachm. |
| Pot. iodidi | 2 drachms. | |
| Vin. colchici | 1 ounce. | |
| Tinct. aurantii | 2 ounces. | |
| Aquam chloroformi | To 8 ounces. | |
| Sig., 2 teaspoonfuls in a wineglass of water twice a day. | ||
Having regard also to the gouty origin, it is hardly necessary to insist on regular and adequate evacuation of the bowels.
Of all varieties of gouty fibrositis the acute brachial type is the most difficult to treat, owing to the marked tendency to prolongation of the acute stages. The only chance of cutting short such an attack is not to treat lightly its earlier manifestations, but to bear in mind its evil potentialities; but only too often they do not come under observation until the condition is well established.
Gowers, who has written so illuminingly on this particular type of fibrositis, obtained the best results in the early stages from a combination of nitrous ether, citrate of lithium, and colchicum, with in addition, in the more intense forms, small doses of perchloride of mercury. Of the salicylates, salicin and aspirin, he speaks with but faint praise, and I have myself known them afford but little aid.
In reviewing the foregoing acute types of fibrositis, I would, as to relief of pain, insist on internal medication of all sorts being held as purely secondary to the infinitely more important matter of procuring rest and fixation for the inflamed structures. Immobilisation, indeed, supplemented by thermic and anodyne applications, hardly, if ever, fails to alleviate the suffering. If these prove futile, aspirin and phenacetin, either singly or in combination, should be exhibited. Here I would remark also on the value of cimicifuga, which I have found strikingly useful. Lastly, only very exceptionally in my experience is morphia called for.
In chronic or recurring forms of fibrositis we should mark any deviation from health in the shape of gastro-intestinal or hepatic derangement, while noting also any inactivity on the part of the kidneys or skin. As to drugs, chief reliance must be placed on the iodides guaiacum, arsenic, and sulphur. They are most useful, of course, when exhibited during the early stages, before organisation of the inflammatory products ensues. When hard and resistant nodules or infiltrations have formed, their administration is of little value.
It is for this reason that I have elsewhere advocated early resort to local massage, viz., at the close of acute attacks, as only by this means can we hope to dissipate these new formations, the persistence of which determines the inveterate tendency to recurrence. In the space at my disposal it will be impossible to consider in detail all the special modes of therapy—electrical, thermal, hydrotherapeutic, etc.—and for this information I must refer the reader to the next chapter.
Oxaluria.—This condition is sometimes met with in the gouty. The subjects are often nervous, irritable, and languid, complaining at the same time of vague pains, most frequently in the loins and along the distribution of the sciatic nerve. It occurs more commonly in persons of sedentary habit, and correction of this, as well as revision of their diet, is almost the only effectual method of getting rid of the complaint.
All vegetables rich in oxalates, such as rhubarb and spinach, must be eliminated, and likewise tea. At the same time, as Sir Alfred Garrod suggests, we should, to influence the proportions of the bases present in the urine, cut off all foods rich in calcium, i.e., milk and eggs. On the other hand, we should advise the intake of such as are rich in magnesium and yet poor in oxalic acid, viz., peas, beans, and coffee, and oxalate-free foods, such as all kinds of meat.
In my own person I suffered for some weeks with obstinate lumbar pain, the cause of which appeared to be obscure until the existing state of oxaluria was discovered by a professional colleague. I would here emphasise the fact that when a case of lumbar or sciatic pain is defiant of cure by the usual methods of therapy we should always suspect this possibility of oxaluria, for commonly the urine is copious and clear; hence perhaps the frequency with which the condition is overlooked.
As to medicinal measures, we should bear in mind that Sir John Rose Bradford pointed out that the production of oxalates was initially due to deficient HCL, with secondary fermentation of foodstuffs, i.e., carbohydrates, especially sugar. The primary indication, then, is to reinforce the digestive capacities by administering hydrochloric acid or, as many prefer the dilute nitric muriatic acid, in combination with nux vomica, and in some cases pepsin. As Sir William Whitla remarks, if organic acidity be prominent, this may be intensified by mineral acids, in which event alkalies combined with a few grains of papain two hours after meals are indicated.
In conclusion, the nerve element in these cases is so pronounced that a thorough change of air and habits is often indicated, combined with freedom from worry, abundance of exercise, and a stimulating course of hydrotherapy.
Glycosuria.—The variety met with in the gouty, being of the alimentary type, is usually very responsive to dietetic measures, and these have been already dealt with. A course of spa treatment is often the best possible mode of therapy for these cases.
As to medicinal measures, these certainly should not be embarked upon until the effect of dietetic revision has been ascertained. If under their influence the glycosuria wholly disappears, then drugs may be uncalled for, save perhaps occasional aperients, antacids, or similar remedies of like nature. If, on the other hand, the glycosuria cannot be kept under control by dietetic measures, then recourse must be had to drugs. Here it may be noted that guaiacum diminishes the amount of sugar excreted, and it may be given a trial before resorting to codeia. Generally speaking, when the case requires codeia it has passed out of the realm of gouty glycosuria into that of true diabetes, the treatment of which grave disorder is beyond the scope of this work.
Hyperchlorhydria.—The disorder is rare in gouty patients, and its diagnosis from organic acidity cannot be made without examination of the stomach contents. Moreover, when found to be present an endeavour should be made to elucidate its cause. If gastric and duodenal ulcer can be excluded and the condition appears to be of the nature of a secretory neurosis, then the underlying nervous defect will call for treatment.
In some cases the exciting cause lies in errors of diet and habits of living. These when faulty require correction; very often in these cases it is not so much the nature of the food as the hurried manner in which it is bolted that is responsible. At times, when free from hurry or worry, they can eat any kind of food with impunity. When the attacks are on, it frequently happens that all types of food, whether easily digestible or not, are equally provocative of acidity. We see then how large a part general hygiene plays in the successful treatment of these cases.
