^ Columbia ®inibergitp , ^cijool oe Bental antJ 0tal burger? ^ ^tltxtntt Eibrarp GOUT ITS PATHOLOGY, FORMS, DIAGNOSIS AND TREATMENT Originally founded on the Goulstonian Lectures on ^'The Chemistry and Pathology of Gout" delivered by the author before the Royal College of Physicians of London in 1897 BY ARTHUR P. LUFF M,D., B Sc , F R.C.P. (LoND.) PHYSICIAN TO ST. MARy's HOSPITAL THIRD EDITION NEW YORK WILLIAM WOOD AND COMPANY MDCCCCVII PREFACE TO THE THIRD EDITION. In the present edition the scope of the book has been considerably extended, and a large portion of it has been rewritten. The new views as to the pathology and causation of gout are fully discussed, and due consideration is given to the view that a bacterial toxin is the primary cause of gout. A chapter has been added on the differential diagnosis of the various chronic diseases of the joints, which it is trusted will prove of use in the distinction of gout from other joint diseases. The various forms of irregular gout, and the clinical features of gout in its acute, subacute, and chronic forms, are much more fully dealt with than in the previous editions. Considerable additions have also been made to the section of the book devoted to treatment, and the subject of diet is dealt with at much greater length. Important additions have also been made to the chapter on hydrotherapy and spa treatment. A. P. L. 9, Queen Anne Street, London, W. May, 1907. PREFACE TO THE FIRST EDITION. Part I. of this book is mainly a reproduction of the Goulstonian Lectures on " The Chemistry and Pathology of Gout," delivered in 1897 before the Royal College of Physicians of London. Part II. deals with the causa- tion of gout, its various forms and its diagnosis and prognosis. Part III. includes a series of investigations undertaken with the object of ascertaining the various conditions affecting the formation and removal of gouty deposits, the influence of alcoholic drinks on the gouty process, the solvent effect of the mineral constituents of various vegetables on gouty deposits, and the value of certain drugs in effecting the removal of such deposits. Part IV. deals with the treatment of gout and of gouty conditions, especially in the light of the knowledge gained by recent investigations. The sub- ject of diet has been carefully dealt with, and a classification of the various mineral waters is given according to their therapeutic value in the treatment of the various forms of gout. Digitized by tine Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/goutitspathologOOIuff CONTENTS. PART L THE PATHOLOGY OF GOUT. CHAPTER I. URIC ACID AND THE PURIN BODIES. PAGE Uric acid and its compounds — Theories as to the causation of gout — View that uric acid is formed from nuclein — The purin bodies — Conclusions concerning the estimation of urinary purins . i CHAPTER II. THE FOIiMATION OF URIC ACID. View that uric acid is formed in the kidneys — Views as to the asso- ciation of gout and kidney disease — View that the liver and spleen produce uric acid — View that uric acid is produced in various tissues — View that excess of uric acid is the result of an animal diet ......... 24 CHAPTER III. PRIMARY CAUSATION OF GOUT. The uric acid compound regarded as acting passively and physically — The uric acid compound regarded as acting as a poison or irritant — Uric acid not a poison — Necrotic changes as the primary cause — Inflammatory or degenerative changes as the primary cause — -Nervous disturbance as the primary cause — Excess of carbonaceous material as the primary cause — A bacterial toxin as the primary cause — The liver as a toxin destroyer .......... 41 CHAPTER IV. AI,KAI, 1. 175 .. 0.556 ,. 0.372 ,, 1.030 „ 0.506 ,, 0.593 .. 1.252 ,, 0.494 .. 0.594 „ 1-203 „ 0.398 ,, 0.572 „ 1. 148 ,, (average) (average) (average) On the other hand, detailed analyses of the urine were made in two cases of typical gout by Chalmers Watson, a daily examination of the urine being made for many weeks. The results of this investigation showed no disturbance in the uric acid elimination either before, during, or after the paroxysm. Chalmers Watson has also recorded a series of observa- tions, the results showing an actual increase of uric acid excretion during the attack of gout. From the analyses made by a number of observers Minkowski states that the following conclusions may be drawn : — (i) The daily excretion of uric acid in the inter- vals between acute attacks ranges within the same limits as does the excretion in healthy individuals. (2) In chronic gout, even in those cases in which there is marked deposition of biurates in the tissues, a constant variation from the normal amount of uric acid excretion in any one direction has not been definitely proved. (3) Immediately preceding an acute attack there is regularly a diminution in the amount of uric acid eliminated in the urine, whereas during and after the attack the uric acid output is increased. Futcher's analyses in a number of cases fully accord with the statement contained in section 3, but they differ materi- ally from those stated in section 2. He almost always found a marked diminution in the uric acid excreted in the inter- vals between acute attacks in chronic tophaceous gout. chap.vii] uric acid excretion. 115 Ratio of uric acid elimination to that of urea.— Haig has advanced the theory that normally there is a constant ratio of i to 35 between the uric acid and urea formation, and that if the uric acid excretion falls below this ratio it is due to the retention and storage of uric acid in the liver, spleen, kidneys, joints, and fibrous tissues, whereas an increase in the proportion of uric acid to urea is due to the washing out from its storage places of the deposited uric acid. According to this view, the amount of uric acid produced in relation to urea in each individual is a constant factor, the variations in the amounts eliminated being due on the one hand to excessive storage, and on the other to the discharge of the stored-up supply. This theory of the existence of a normal ratio of uric acid to urea, and of every departure from it being due to a pathological cause, is disproved by the following experi- ments : — (i) Bleibtreu and Schultze,* experimenting on themselves, showed that the ratio between uric acid and urea can be considerably altered by means of the diet with- out the general health being influenced. (2) Herringham and Groves, t as the result of a series of experiments that they made, entirely fail to corroborate Dr. Haig's observa- tions, and think that either what was true for his system was not true for theirs, or that Dr. Haig's results were, to quote their own words, " inaccurate and deceptive owing to his having employed a very uncertain and inaccurate method for the estimation of uric acid." (3) The follow- ing results of the determinations which I have made of the total daily eliminations of uric acid and urea in the urine of a healthy adult man, and which consist of observations extending over a period of fifty days, show that the ratio of uric acid to urea varied from i : 28 to i : 55 (the average being i : 42), although throughout the entire period the individual remained in good health. * Pfluger's Archiv, Bd. xlv. t Journ. of Physiology, 1891. Ii6 GOUT : ETIOLOGY AND VARIETIES, [part ii. TABLE XV. Fifty daily eliminations of uric acid and urea of a healthy adult man on a mixed diet. No. of oz. of Uric acid excreted Urea excreted per Ratio of uric urine per diem. per diem (gramme). diem (grammes). acid to urea. 63 0.654 28.34 i: 43 68 0.714 31.62 i: 44 72 0.626 29.82 I : 47 42 0.532 29.39 i: 55 61 0.819 30.19 l: 2>7 56 0.663 25.22 I : 38 65 0.616 27.67 l: 45 59 0.612 24.44 I : 40 41 0.826 30.32 i: 37 57 0.705 21 .91 I : 31 49 0.618 31.27 i: 50 63 0.751 27.57 l: 37 48 0.722 28.89 I • 40 64 0.569 23.44 i: 41 51 0.652 29.89 I : 46 60 0.608 27.00 I • 44 56 0.591 27.71 I 47 50 0.561 27-54 I 49 60 0.630 27.91 I 44 45 0.742 26.56 I 36 45 0.550 23.60 I 40 60 0.640 31-34 I 49 61 0.581 28.34 I 49 61 0.537 22.35 I 41 64 0.572 26.49 I 46 53 0.595 21.24 I 36 55 0.764 24-73 I 32 69 0.637 28.58 I = 45 63 0.526 23.13 I :44 72 0.583 28.88 I :49 45 0.620 24.26 I : 39 45 0.698 28.01 I :40 52 0.680 30.04 I :44 69 0.705 33--^^ I :47 40 0.837 25.62 I : 31 42 0.728 30.54 I :42 67 0.665 30.11 I = 45 44 0.550 29.50 I : 53 54 0.554 29.88 I : 54 62 0.582 26.13 I = 45 55 0.515 22.15 I :43 55 0.632 27.14 I :43 54 0.585 28.34 I = 48 chap.vii.] amorphous urate deposit. TABLE XV. (continued). 