Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

In my own person I suffered for some weeks with obstinate lumbar pain, the cause of which appeared to be obscure until the existing state of oxaluria was discovered by a professional colleague. I would here emphasise the fact that when a case of lumbar or sciatic pain is defiant of cure by the usual methods of therapy we should always suspect this possibility of oxaluria, for commonly the urine is copious and clear; hence perhaps the frequency with which the condition is overlooked.

As to medicinal measures, we should bear in mind that Sir John Rose Bradford pointed out that the production of oxalates was initially due to deficient HCL, with secondary fermentation of foodstuffs, i.e., carbohydrates, especially sugar. The primary indication, then, is to reinforce the digestive capacities by administering hydrochloric acid or, as many prefer the dilute nitric muriatic acid, in combination with nux vomica, and in some cases pepsin. As Sir William Whitla remarks, if organic acidity be prominent, this may be intensified by mineral acids, in which event alkalies combined with a few grains of papain two hours after meals are indicated.

In conclusion, the nerve element in these cases is so pronounced that a thorough change of air and habits is often indicated, combined with freedom from worry, abundance of exercise, and a stimulating course of hydrotherapy.

Glycosuria.—The variety met with in the gouty, being of the alimentary type, is usually very responsive to dietetic measures, and these have been already dealt with. A course of spa treatment is often the best possible mode of therapy for these cases.

As to medicinal measures, these certainly should not be embarked upon until the effect of dietetic revision has been ascertained. If under their influence the glycosuria wholly disappears, then drugs may be uncalled for, save perhaps occasional aperients, antacids, or similar remedies of like nature. If, on the other hand, the glycosuria cannot be kept under control by dietetic measures, then recourse must be had to drugs. Here it may be noted that guaiacum diminishes the amount of sugar excreted, and it may be given a trial before resorting to codeia. Generally speaking, when the case requires codeia it has passed out of the realm of gouty glycosuria into that of true diabetes, the treatment of which grave disorder is beyond the scope of this work.

Hyperchlorhydria.—The disorder is rare in gouty patients, and its diagnosis from organic acidity cannot be made without examination of the stomach contents. Moreover, when found to be present an endeavour should be made to elucidate its cause. If gastric and duodenal ulcer can be excluded and the condition appears to be of the nature of a secretory neurosis, then the underlying nervous defect will call for treatment.

In some cases the exciting cause lies in errors of diet and habits of living. These when faulty require correction; very often in these cases it is not so much the nature of the food as the hurried manner in which it is bolted that is responsible. At times, when free from hurry or worry, they can eat any kind of food with impunity. When the attacks are on, it frequently happens that all types of food, whether easily digestible or not, are equally provocative of acidity. We see then how large a part general hygiene plays in the successful treatment of these cases.

As to diet, this is, of course, of primary importance, the main indications being the reduction or withdrawal of farinaceous foods, and for a short period on a Salisbury regimen or some modification thereof.

The medicinal indication is to afford relief during the acute attacks. Fortunately these are usually intermittent, and when the occasion arises are fairly readily controlled by massive doses of alkalies, frequently combined with an artificial digestive, i.e., papain. While magnesia and bicarbonate of soda are, as a rule, invoked, others speak well of sodium phosphate (5 grams) with menthol (0·25 gram), given two hours after each meal.

Luff, discussing hyperchlorhydria in the gouty, highly extols hopogan (magnesium peroxide), in doses from 20-30 grains, one hour after food, the amount to be reduced if it causes purgation. To inhibit excessive production of HCL, belladonna, in 5-minim doses of the tincture, before meals results in reduction of acid values, both absolute and relative, of the stomach contents, and, moreover, relieves spasmodic contractions. Constipation in these gouty subjects is best combated by an occasional nightly pill containing colchicum in combination with aloes or other laxative. Lastly, when digestion becomes more normal nervine tonics, such as arsenic, valerian, and the like, may be given to correct, if possible, the underlying nerve element in these troublesome cases.