Alkalies.—It was formerly thought that by increasing the alkalescence of the blood its solvent effect on uratic deposits was enhanced and their formation thereby delayed or prevented. But subsequent researches by Sir William Roberts conclusively proved to his mind “that alkalescence as such has no influence whatever on the solubility of sodium biurate.”
Luff, again, from his investigations, held that administration of the ordinary alkalies, of lithium salts, of piperazine, and of lysidine, with the object of removing gouty deposits, appears to be useless. He also claims that no general acidity of the system is associated with gout, and no relationship exists between the acidity of the urine and the alkalinity of the blood.
Nevertheless let us not sin against light, which is exactly what we are very prone to do if we allow ourselves to be obsessed by uric acid and overlook the records of clinical experience. Take Sir Thomas Watson; he, without any reference to uric acid elimination, recommended as a prophylactic against gout 15 grains of bicarbonate of potash in combination with tincture of rhubarb and some light bitter, to be taken every day. Fagge, again, observes, “Alkalies are decidedly useful in gout,” and the same views were held by the elder Garrod, Lecorche, and Dieulafoy, etc.
In short, forgetting for the moment the existence of uric acid and shedding all hope of their dissolving tophi, we find that alkalies have ample justification besides for their employment. They are valuable as antacids, diuretics, and as alteratives, and, moreover, their routine employment has been tried and approved.
In other words, the benefit of alkalies depends, not upon any special solvent effect upon uratic deposits, but upon their remedial influence upon associated and, I believe, causally related gastric and hepatic disorders, and through these on general metabolism. Albeit, let us be guided by rational considerations when we invoke their aid.
The fact that alkalies are incapable of dissolving tophi is a clear indication that that deleterious habit of continuously taking potash and lithia water is not only unnecessary, but undesirable. Alkalies should be prescribed in short courses and to meet special indications, i.e., intermittent, not continuous, administration.
Thus in the minor gastric disturbances which in chronic gout we are constantly called upon to treat there is no doubt as to the superiority of the sodium compounds. Moreover, apart from their value in gastric or intestinal catarrh, we have to note their usefulness in dyspeptic states complicated by torpid liver.
When constipation exists, the sodium bicarbonate may be combined with magnesia, and all will admit the striking benefit attained by short courses of these drugs with the addition of rhubarb, some simple bitter infusion, quinine, or strychnine, all rendered more effective by the addition of some carminative or aromatic.
Sydenham’s electuary was compounded of gastric tonics, and the more recent Portland and Pistoja powders are in this respect but an imitation thereof. Indeed, stomachics are the most valuable tonics in gout. Lastly, it is in the inter-paroxysmal periods of chronic gout that the sodium compounds are indicated, when the joints, though enlarged, are quiescent, and the more prominent symptom in the clinical picture is lack of gastric tone, with or without acidity.
As to the potash compounds, it is during and immediately after articular paroxysms of acute or subacute gout that they find their chief sphere of usefulness. Apart from this, they are, because of their diuretic properties, valuable at all times in cases in which the renal secretion appears to be deficient. The bicarbonate, citrate, or acetate of potash are the most valuable. The last-named is the most diuretic, but is rarely used, the citrate enjoying more favour, being more palatable and most eligible when no direct antacid effect is desired, in which case it should be replaced by the bicarbonate.