117 No. of oz. of Uric acid excreted Urea excreted per Ratio of uric urine per diem. per diem (gramme). diem (grammes). acid to urea. 66 0.776 28.05 36 49 0.536 25 .20 47 67 0.560 23.56 42 45 0.550 21.63 39 35 0.660 23.10 35 55 0.624 23.09 37 87 0.691 19.76 28 TABLE XVI. Excretion of uric acid. Excretion of urea. Ratio of uric acid to urea. Daily average in grammes Daily average in grains Average in 24 hours for each lb. of body weight (in grains) 0.639 9.8 0.07 26.89 415.0 3.19 I : 42 I : 42 It is evident from the above results that no constant ratio exists in a given individual between the excretion of uric acid and urea. Amorphous urate deposit of urine. — Sir William Roberts * has shown that the amorphous urate deposit of human urine is of the same composition as the solid or semi-solid urinary excrement of birds and serpents, the only difference being one of physical form. The deposit from human urine is amorphous, whilst the urinary excre- ment of birds and serpents consists of minute crystalline spheres. Sir William Roberts shows that this difference in physical form is a mere accident of molecular aggrega- tion, since, under certain conditions, the amorphous urate deposit can be transformed into crystalline spheres, whilst * Croonian Lectures en " Uric Acid Gravel and Gout," 1892. ii8 GOUT: ETIOLOGY AND VARIETIES. [Part ii. the crystalline urinary substance of birds and serpents can be converted into amorphous deposit. Bence Jones * was the first to show that the amorphous urate deposit yielded to water a soluble moiety consisting of true biurate, and left a sediment consisting of pure uric acid, and from the results of his analyses he inferred that the amorphous urate deposit consisted of, or at least often contained, a molecule of biurate in loose combination with a further molecule of uric acid. Sir William Roberts took up and continued the investigation dropped by Bence Jones thirty years before, and has shown that a third order of uric acid salts — the quadriurates — exists, and that the amorphous urate deposit of human urine and the urinary excretion of birds and ser- pents belong to this order, and consist of a compound of biurate and uric acid in the proportion of one molecule of each. Sir William Roberts concludes that the quadriurates are the physiological combinations of uric acid. The amorphous urate or quadriurate deposit of urine is generally referred to as consisting of a mixture of the potassium, sodium, ammonium, and calcium urates. As far as I can ascertain, however, no quantitative determination of the bases in the deposit has yet been made. The near- est approach to it is an analysis made by Sir William Roberts f of a sample of amorphous urate deposit pre- pared by an artificial process with potassium carbonate, which would therefore most probably contain more potas- sium than the natural deposit. I therefore considered it advisable to determine the actual bases present in the amorphous urate deposit and their relative propor- tions. Composition of the amorphous urate deposit of urine. — The deposit was obtained from several gallons of acid urine passed by patients suffering from febrile diseases, and was collected on a filter and allowed to drain. * Journ. of the Chemical Society, 1862, vol. xv. t Croonian Lectures on " Uric Acid Gravel and Gout," 1892, p. 20. CHAr.viij AMORPHOUS URATE DEPOSIT. 119 It was decomposed by boiling with distilled water and ex- cess of hydrochloric acid, the mixture was then allowed to cool, filtered from the deposited uric acid, and the filtrate, which then contained the bases in the form of chlorides, was evaporated to dryness. The residue was taken up with distilled water, filtered from the minute amount of uric acid left in solution after precipitation of the bulk of the acid, and evaporated to dryness. Part of the residue was submitted to qualitative analysis, and found to contain ammonium, sodium, and potassium, with very small traces of calcium and magnesium. The amounts of ammonium, sodium, and potassium were then estimated in the usual manner in the other portion, when their relative quantities were found to be as follows : — • Paris per loo. Ammonium ....... 46 Sodium . . . , . . . 40 Potassium ....... 14 These amounts, calculated as the respective quadriurates, would approximately give the following composition for the amorphous uratic deposit that naturally forms in acid febrile urines : — ■ 7 molecules NH,HC-H„N^O.,, HX-H,N^O., — Ammonium quadri- urate. 5 molecules NaHC-H,N,0 , H„C.H„N,0., — Sodium quadriurate. I molecule KHC.H^N^O.,, H^CgH^N^Oj, — Potassium quadriurate. It is possible, however, apart from the quadriurates, that the uric acid is in part excreted in loose combination with some other organic substance. This combination, if it exists, is probably easily broken up, and the uric acid then set free. Estimation of uric acid in urine. — Various methods have been employed for the estimation of uric acid in the urine, including Heintze's process, Haycraft's process, Fokker's process, Salkowski's process, and Ludwig's modi- fication of Salkowski's process. In connection with all 120 GOUT : ETIOLOGY AND VARIETIES, [part ii. these processes there are faults or objections from which the following processes are free. Gowland-Hopkins method. — This process depends upon the fact that when urine is saturated with ammonium chloride all the uric acid is precipitated as an ammonium urate. From the ammonium urate the uric acid is set free, and the amount of it is determined by titration with a standard solution of potassium permanganate. One great advantage of this process is that there is no danger of the reduction of the ammonium urate as there is of the silver urate produced in some of the other processes ; more- over, the ammonium urate is easy to filter, and permits of the liberation of its uric acid with great readiness. Another great advantage of the process is that although xanthin is at first precipitated along with the ammonium urate, yet the subsequent treatment with hydrochloric acid entirely removes it, so that finally it is not estimated along with the uric acid. The process is worked as follows : — ^To lOO c.c. of the urine powdered ammonium chloride is added till- practical saturation is obtained ; about 30 grammes of ammonium chloride as a rule are required. When a small quantity remains undissolved, after brisk stirring for a few minutes, saturation is sufficiently complete. The urine is then al- lowed to stand for two hours, during which time, if possible, it is occasionally stirred to promote subsidence, and is then filtered through thin filter-paper, and washed three or four times with a saturated solution of ammonium chloride. The filtrate should remain perfectly clear and bright. The precipitated ammonium urate is then washed off the filter into a small beaker with a jet of hot distilled water, and is heated just