Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

It was to this end that in a preceding chapter I urged the desirability of more attention being paid to the prodromal symptoms of gout and the clarifying light that might be thrown on otherwise inexplicable derangements by the disclosure of a hereditary tendency thereto. The failure to elicit such familial predisposition is but too common, and so those who may be led to expect the gout by inheritance are bereft of all the benefit that might accrue from a prophylactic regimen.

The indications may, indeed, be more explicit, for, apart from hereditary proneness, some subjects, even though they may never have experienced an articular outbreak, yet exhibit tophi, and therewith frequently suffer from gastric or hepatic disturbance. Obviously, is not this the opportune time for prophylaxis—the institution of hygienic and dietetic rules conjoined with the occasional use of medicines? For the “potentially” gouty, as Scudamore said, cannot “too early be taught to pay the most careful regard to their constitution, nor too surely confirm the best habits by long practice.” We hear much nowadays of the “beginnings” of disease, and who can doubt that this is a fruitful sphere for their study?

Unfortunately it is, as a rule, only when the disease has made its invasion that we wake up to our responsibilities in this respect; but happily even then we may do much to prevent consolidation of its tyranny, for even in those who have experienced regular gout there are derangements to correct, warnings to note, if we do but take heed. Of these the more common are dyspepsia and costiveness, signs of portal congestion, etc., not to mention local symptoms, i.e., the onset of pricking and tenderness in already existing tophi, twinges in the toes, etc.

We see therefore that in regard to the prophylaxis of gout the victims fall into two main groups, i.e., firstly, the “potentially” gouty, who as yet have not experienced arthritic outbreaks, and, secondly, those who have, and wish to obviate their recurrence. Happily the premonitory gastric symptoms, though varied in character, are in both instances more or less similar; nor need I say that in either alike medicinal measures are but the smallest part of the prophylaxis, whose chief stay and strength must be the golden rule of temperance in eating and drinking conjoined with adequate exercise. For, whatever our views as to the proximate origin of gout, there is every reason to suppose that the principal exciting cause resides in the alimentary canal. As Sydenham long since said, “The more closely I have thought upon gout, the more have I referred it to indigestion or to the impaired concoction of matters both in the parts and the juices of the body.” Even so to-day do medical men suffering from gout tell me that they, like Sydenham, have found by experience that almost invariably dyspeptic symptoms are the forerunners of attacks, and that their avoidance or timely correction is the best means wherewith to avert paroxysms.

As to the nature of the “indigestion,” it is of subacute or chronic type, and only very exceptionally is it acute. As to symptomatology, there is nothing distinctive about the “dyspepsias” of the “gouty,” save perhaps their marked tendency to recurrence, the facility with which they are occasioned by trivial causes, their frequent obduracy to ordinary measures, and their response to such as take cognisance of the constitutional factor.

Nevertheless such is the frequency and persistence often of gastric derangements in the “gouty” that it may safely be affirmed that the treatment of these subjects in their inter-paroxysmal periods is essentially that of the “dyspeptic.” It is, in truth, the basal indication in their therapy, for correction of the “gouty” man’s digestive disabilities is the surest way to prevent articular outbreaks, or, failing this, to postpone their recurrence or mitigate their severity.

The primary object of medicinal treatment is the restoration to functional efficiency of the alimentary tract and its accessory glands and maintenance of the action of the kidneys and skin. While diet and general hygienic regulations are all essential, we often have to fight the vicious inclination of the victim who is desirous that some medicine may be found which will avert the threatened gout without his being obliged to forego his accustomed indulgence.

He must be promptly and firmly disabused of this fallacy. Indiscriminate drugging is the bane of these cases. They fly from one remedy to another rather than give up this or that excess, and so frequently superimpose a “drug dyspepsia” upon the original disorder.

The most common form of indigestion in the “gouty” is atonic dyspepsia. The primary indication is, of course, to correct the dietetic errors, i.e., to remove the cause, and, secondly, to stimulate the secretory and motor power of the stomach. To this end, the alkalies and alkaline carbonates should be administered shortly before meals in combination with nux vomica, bitters, and carminatives.

℞	Mag. carb.	gr. 10
	Sodæ bicarb.	gr. 15
	Tinct. nucis vomicæ	♏︎ 7
	Spts. chloroformi	♏︎ 10
Infus. calumbæ ad unciam, ter in die sumenda ante cibos.