Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

Nevertheless, from time to time, either from failure of the patient’s co-operation or other mischances, our best efforts at prophylaxis fail, and it becomes clear that an attack is imminent. What then, save brisk purgation, can be done to avert the threatened outbreak? Our forefathers, in cases in which the fits recurred periodically and might be forecast with tolerable accuracy, were accustomed some time before the threatened attack to place the subject on a rigorous diet, this in combination with a course of alkalies, those of soda being given the preference in dyspeptic or hepatic disturbance and those of potash when the urine was scanty.

That this was sound treatment and abundantly justified by the results is well acknowledged, and all I would suggest is that this is yet another juncture at which atophan is indicated, viz., immediately before a paroxysm. At this particular time the urinary output of uric acid is often diminished, a clear indication for enlistment of atophan, which increases uric acid elimination. I note that both Retzlaff and Brugsch consider it an especially advantageous time for its exhibition. As a prophylactic measure the former gives 30-45 grains daily for three days at intervals of a fortnight, and if cardialgia or heartburn ensues, adds ¼-½ teaspoonful of bicarbonate of soda to each gramme of the drug.

Lastly, we have to recollect, too, that colchicum is credited with some prophylactic powers. Some, it is true, discountenance its employment in the inter-paroxysmal period, on the plea that it tends to favour recurrence and chronicity of attacks. While I think it is better to reserve it for acute or subacute attacks, still I have not found that colchicum, given in what Sir Thomas Watson called alterative doses, is anything but beneficial, provided that it be taken intermittently, not continuously, for long periods. As to special indications for its employment, I think it is more effectual in aborting a threatened attack when, in addition to dyspeptic phenomena, the imminence of a fit is betokened by what may be termed specific harbingers thereof, i.e., pricking and tenderness in existing tophi, twinges in the toes, etc.

In conclusion, are we not in this matter of the prophylaxis of gout somewhat too prone to resort, both in and out of season, to what we are pleased to term special medication? Almost every week some new and of course infallible “uric acid solvent” is lauded ad nauseam in the press. Are not we ourselves, too, somewhat overanxious to go with the tide in prescribing these vaunted “gout specifics”?

The true aim of prophylaxis is rather to prevent the incidence of those functional derangements that in some subtle way determine the disturbances in nuclein metabolism, with secondary accumulation of uric acid in the organism. That drugs, such as atophan, which diminish the uric acid content of the blood and increase its urinary output, fulfil an invaluable rôle in ridding the system of excessive amounts of this chemical outcast, I fully admit.

Albeit, this achievement does but deal with the consequences or sequels, not the exciting causes, of gout. In truth, there is no short cut to the cure of gout. Only under suitable treatment, applied to meet all the necessities of individual cases, will any long immunity from its onslaughts be secured or their intensity attenuated.

CHAPTER XXX
MEDICINAL AND OTHER MODES OF THERAPY (continued)—CHRONIC ARTICULAR GOUT AND ASSOCIATED MORBID CONDITIONS

Chronic Articular Gout

The gastric derangements that precede acute gout nearly always become aggravated when the disease is permanently established. Consequently from time to time many of the measures outlined in previous paragraphs must be resorted to. But there is this also to be borne in mind, that in these later stages of the evolution of the disorder the intervals of relative health grow shorter and shorter. The victim lies more or less always under the shadow of the malady, and its peculiar impress on the constitution becomes more and more ingrained. Therewith his sensitiveness to the exciting causes becomes more and more pronounced.