to boiling with an excess of hydrochloric acid. The beaker and its contents are allowed to stand in the cold for two hours, when the uric acid separates out com- pletely, and is then collected on a filter and washed with cold distilled water. The filtrate should be measured Chap. VII.] ESTIMATION OF URIC ACID. 121 before the washing is begun, and i milligramme added to the final result for each 15 c.c. of filtrate present — this need never be more than 20-30 c.c. The uric acid is then washed off the filter with hot water, warmed with sodium carbonate till dissolved, and made up with water to 100 c.c. The liquid is now transferred to a flask, 20 c.c. of strong pure sulphuric acid are added, and the mixture is immediately and while warm titrated with one-twentieth normal potassium permanganate solution. The latter should be added slowly towards the end of the reaction, the close of which is marked by the first appearance of a pink colour, which is permanent for an appreciable interval. Previously the disappearance of the colour is instantaneous. The permanganate solution is made by dissolving 1.578 grammes of pure potassium permanganate in a litre of distilled water, i c.c. = "00375 gramme of uric acid. Otto Folin method. — It is contended that the method of Otto Folin is a more accurate method than that of Gow- land-Hopkins for the estimation of uric acid in urine. The following is the process : — Take 100 c.c. of urine, add 10 grammes of ammonium sulphate, render it slightly alkaline with ammonia, shake, and set aside for two hours. Collect the precipitated ammonium urate on a filter and wash with 10 per cent, solution of ammonium sulphate. Then dissolve the precipitate on the filter with boiling water made slightly alkaline with ammonia, allow the solution to cool, and make up the volume to 100 c.c. by the addition of water. On adding 15 c.c. of concentrated sulphuric acid the temperature should rise to 55° to 60° C. This temperature is necessary for the final operation, viz. titra- tion with standardised potassium permanganate solution. Add to the result obtained by calculation i milligramme, to allow for loss due to the solubility of ammonium urate. Methods of Dimmock and Branson. — Dimmock and Branson ^- have recently described three new methods for * Lancet, 1907. 122 GOUT : ETIOLOGY AND VARIETIES. [Part ii. the determination of uric acid : — (a) A measuring process, in which a precipitate of ammonium urate is measured in a tube specially shaped and graduated in parts per cent, of uric acid, (b) A volumetric process in which a precipi- tate of ammonium urate is collected and washed with a saturated solution of ammonium nitrate until free from chlorides, and decomposed after solution in distilled water by adding in excess a known amount of a volumetric solu- tion of silver nitrate. After filtering off and washing the precipitate of urate of silver, the amount of nitrate of silver in the filtrate is determined by means of a standard solu- tion of thiocyanate of potassium, the filtrate being first rendered acid with a few drops of dilute nitric acid (i in 3) ; a few drops of saturated solution of iron alum are used as an indicator, (c) A gasometric process, in which the washed ammonium urate is decomposed by hypobromite of sodium in a specially devised apparatus which can also be used for the determination of urea. Process (a) is a very convenient method, and gives approximately correct results in a short time. Process (/;) is a quick method, and gives very concordant results. Process (c) is suitable for proportions of uric acid ranging from I in 1,000 to i in 5,000. General preliminary treatment for all three processes . — The precipitate used in the three foregoing processes consists of ammonium urate, which is obtained by adding ammonium chloride or ammonium nitrate to urine which has previously been rendered slightly alkaline by the addi- tion of I per cent, of lithium carbonate, and subsequently boiling, the precipitated phosphates, etc., being removed by filtration. The method employed is as follows : — Take 100 c.c. of clear urine (warm if necessary to dissolve uric acid or urates), and place in a conical flask of about 400 c.c. capacity, add i gramme of lithium carbonate, and boil the whole for three minutes. If frothing occurs it can be checked by blowing on the upper portion of the Gup.vn.] ESTIMATION OF URIC ACID. 123 outside of the flask. Filter the liquid whilst hot, and wash the precipitated earthy salts with a little distilled water until the filtrate measures 100 c.c. Process [a). — To 50 c.c. of the filtered alkaline urine, which contains the uric acid as lithium urate, add 5 grammes of ammonium chloride, and shake the flask until solution occurs. After three minutes warm the contents of the flask to 50° C. so as to secure a uniform aggregation of the precipitated urate of ammonium. Now pour the whole into a tube graduated in parts of uric acid per 100, allow deposition to take place, and take the reading after twenty-four hours have elapsed. If the urine does not contain a high percentage of uric acid the reading can be taken in four hours. If any ammonium urate adheres to the surface of the glass the tube should be gently rotated. Process (6). — The ammonium urate is obtained as fol- lows : — To 50 c.c. of the filtered alkaline urine add 15 grammes of ammonium nitrate, and shake the flask until solu- tion occurs. After three minutes warm the contents of the flask to 50° C, as in process {a). Transfer the whole to a beaker, and allow to stand for two hours. Collect the pre- cipitate on a filter paper of 5.5 centimetres diameter, and wash with about 10 c.c. of a saturated solution of ammonium nitrate until no trace of chloride is indicated by the addi- tion of a few drops of a solution of 5 per cent, of nitrate of silver acidulated with nitric acid. After washing the pre- cipitate with about 5 c.c. of distilled water to remove excess of ammonium nitrate, transfer it with the filter paper to a beaker with about 40 c.c. of hot distilled water ; solu- tion being effected, pour off from the filter paper and wash the latter with two successive quantities of 5 c.c. of distilled water ; to the 50 c.c. of solution thus obtained a measured quantity of the nitrate of silver solution is added — e.g. 10 c.c. or 15 c.c. Add about h gramme of powdered talc, and stir the whole well, filter into 124 GOUT : ETIOLOGY AND VARIETIES, [part h. a flask previously rinsed with a little distilled water, and wash the precipitate with about lo c.c. of dis- tilled water. Add to the filtrate in the flask a few drops of dilute nitric acid (i in 3), and a few drops of a saturated solution of iron alum, and titrate with a standard solution of thiocyanate of potassium. The number of cubic centi- metres thus obtained is subtracted from the number of cubic centimetres of nitrate of silver solution originally used, and this gives the exact amount of nitrate of silver required for the uric acid in solution. Solutions required n for this process : — Standard silver nitrate solution : — solution silver nitrate, 500 c.c. ; distilled water, 20 c.c. One c.c. of the above equals uric acid 0.005 gramme. Solution of potassium thiocyanate of equivalent strength to above ; dilute nitric acid, i in 3. Process (c). — Dissolve 31 grammes of ammonium chloride in 100 c.c. of urine previously treated with lithium car- bonate, decant off the clear portion, and transfer the re- mainder, with the precipitate, to a narrow cyhndrical jar of about 25 c.c. capacity. In a few hours the precipitate will be ready to transfer to a small filter paper, 5.5 centi- metres in diameter. Care must be taken that any precipi- tate adhering