In those instances in which the skin is notably inactive Garrod thought highly of the phosphate of ammonium, holding that “there is much clinical evidence to prove its value in the treatment of chronic gout.” Many, like Burney Yeo, believe that a combination of soda and potash compounds acts better than when either is given singly. Thus Garrod in cases in which the action of the liver was defective frequently used the bicarbonate of soda in combination with the citrate of potash.
As to the lithium salts, general opinion has it that their value in the treatment of gout has been greatly over-estimated, and that they are not so serviceable as the potassium and sodium salts. They are also more toxic and lowering, and Luff some years ago issued the following caveat: “I constantly meet with patients suffering from cardiac depression, and even dilatation, as the result of the excessive and continued consumption of lithia tablets, which are so persistently, so speciously, and so wrongly vaunted as curative of gout.”
In conclusion, it will be seen that clinical experience testifies with no doubtful voice to the value of most salines. At the same time it is clear, also, that we should use discrimination, seeing that some, as Garrod says, are “certainly more adapted to particular cases than others.” They should also be given well diluted, in moderate doses, and not continuously but intermittently. These rules should certainly be followed when alkalies are invoked in gout, not for local antacid effect, but for their general influence on metabolism. Moreover, at the close of a course of alkalies for this purpose, we may often with advantage place the subject on acids in combination with quinine, nux vomica, or strychnine.
Alteratives.—Of these the salicylates and the benzoates are, by some, greatly prized, in that they act especially on uric acid, promoting the elimination thereof. The benzoates are favoured in examples in which the kidneys are not above suspicion, the latter disability contra-indicating the use of the salicylates. Some, like Ewart, advocated a course of benzoates in alternation for periods of a week or a fortnight with a saline treatment. By Lecorche and Haig, salicylate of soda in doses of 60 grains or more per diem was advocated continuously for prolonged periods.
In my opinion, salicylates are best used during a paroxysm, when, for some reason, colchicum is contra-indicated, or immediately after, to promote elimination of uric acid and to minimise or inhibit the development of tophi. As to the benzoates of sodium and potassium, they are now rarely, if ever, prescribed, though hexamine is growing in favour as a “urinary antiseptic diuretic and anti-lithic.” Occasionally I have met with B. coli infections in gout, and in such cases one of the preparations of hexamine, with lithium or sodium benzoates, is of value, whilst among the laity urodonal stands in high repute as a means of removing uric acid and allied bodies.
Iodides.—Turning to well-tried alterative remedies, there is no doubt that the iodides well deserve their high repute in the treatment of chronic gout. Thus in subacute and obstinate swelling of the joints, and alike in painful gouty affections of the muscles, fasciæ, and nerve sheaths, iodine in one or other of its forms is par excellence our most reliable remedy.
In no type of case is it more serviceable than when the joint inflammation is of low asthenic type—enlarged, stiff, and painful. It may be given in some such combination as the following:—
| ℞ | Pot. iodidi | gr. 5-10 |
| Pot. bicarb. | gr. 15 | |
| Spts. ammon. aromat. | ♏︎ 20 | |
| Vin. colchici. | ♏︎ 5 | |
| Tinct. capsici. | ♏︎ 1 | |
| Inf. aurantii co. ad unciam ter in die sumenda post cibos. | ||
If colchicum be contra-indicated, a useful substitute to quell pain is tincture cimicifugæ in 15-minim doses. The dose of the iodide need not exceed 3-5 grains, as, from my observation, no appreciable advantage is gained by larger doses. Iodine-albumen compounds may be substituted for the alkaline iodides as less likely to cause derangement of the stomach, inasmuch as assimilation is believed to take place in the intestine. Thus iodo-protein may be administered in doses from 10-15 grains. A tablet containing 10 grains is equivalent to 1 grain of combined iodine. Excretion being taken as the measure of absorption, it has been experimentally shown that, six hours after administration, a lower percentage of iodine was excreted in the case of iodised protein than with potassium iodide. In other words, the iodine-albumen compound yield up their iodine to the system at a slower rate. In short, they disintegrate more slowly and are, therefore, the more likely to exert a longer continued activity.