What we need in gout is, rather, what Harry Campbell calls “a broad commonsense-rationalism—not a meddling finnicking pseudo-rationalism.” Ignorant of the intimate etiology of gout, we are not as yet capable of determining the exact nature of the underlying morbid processes. Much less are we in a position to devise a rational system of drug treatment whereby to antagonise the same. For us, then, the wiser, if more humble, rôle of correcting, if we may, such obvious deviations from physiological righteousness as we may discern, but ever mindful that we assist, not thwart, the subtle workings of the vis medicatrix naturæ, whereby the balance of the nuclein exchanges is restored.
Local Measures in Chronic Articular Gout
When treating of these in relation to acute articular gout, we dealt with the topical applications best calculated to achieve the absorption of inflammatory exudates and mitigation of the pain and stiffness associated therewith. It now remains for us to discuss the treatment of that specific product of gouty inflammation, viz., uratic deposition.
Treatment of Tophi.—Subcutaneous tophi in the neighbourhood of joints sometimes become tense and painful, and restrict the movements of the adjacent articulations. Garrod held that the continuous application of pledgets soaked in solutions of carbonate of lithia or of potash to tophaceous swellings had some power in reducing their size, and even effecting, in some cases, their total absorption. Also, with the intent of dissipating collateral inflammatory thickening, he sometimes used a solution composed of equal parts of iodide of potassium and carbonate of lithia.
More recently, Robin states that the resolution of tophi may be hastened by local applications of mineral waters containing magnesia and sodium chloride or a solution of sodium perborate, these affixed with considerable pressure over the harder parts of the tophus, gentle massage of which, he thinks, at other times, will aid absorption.
Luff, however, on this point, holds that “the application of the so-called solvents externally to affected joints is useless, as they are not solvents of sodium biurate,” and I am inclined to agree with him that but little is to be hoped for from this method of treatment. A more effectual method of local medication is by the electrolytic introduction of drugs.
Ionisation.—We may enlist cataphoresis, either for its analgesic or its sclerolytic effect. If relief of pain be desired, the electrolytic introduction of the salicylic ion from a cathode of a 2 per cent. sodium salicylate solution is most valuable. A current of 20-40 milliamperes, but only gradually raised, should be passed for twenty to thirty minutes. Too frequent applications of the latter strength may cause injury to the skin, and, in Lewis Jones’s opinion, are inadvisable oftener than twice a week.
If we wish to exercise a favourable stimulant effect in alterations of nutrition and atrophy caused by gouty inflammation, the chlorine ion definitely accelerates return to the normal state. Six-fold pads of ample size, soaked in a warm solution of sodium chloride, are used as a cathode and bandaged round the joint. The other “indifferent” electrode, similar in nature, is applied to different parts at different sittings, and in this way the pathway of the current through the joint changed. Currents up to 100 or even 200 milliamperes may be tolerated when applied to the knee; but the intensity of the current should only be raised gradually, as the burns that sometimes ensue occasion no small pain to the subject as well as discomfiture to the operator.
Iodine has a like sclerolytic action, and is commonly held to be superior to that of chlorine. On the other hand, the iodine ion is much less readily tolerated by the skin, and, according to Leduc, the necessary reduction in intensity of the current employed goes far to nullify the greater sclerolytic effect it may possess.
In chronic gouty arthritis we are, as before remarked, confronted not only with inflammatory products, but also with uratic deposits. Fortunately, these latter also are benefited by the electrolytic introduction of the lithium ion under an anode of lithium chloride. The current serves a double purpose in this case, for it not only drives in the lithium, but removes the uric acid ion which is to be found in the electrode. Edison, some years ago, suggested ionisation with lithium in gout, and the good results he obtained have since been abundantly confirmed by others.