As to diet, this is, of course, of primary importance, the main indications being the reduction or withdrawal of farinaceous foods, and for a short period on a Salisbury regimen or some modification thereof.
The medicinal indication is to afford relief during the acute attacks. Fortunately these are usually intermittent, and when the occasion arises are fairly readily controlled by massive doses of alkalies, frequently combined with an artificial digestive, i.e., papain. While magnesia and bicarbonate of soda are, as a rule, invoked, others speak well of sodium phosphate (5 grams) with menthol (0·25 gram), given two hours after each meal.
Luff, discussing hyperchlorhydria in the gouty, highly extols hopogan (magnesium peroxide), in doses from 20-30 grains, one hour after food, the amount to be reduced if it causes purgation. To inhibit excessive production of HCL, belladonna, in 5-minim doses of the tincture, before meals results in reduction of acid values, both absolute and relative, of the stomach contents, and, moreover, relieves spasmodic contractions. Constipation in these gouty subjects is best combated by an occasional nightly pill containing colchicum in combination with aloes or other laxative. Lastly, when digestion becomes more normal nervine tonics, such as arsenic, valerian, and the like, may be given to correct, if possible, the underlying nerve element in these troublesome cases.
Gouty Phlebitis.—To obviate the risk of embolism, absolute immobilisation of the affected limb is imperative, and it should be slightly elevated and protected by a cradle. In many cases it will suffice if the limb be enveloped in cotton wool and a broad, many-tailed bandage lightly and evenly applied. If the pain be severe, equal parts of glycerine and the green extract of belladonna should be smeared along the course of the inflamed vein and hot fomentations applied. Internally saline aperients should be given to secure daily evacuation of the bowels, and a mixture containing iodide of potassium and ammonium carbonate taken three or four times a day, to promote solution of the clot.
Gouty Eczema.—In these cases the primary indication is to revise thoroughly the diet, to the end of correcting a frequently associated gastro-intestinal derangement, notably any tendency to constipation. If these the basal indications are not fulfilled, all local forms of medication will be futile. As to these last, the primary desideratum is to protect the parts from all accidental irritants, and the chief source of offence is scratching by the victim himself. Otherwise we should take every care to prevent irritation by clothing, hard collars, etc.
While cleanliness is essential, the soaps used should be of the neutral kinds, or bran or barley-water substituted. Ointments and lotions are best avoided. In the milder cases protection of the parts is the essential. In the limbs this may be attained by glyco-gelatine zinc; but on the neck, the groin, the inside of the thighs or lower parts of the abdomen, the tragacanth pastes or similar preparations are more suitable. Both the gelatine and the pastes and varnishes may be readily medicated with drugs of anti-pruritic properties, such as oil of cade, carbolic acid, resorcin, or salicylic acid.
Gouty Nephritis.—This must be treated on the lines recognised as suitable for chronic Bright’s disease, the underlying gouty condition being always borne in mind, as also any contamination with lead. As general measures any excess in eating or drinking must be avoided, the skin kept active, and the bowels open; and where possible favourable climatic conditions should be attained.
Frequently the treatment resolves itself into that of the associated arterio-sclerosis with high blood pressure. This we should endeavour to control by regulation of the subject’s habits in the matter of diet, work, exercise, etc., rather than by flying forthwith to the use of vaso-dilators, premature resort to which has often proved the beginning of the end.
Moreover, I would, like many others, strongly deprecate the far too prevalent practice of dilating to these subjects on the evil potentialities of raised blood pressure. Not a few thenceforth literally walk in the valley of the shadow, and the fear of sudden death is ever before them. It is not only cruel, but frequently unnecessary. Often the increase of tension is no more than their age would account for, and equally often no symptoms indicative of raised blood pressure are complained of. Why then make the subject miserable?
By all means, take the blood pressure, but say as little as possible about it. These people, in my experience, need more often to be reassured than frightened. Only now and again does one meet with individuals who must for their own sake be gravely warned of the dangers incidental to their condition, men who, despite the warnings afforded by giddiness, epistaxis, etc., will not alter their ways of living.
As to medicinal measures, all agree that an occasional blue pill or a dose of calomel, ½-1 grain, for three or four nights in succession, and followed in the morning by a saline purge, is one of the most satisfactory procedures to adopt. Hand in hand with this, a course of iodides, gr. 10-15 three times a day, for some weeks, is also most beneficial. After six or eight weeks of the above we may substitute a course of nitrites, e.g., nitro-glycerine, sodium nitrite, or erythrol tetranitrate. Nothing is better in the milder cases than Sir Lauder Brunton’s formula, the efficacy of which I have often proved:—
| ℞ | Sodium nitrite | gr. ½-2 |
| Potassium nitrate | gr. 10-20 | |
| Potassium bicarb. | gr. 10-30 | |
| Fiat pulvis, to be taken in a tumblerful of water every morning. | ||
Needless to say, vaso-dilators should not be exhibited if signs of waning cardiac power are evident. Also when there is much albumen the use of mercurial purges calls for great discretion, and saline aperients should be given the preference. Insomnia, a frequent trouble in these cases, is best met by bromides, and I agree with Luff that in gouty subjects sleeplessness is better combated by measures which reduce arterial tension than by resort to hypnotic drugs.
Lastly, symptoms of cardiac dilatation and failure, which should be suspected when the arterial pressure falls without the previous use of vaso-dilators, will call for the exhibition of cardiac tonics: digitalis, strophanthus, and strychnine; and threatened uræmia may be postponed by a judicious dietary, saline purgation, and diaphoretic measures.