to the vessels used is detached and washed out on to the filter paper with some of the clear urine. Wash the precipitate and edges of the filter paper carefully with distilled water, the precipitate being disturbed as little as possible, so that the wash water may percolate through it. The washing of the precipitate may be per- formed in the following manner. Allow the liquid to drain from the precipitate, then fill the filter paper with distilled water by means of a wash-bottle with a fine jet. Repeat this operation a second and a third time. Test some of the filtrate with a 5 per cent, solution of nitrate of silver, acidu- lated with nitric acid 5 per cent. Only a very shght pre- cipitate should be given, indicating the absence of any Chap. VII.] ESTIMATION OF URIC ACID. 125 appreciable amount of ammonium chloride ; but should the filtrate still contain this salt, wash with a small addi- tional amount of distilled water. Place the precipitate with the filter paper in the generating bottle of apparatus, fill the tube up to the mark (25 c.c.) with the hypobromite solution, and lower it into the bottle by means of string. The temperature of the solution should approximate to that of the room in which the operations are carried out. This may be easily attained if the hypobromite solution is immersed for some time in the water vessel in which the generating bottle is placed. Now place the cork in the generating bottle, and plunge the bottle in a vessel of cold water of a similar temperature to that of the hypo- bromite solution. After two minutes adjust the water level in the measuring burette to zero, and then close the tap and observe if the water level remains constant. In order to test if leakage occurs in any part of the apparatus, alter the water level in the measuring burette ; any defect is then easily seen. Finally, lift the generating bottle and allow the reagent to flow out of the tube, and shake so as to promote the reaction between the sodium hypobromite and the ammonium urate. After ten minutes, during which time the bottle should be shaken at intervals, adjust the level in the two tubes, and read off the percentage of uric acid, as indicated by the nitrogen evolved. The hypo- bromite solution is prepared as follows : — I Caustic soda, 41 grammes. I Distilled water to measure 100 c.c. /■ Bromine, i c.c. Bromine solution ' Potassium bromide, 2 grammes. I Distilled water to measure 10 c.c. For use mix equal volumes immediately before being required, and cool. Plumbism and gout. — Chronic lead-poisoning gives 126 GOUT: /ETIOLOGY AND VARIETIES. [Part ii. rise to both chronic kidney disease and gout. A prolonged period of lead intoxication is, as a rule, required to pro- duce true saturnine gout. The patient suffering from saturnine gout, unlike the majority of sufferers from inherited gout, is pale, thin, and anaemic. The gouty attacks are frequently repeated, and affect many joints, whilst signs of interstitial nephritis make their appearance. If the lead-poisoning has been of short duration the lesions may yield to treatment, but after a prolonged absorption of lead into the system the kidney condition is generally incurable. In plumbism bluish-black discolorations of the mucous membrane of the intestine occur. These patches, on micro- scopical examination, exhibit a similar condition to the mucous membrane of the gums affected with the lead line. The dark deposits are on the surface of the membrane, and also in and underneath it. They are not specially associated with the blood vessels, but rather with the lymphatics and the large cells of the mucous membrane. During the attack of lead colic there is heightened arterial tension, which is the cause of the partial suspension of the renal function. In the liver a fatty-granular degeneration of the hepatic cells occurs, together with an intercellular cirrhosis. In the kidneys a very similar change takes place. A parenchymatous nephritis is first produced, and this runs on to an interstitial nephritis. Sir William Roberts * considered that it was difficult to believe that lead-poisoning produces the same constitu- tional diathesis as that which exists in true gout, and pre- ferred to think that, while gout and plumbism differ in all other respects, they have one tendency or vice in common, namely the tendency to uratosis — that is, to the deposition of sodium biurate. He regarded this precipitation as a gouty tendency which may be reinforced by lead-poison- ing, and the precipitation in connection with plumbism as * " Transactions of the Medical Society," vol. xiv., p. 88. CAP.vir.] PLUMBISM AND GOUT. 127 one in which lead-poisoning is reinforced by a previously existing gouty tendency. In the south of England there is an intimate relation- ship between gout and lead-poisoning ; but, according to the observations of Thomas Oliver, this relationship does not hold good in the north of England. He has observed that workmen from the south who become the subjects of lead-poisoning develop gout in the north of England, whilst the natives of the north, though equally exposed, seldom become gouty, even when the kidneys are affected by the plumbism. At the same time it must be borne in mind that gout, as a disease, is not met with in the north with anything like the frequency that it is in the south of England. This has been ascribed to the difference in the drinking habits of the people, whisky and not malt liquor being the general drink in the north. Oliver, however, does not regard this as a complete explanation, but con- siders that in some way or other the result is due to external conditions rather than to the use of beverages. Lorimer * arrived at the following facts and conclu- sions based on an analysis of 107 cases of gout associated with lead impregnation : — (i) Age. — The first attack of gout in connection with lead impregnation occurs at an earlier age than when independent of it. (2) Hereditary tendency. — In gout associated with plumbism the influence of direct hereditary predisposition is less marked. (3) Ancemia. — In gout the blood corpuscles undergo no change in number and quality, but in gout associated with lead impregnation the red corpuscles are diminished in number, the white sometimes increased, and the red colouring matter is reduced in amount. (4) Asthenic type of arthritis. — From the early age at which saturnine gout occurs, when functional activity is * Quarterly Med. Journ., 1901. 128 GOUT : .ETIOLOGY AND VARIETIES, [part ii. more vigorous, an acute and asthenic type of arthritis might be expected to prevail. In a number of cases in the first attack, and in a minority of cases in a subsequent attack, the arthritis assumes this type ; but in the majority of cases the type of arthritis is asthenic and the accompany- ing pyrexia sHght, with a tendency for the arthritis to pass insidiously into a chronic and adynamic form ; the local and constitutional phenomena are less intense, but more persistent, lingering, and obstinate. The asthenic type of arthritis appears to be due to impaired vitality, to the effects of lead on the trophic centres, and to the renal changes. (5) The aharticular manifestations of gout are gener- ally less marked than in ordinary gout, renal affection in lead gout, however, being excepted. (6) Arterial thickening and degeneration. — A sign which was observed to be more or less constantly present, and in two-thirds of the total number of cases pronouncedly marked, was an arterio-capillary fibrosis, along with athero- matous changes, the result of the combined effects of gout and plumbism, leading to premature senile changes in the arterial system. The combined effect of the two toxic influences