Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

To detect and thereafter to eliminate the most fruitful excitant of articular outbreaks in individual examples will form no small portion of the task that falls on physician and patient alike. In the majority, it will be some indiscretion of food or drink; in some, insufficient exercise; in others, intellectual strain or worry, etc. By determining the particular nature of the excitant in the individual under review we arrive at his personal idiosyncrasy—a matter of much moment in prophylaxis.

Moreover, with increasing experience the physician cannot help noting that the vulnerability to assaults varies in different subjects. Thus the development of gouty paroxysms in some will be found to be associated with gastro-intestinal or hepatic derangements, in others with defects of elimination through kidneys, bowels, or skin.

In short, these cases must be approached in a catholic frame of mind, and the success of medicinal therapy will depend on the judgment and clinical acumen displayed in meeting the ever-varying necessities of individual instances, not by an almost flippant prescribing of alkalies or, it may be, iodides, colchicum, or guaiacum. All these are valuable, but only if invoked with discrimination, and not after stereotyped or routine fashion.

The joints in these cases are the seat of chronic change, and though they call for due attention, it is the constitutional taint that is of paramount importance. How best shall we influence this? How else save by recognition of the morbid content of the blood and cleansing of the impurities with which it is charged?

I have before stated my belief that functional derangements of the alimentary canal are the determining cause. It is through their agency that the toxicity of the blood plasma ensues. In the vast majority of cases these constitute the dominant departure from physiological righteousness. It is to these that the high uric acid content of the blood may presumably be referred. Yet nevertheless retention of the same in the form of tophi may be relatively slight. Is it that in their instance the avenues of excretion are more permeable?

In others, again—not necessarily those with more pronounced dyspeptic symptoms—the retention of uric acid proceeds apace. Clinically the explanation appears to be that cases with massive tophaceous deposits often display renal changes. In other words, it is the channels of elimination that appear to be at fault.

But, more than likely, these superficial differences hark back to infinitely more subtle inward disparities, to tissue peculiarities of function, with correlated variations in their retention capacity for uric acid. Here again the clinician waits upon the bio-chemist, and meanwhile must base his differential treatment on somewhat coarser indices.

Thus in one class of case the toxicity of the blood seems attributable to dyspepsia or mal-assimilation, and the physician’s efforts must be concentrated on correction of the same. In another type such may be absent, and yet uric acid accumulates, tophi multiply, and his attention turns to the kidneys, the avenues of excretion. In others, again, both symptom complexes may be combined, and his resourcefulness is taxed to the utmost to meet these several necessities, for, as Sydenham wisely said, “the weakness of all the digestions and the loss of natural strength in the several parts are the essence of gout. Each must be dealt with.”

Nor must we forget that long-continued gout engenders not only a depravation of general nutrition, but paves the way also for the insidious production of structural organic changes. In a word, it favours the onset of pre-senilism, with all that such connotes. So it is that in these subjects, too often past the meridian of life, we have not only gout to combat, but the grisly appanage of oncoming age.

It is this larger view of our responsibilities that we must cultivate if our treatment of chronic gout is to be in any sense rational, and not wholly haphazard. Also, if my contention be correct that the alimentary canal is the fons et origo mali, the major source of the provocatives of gout, then the basal and essential part of our therapy must be diet and regimen. As to the subsidiary medicinal indications, it will perhaps be more convenient if I proceed to discuss shortly the use of the various drugs that experience has shown to have been of most avail in chronic gout.