is to increase and accentuate arterial degenera- tion and induce cardiac hypertrophy, which is generally present as the disease advances. (7) Albuminuria. — Albuminuria occurs frequently in lead-poisoning ; in the 107 cases it was present in 89, either as an intermittent or a permanent condition. In the initial stages it may be absent, or be intermittent ; in subsequent stages it is more frequently found, either as an occasional or constant occurrence ; but in the later stages it always exists ; so that it may be affirmed that albuminuria is one of the most constant, certain, and characteristic symptoms in saturnine gout, and is always present at some time in the progress of the disease. (8) Frequency of chronic interstitial nephritis. — It is, CAP. VII.] PLUMBISM AND GOUT. 129 however, when the combined effects of gout and plumbism are concentrated on the kidney that the distinguishing feature of most serious import arises — namely, chronic interstitial nephritis. Under the influence of lead, there is swelling, degeneration, and shedding of the renal epi- thelium, glomerulitis, thickening of the vessels, and inter- stitial nephritis. It is peculiar to the gouty kidney that it is a disease of advancing years ; its progress is slow, and its duration long. When, however, the kidneys are assailed by gout and lead, the onset of disease is accelerated and the duration shortened. CHAPTER VIII. IRREGULAR GOUT. Irregular gout affecting the alimentary tract — Irregular gout affecting the air-passages and lungs — Irregular gout affecting the heart and vessels — Irregular gout affecting the nervous system — Irregular gout affecting the genito-urinary system — Irregular gout affecting the skin — Irregular gout affecting the eye and ear — Other irregular gout affections — Retrocedent or metastatic gout. Gout appearing in any situation other than a joint is regarded as irregular or abarticular. Different forms of regular gout may accompany arthritic gout, or may take its place, or may alternate with it. Although attacks of ir- regular gout may occur in persons subject to articular gout, yet they more frequently occur in those who have never suffered from gout in the joints, but who are predisposed to gout either by inheritance or by their mode of life. Metas- tatic and irregular forms of gout are especially apt to occur in persons of poor physique, and who are broken down in health. Undoubtedly the terms " irregular gout " and " sup- pressed gout " have frequently been applied to pathological conditions in no way connected with gout, and it is there- fore important that a diagnosis of irregular gout should be based on good and sufficient grounds. The most important points to pay attention to in the diagnosis of irregular gout are the question of heredity, the habits of the patient, the nature of the attack, a careful examination of the urine, and, if possible, of the blood or blood serum, and, lastly, the successful reaction to therapeutic remedies. Cramps 130 Chap. VIII.] IRREGULAR GOUT. 131 and aching pains in various muscles and tingling sensations in the hands and feet are frequently associated with irregu- lar gout. It is most probable that the symptoms of irregular gout are not merely dependent on the local deposit of minute crystals of sodium biurate in the affected parts, but are rather due to the selective action of a soluble toxin in the blood on a naturally weak spot. The symptoms vary with the age and constitution of each subject, but in every case they are more liable to develop in that system of tissue which happens to have, from natural or acquired defects, the weakest nutritional activity. The various forms of irregular gout may be conveniently classified into the following groups : — (i) Irregular gout affecting the alimentary tract ; (2) irregular gout affecting the air-passages and lungs ; (3) irregular gout affecting the heart and vessels ; (4) irregular gout affecting the nervous system ; (5) irregular gout affecting the genito-urinary system; (6) irregular gout affecting the skin; (7) irregular gout affecting the eyes and ears ; (8) other irregular gout affections. 1. Irregular gout affecting the alimentary tract.— A gouty tonsillitis is occasionally a precursor of articular gout. It is characterised by intense congestion and oedema of the tonsils and soft palate. It lasts from some hours to three days, but always subsides on the appearance of the gout in the joints. Acute gouty pharyngitis. — This affection is charac- terised by a sudden onset, acute course, and sudden dis- appearance of symptoms. The temperature is generally high, and the local pain is intense and out of proportion to the apparent involvement of the throat. The local condi- tion consists of inflammation of the pillars, soft palate, uvula, and posterior wall of the pharynx, with a general red cedematous appearance, and a tendency for the inflam- mation to descend to the larynx. The mucous membranes 132 GOUT: ETIOLOGY AND VARIETIES, [part ii. are free from exudation, and the glands at the angle of the jaw are not involved. Chronic gouty pharyngitis. — A chronic pharyngitis is a fairly common form of irregular gout, and is also occasion- ally associated with active gout. As a rule, there is a general irritation and congestion of the whole pharyngeal mucous membrane, with a tendency to lateral thickening. There may be some secretion of tenacious mucus, but not usually to any marked degree. The uvula assumes a dusky- red colour and is oedematous. Gouty parotitis is an extremely rare form of irregular gout, but when present it seriously interferes with mastica- tion and deglutition. It usually develops suddenly, per- sists for a few hours, and disappears. Like gouty orchitis, it readily yields to treatment with colchicum, and also rapidly subsides on the appearance of regular gout in one or more of the joints. One case has been reported in which gouty orchitis occurred during an attack of gouty parotitis. Gouty cesophagismus occasionally occurs, and may be severe. A sudden gastralgia, with accompanying derangement of the digestive functions, constitutes an occasional form of irregular gout ; it may alternate with a true arthritic attack, or with urticaria, or eczema. Acute attacks of enter algia also occur in gouty subjects. Gouty dyspepsia is a very common form of irregular gout. It is usually accompanied by excessive gastric acidity, flatulence, and heartburn. Gastric pain, dilata- tion of the stomach, and pyrosis are occasionally associated with this form of dyspepsia, which is frequently of a pro- longed and obstinate nature. In other cases slight attacks of gastric catarrh occur characterised by loss of appetite, furred tongue, foul breath, and constipation. Hyperchlorhydria, or excessive secretion of hydrochloric acid in the gastric juice, occurs in some gouty subjects, and in such should be regarded as a form of irregular gout. Chap. VIII.] IRRECxULAR GOUT. 133 By this, I do not mean that hyperchlorhydria occurs only in gouty subjects, as I have met with many cases of it in individuals who have no tendency to gout, either inherited or acquired ; but I have on several occasions met with it in gouty people, and have not uncommonly seen it alter- nate with attacks either of regular gout or of some other form of irregular gout. The gastric discomfort does not begin until from one to two and a half hours after a meal, and generally continues up to the next meal, which for a time relieves it. The discomfort may simply be one of distension or oppression, or may amount to severe pain, which is generally described as being of a burning charac- ter. The pain is usually referred to the epigastrium, but may also be felt beneath either shoulder blade. The condi- tion is usually accompanied by flatulent distension, acid eructations, and severe heartburn. The eructations give, for the time, considerable relief, as a rule. The effect of this excessive secretion of hydrochloric acid is to cause a too rapid digestion of the proteid elements of the food, with retention in the stomach of the starchy and fatty constituents of the food. In consequence of this retention, the gastric secretion is kept up, while at the same time no constituent is present with which the gastric juice can combine, and, in consequence, an excessive amount of free hydrochloric acid accumulates in the stomach. Un- doubtedly, some gouty subjects have the habit of secreting an excessive amount of gastric juice, and especially does this occur as a consequence of the consumption of a diet too rich in nitrogenous substances. Gastro-intestinal gout. — Attacks of gastro-intestinal gout occasionally alternate with attacks of articular gout. A patient who has been the subject of articular gout may be suddenly seized with epigastric pain, nausea, and vomit- ing, which recur in bouts. The vomiting is generally re- peated in each attack several times, and the attack gener- ally lasts from three to five hours. At other times there 134 GOUT : ETIOLOGY AND VARIETIES, ipart ii. may be intestinal crises, in the form of diarrhoea, lasting from three to four hours, and accompanied by colic and sweating. These gastro-intestinal attacks are accompanied by a marked temporary relief to the joints. The gastric form of gout manifests itself by the sudden occurrence of abdominal pain, not necessarily associated in any way with the taking of food, and not necessarily referred to any particular spot. The pain may be very severe, so as to cause more or less collapse, and vomiting may occur. This form can only be diagnosed by the absence of other conditions which could cause the pain, and by the complete and immediate disappearance of the pain on the occurrence of an acute attack of regular gout. 2. Ipregfular gout affecting* the air-passag^es and lung-s. — Gouty laryngitis. — Deposits of sodium biurate have been found in the vocal cords, the arytenoids, and the crico-arytenoid ligaments and joints. Congestion and swelling of the mucous membrane occur, and the conges- tion may extend to the vocal cords. The principal symp- toms are hoarseness, irritable cough, and scanty expectora- tion, which is occasionally streaked with blood. Gouty tracheitis. — This affection is accompanied by very irritable cough and scanty expectoration. Acute gouty bronchitis frequently precedes an arthritic attack, and often subsides when the joints become affected. The symptoms of acute gouty bronchitis may be very severe, and the heart's action often becomes irregular and feeble. The expectoration may be blood-stained, and the dyspnoea is frequently severe. Chronic gouty bronchitis. — This affection is accompanied by an irritable cough and scanty expectoration. It is especially liable to alternate with arthritic attacks. Gouty asthma. — Attacks may alternate with arthritic attacks, or gouty asthma may occur in early life, and articular gout may develop later, or gouty asthma may Chap. VIII.] IRREGULAR GOUT. 135 be the only form of gout inherited from a parent who was the subject of articular gout. Gouty pulmonary congestion. — This is usually at the base of the lungs, but occasionally may be apical. It is accompanied by haemoptysis, and is a condition that may be mistaken for phthisis. 3. Irregrular grout affecting" the heart and vessels.— Cardiac disorders. — Paroxysmal attacks of cardiac irri- tability are very apt to occur in gout}^ subjects. The attacks are nervous in origin, and are evidenced by irregu- larity, tachycardia, or occasionally bradycardia, and by dyspnoea if organic disease of the heart exist. Alterations in the cardiac action, from the influence of the toxic agents on the nervous mechanism of the heart, e.g. arrhythmia, tachycardia, bradycardia, angina, frequently occur. The liability to these disturbances is increased if myocardial degeneration is also present. Sansom * states that he has observed a considerable number of cases of gout and gouty manifestations in which there has been a course of severe or of peculiar and per- plexing symptoms after an attack or after repeated attacks of influenza. He thinks that the most important association of the post-influenzal irregular heart is with gout and goutiness. In many cases the heart symptoms — pain, distress, and heart failure — have been very severe, and in some fatal. Mitchell Bruce accepts as evidence of the gouty nature of a cardiac disorder various circumstances, or combinations of circumstances, which may be stated briefly as follows : — (i) a personal history of declared gout, present or pre- vious ; (2) a personal history of free living, and usually of hard work, with occasional explosions suggestive of irregular gout, in the form of haemorrhage from the bowels, intestinal fluxes, sick headaches, irritability of the bladder, eczema, insomnia, and fits of irritability or depression ; * Lancet, October, 1899. i3'6 GOUT : ETIOLOGY AND VARIETIES. [Pa.t n. (3) relief of these symptoms by treatment directed against gout — purgatives, exercise, spare living, and various alka- line salts ; and (4) a family history of gout, megrim, gravel, glycosuria, asthma, and their allies — well marked, direct, and often on both sides. The first evidence of gouty trouble in connection with the heart frequently comes on after exertion. The follow- ing is the description given by Mitchell Bruce of the in- cidence of such an attack. The patient becomes con- scious of a distressing sensation in the prsecordia — most likely behind the middle of the sternum. This is pain, or it may be but " oppression," driving him to unbutton his vest, or to unfasten his jersey, which seems to him to gird him too tightly. If the attack occur during exertion, he has to pause, looks anxious, and clings to the nearest support. In many instances the paroxysm is anginal. There may be no palpitation, unless the attack has come on in bed, when irregular cardiac action — " fluttering " — is common. In either case the mind becomes anxious. A sense of weakness or faintness pervades the chest and head, the extremities become chiU, and a cold sweat breaks out on the surface of the body. Presently abundant flatu- lent eructations occur ; and with these the distressing sensations, and the attack as a whole, pass away. The pain complained of by the gouty subject appears to be essentially cardiac. When fully developed it occupies the common situations of the pain in structural disease of the heart, particularly such as involves the aortic valves and the root of the aorta. It is referred to mid-sternum ; or it is a " tearing sensation at the heart." In other instances it is not a pain proper, but a sense of oppression across the chest, or a sense of tightness, or of burning like heartburn. In its full development it is anginal, and may then be accompanied by a variety of disturbances of associated parts, as we have already described. Pal- pitation occurs in different forms and at different times Chap. VIII.] IRREGULAR (iOUT. 137 in the subjects of gouty heart. Palpitation in these sub- jects may be readily induced by indigestion, and as readily relieved by eructation. In other instances of the gouty heart it is entirely absent. Faintness may be of different degrees, from simple " giddiness " to complete syncope. Respiratory disturbance and distress are prominent features of some of the acute attacks. In other instances the breathing is entirely unaffected. In a patient complaining of such symptoms physical examination of the heart generally reveals the absence of any valvular lesion. Usually there are present a feeble impulse, ill-defined limits of prsecordial dulness, feeble, dull or indefinite sounds, and no murmur. This indeter- minateness of the results of physical examination may be regarded as a characteristic of the gouty heart. The pulse is frequently irregular, sometimes intermittent. Often it is peculiarly indefinite, or indeterminate, like the prae- cordial signs. The tension is either moderate or actually low. In some instances the wall of the vessel is thickened. Anginal and pseudo-anginal attacks.— These attacks may occur either in connection with chronic gout, or as an occasional manifestation of irregular gout. True angina pectoris, associated with widespread arterial degeneration and softening of the walls of the heart, occasionally occurs in gouty subjects, the gouty condition no doubt being a powerful factor in the production of the degenerative changes leading up to the anginal attacks. Pseudo-angina pectoris unassociated with any general arterial degeneration also may occur in the gouty, and is accompanied by severe pain in the region of the heart, passing down the left arm, a feeling of suffocation, flatulency, and gastric disturbance. The toxic agents of gout acting on the walls of the heart may set up chronic myocarditis, with disease of the coronary vessels. Pericarditis is an occasional termination in cases where the gouty form of Bright's disease is developed. 138 GOUT : ETIOLOGY AND VARIETIES, [part ii. Gouty phlebitis. — This affection is a fairly common complication of chronic gout, but it may also be a phase of irregular gout. It may occur either in the veins of a portion of a limb which is the seat of gouty inflammation, or in veins quite apart from the presence of gouty inflam- mation in the vicinity. The veins of the lower extremities are most commonly affected, especially the veins of the calf. This affection is not uncommonly of prolonged duration, and is very apt to recur. In consequence of the thrombosis that ensues great care must be exercised to prevent detachment of the clot, and the consequent risk of pulmonary embolism. The oedema of the limb conse- quent on the thrombosis generally persists for some time. When the deep veins of the calf are affected, the first symptom is frequently a sudden and acute cramp-like pain, which is soon followed by deeply-seated tenderness to pressure. There is a tendency to frequent recurrences of the attacks, which are especially prone to occur when the patient is fatigued or below the usual standard of health. It is sometimes the only manifestation of gouty inheritance, but is frequently combined with other obviously gouty symptoms. There is no doubt that persons of gouty habit or an- cestry are more than commonly liable to phlebitis, and that in them the affection usually has certain distinguishing characters. To quote Sir James Paget's description : " Gouty phlebitis is far more frequent in the lower limbs than in any other part ; but it is not limited to the limb that is, or has been, the seat of ordinary gout. It affects the superficial rather than the deep veins, and often occurs in patches, affecting (for example) on one day a short piece of a saphenous vein, and on the next day another piece of the same or a corresponding piece of the opposite vein, or of a femoral vein. It shows herein an evident disposition towards being metastatic and symmetrical : characters which, I may remark by the way, are strongly Chap. VIII.] IRRECxULAR GOUT. 139 in favour of the belief that the essential and primary dis- ease is not a coagulation of the blood, but an inflammation of portions of the venous wall." 4. Ippegular g"out affecting the nervous system. — Migraine and neuralgia. — Attacks of migraine and of neuralgia not unfrequently occur in persons of gouty habits. Neuralgia is the commonest and also one of the most troublesome of gouty derangements. The fifth nerve, posterior tibial, sciatic, and occipital are the ones most frequently involved, and their derangements are liable to appear and disappear suddenly, or take the place of other manifestations of the disease. Neuritis. — Neuritis is by no means infrequent, and is probably most encountered in the third and fourth decades of life ; the symptoms are numbness, tingling, loss of power in the affected part, muscular wasting occa- sionally, and sometimes very severe pain. The sciatic nerve and the brachial plexus and its branches are most liable to this form of neuritis. The affection is probably started by a deposit of sodium biurate in the nerve-sheath setting up a perineuritis, with subsequent effusion of lymph within the sheath, and consequent compression of the nerve fibres. When this occurs in the sciatic nerve it is the cause of the severe and prolonged sciatica that some gouty subjects suffer from. In sciatica of gouty origin the affection is not always confined to the sciatic nerve alone ; frequently the crural nerve is simultaneously involved, and under certain circumstances the obturator nerve is also affected. Apart from injury, gout is undoubtedly a prominent setiological factor in the development of brachial neuritis. The neuritis may be accompanied by any of the ordinary manifestations of gout, or by any of the forms of irregular gout. The prominent symptom in every case is pain, sometimes sudden in onset, but more often slight and occasional at first and only felt on making certain move- 140 GOUT : ETIOLOGY AND VARIETIES, ipart il ments, notably those of raising the arm, but it increases and becomes more continuous with paroxysmal exacer- bations. The acute forms are probably in most cases at the outset acute inflammations of the fibrous structures of the muscles, or as the condition is aptly termed " fibro- sitis." The mischief spreads from the muscles to the sheaths of the nerves, and often to other fibrous structures in the vicinity, and when the acute condition subsides a chronic neuritis is often left. The pain is often very severe, and wasting may go on to an extreme degree ; while, on the other hand, cases occur in which the extent of the neuritis is very limited and the symptoms are slight. The duration is seldom less than three or four months, and may extend over a year or more. The older the patient the more chronic the case is likely to be, while much depends on the degree of rest which the parts obtain. Insomnia is an occasional accompaniment or mani- festation of irregular gout. This condition may be due to the ingestion of improper food, giving rise to abnormal gastric fermentation, or to hepatic derangement. In such cases it is frequently accompanied by heartburn and palpitation. Mental depression is frequently associated with gouty attacks affecting the liver, and, as a rule, is almost imme- diately relieved by a dose of blue pill at night, followed by a purge of Epsom salts in the morning. Attacks of vertigo and epilepsy are occasionally asso- ciated with the gouty state. Gouty inflammation of the meninges of the spinal cord occasionally occurs, associated with pain and tenderness over the affected area, and with pain and hyperassthesia in the lower extremities. Three cases of transient paraplegia supposed to have been due to gouty congestion of the spinal cord have been described. 5. Irregular grout affecting" the grenito-urinary system. — Gouty kidney. — It is possible that a functional affection of the kidneys may occur in connection with gout. This Chap. VIII.] IRREGULAR GOUT. 141 functional affection may subside if the exciting cause of it be removed, or it may pass on to a structural lesion, which is then of the contracted granular type. The symptoms associated with the gouty kidney so produced are those usually met with in cases of contracted granular kidney. There is increased frequency of micturition, and more than the normal quantity of urine is passed. The urine may or may not contain a small quantity of albumen. The arterial tension is increased, and this constitutes a point of great importance to be noticed, since cerebral haemorrhage, hypertrophy and dilatation of the heart, and congestion of the lungs are liable to supervene on this condition. Uric acid gravel and calculi. — These deposits frequently occur in early life among those with a gouty inheritance, and are not uncommonly followed later in life by true gouty attacks. The presence of uratic deposits in the kidney may produce a referred pain down the back and sometimes the front of the thigh. This pain may be sufficiently severe to interfere with walking, and is apt to be confounded with sciatica or rheumatism. The pain is a referred one and is dependent on the irritation pro- duced within the kidneys, which irritation is caused by uratic deposits, or by the passage of fine uric acid gravel, or occasionally by the passage of an excessive amount of uric acid, as sometimes occurs in cases of gouty diabetes. A careful examination of the urine and palpation of the kidneys will reveal the source of such referred pains. Irritability of the bladder is associated with the passage of scanty urine of high specific gravity, which yields a copious deposit of amorphous urates on cooling. Gouty orchitis and epididymitis are rare forms of irregular gout, but undoubtedly these affections occasionally occur quite independently of any urethral infection. The gouty origin is frequently shown by the rapid subsidence of the 142 GOUT : ETIOLOGY AND VARIETIES. [Part ii. orchitis and epididymitis if an attack of articular gout supervenes, and also by the successful results following treatment with colchicum. 6. Irreg-ulap gout affecting" the skin. — Gouty sub- jects are peculiarly liable to certain affections of the skin, and amongst those who have inherited a gouty tendency the skin affections may constitute the only manifestation of gout. The following are the skin affections liable to be associated with the gouty state. Eczema. — This disease of the skin more frequently occurs in association with gout than any other. It often precedes arthritic gout, and may even occasionally be the sole manifestation of gout. It may assume either the acute or chronic form, and generally occurs symmetrically on both sides of the body. It is most prone to occur in spring, and is very apt to recur. Gouty eczema occurs most frequently in the following situations, viz. the external ear and around it, the face and forehead, the back of the neck, the flexures of the joints, the scrotum and prepuce, the backs of the hands and feet, the interdigital surfaces, and more rarely the arms, legs, and trunk. Some authorities have doubted whether there is such a disease as a gouty eczema pure and simple, but it is a common experience, in my practice, to find that eczema is very prone to occur among the gouty. Among the descendants of gouty ancestors, I frequently find that certain members suffer from recurring attacks of eczema, while others suffer from regular gout. Again, with some individuals it is not uncommon to find attacks of eczema alternating with attacks of articular gout, or to find that an attack of eczema subsides with almost startling rapidity when an attack of true gout supervenes, or vice versd. It is true that it is impossible to diagnose a gouty eczema at sight, but a careful inquiry into the patient's history, and into the family history, makes the diagnosis, in my opinion, in many cases a certainty. Chap. VIII.] IRREGULAR GOUT. 143 Herpes is not unfrequently met with in association with gout. Pruritus and prurigo occasionally occur in gouty sub- jects, especially in connection with gouty glycosuria. Pruritus is generally localised, and especially affects the arms and the vulva ; occasionally it is general. Urticaria sometimes occurs as a result of the gouty state. For a long time, and by many authorities in this country, psoriasis has been regarded as to a great extent a mani- festation of the " gouty diathesis." My experience, how- ever, is that psoriasis is not met with more frequently among gouty individuals than among the non-gouty, and I am strongly of opinion that no such entity as a gouty psoriasis exists. Pospeloff has observed a macular form of gouty skin eruption. The latter can be seen in three different stages. The first stage consists of disseminated, rusty brown, irregular or dendroid spots, which do not disappear on pressure and are seen chiefly on the shins. Under suit- able treatment, and often without it, these spots disappear, but are observed again with each fresh attack of gout. If the original disease persists, owing to the patient's habits, the second stage of the eruption occurs, which consists of bluish-violet spots in addition to those of a rusty brown colour. The spots do not disappear on pres- sure with the finger, thus indicating an effusion of blood into the skin and cellular tissue. As the blood collects under the horny layer of the epidermis the latter gets soaked and separated, and forms a series of large scales with tooth- like margins of the macerated white horny layer. A micro- scopical examination of an excised piece of skin by direct and by polarised light shows that the violet-coloured and rusty red spots are due not only to a deposit in the corium of blood pigment, but also of sodium biurate and of crystals of uric acid. If the gout increases a general erythema 144 GOUT: ETIOLOGY AND VARIETIES, [part ii. of the affected limb occurs ; the reddened skin becomes shiny, sloughs in places, and ulcers are formed ; this con- stitutes the third stage of these gouty skin lesions. 7. Irregular grout affecting" the eye and ear.— Gout certainly plays an important part in eye affections, although in only a few cases have definite deposits of sodium biurate been found in the conjunctiva or elsewhere. Conjunctivitis, episcleritis, sclerotitis, iritis, and irido- cyclitis are the most common forms of gouty eye affections, and they are all extremely liable to recur. Gouty sub- jects are more prone than others to suffer from glaucoma, and cases of hsemorrhagic retinitis and optic neuritis of gouty origin have been described. Gout may be a cause of ear diseases, especially in causing earache at night and tinnitus aurium. Mirk has recorded deposits in the tympanic membrane, and he is of opinion that some cases with subjective noises are due to gouty deposits in the labyrinth. Gout is also said to exercise considerable influence in the development of exostoses in the external auditory canal. Occasionally a gouty neuritis affecting the terminations of the auditory nerve causes deafness. 8. Other irregular gout affections. — Glycosuria and diabetes. — The development of glycosuria or diabetes in persons of gouty ancestry is undoubted. The glycosuria is in all probability frequently hepatic in its origin. Glycosuria is generally associated with some form of irregular gout, and but seldom with the ordinary articular gout, but very occasionally it alternates with true gouty attacks, and then, while the glycosuria lasts, the patient is quite free from articular gout, and vice versa. The glycosuria may at first be very slight, but if not checked by proper dietetic treatment it may lapse into true diabetes. With regard to the prognosis in gouty diabetes, much depends on the manner in which the affection responds to dietetic treatment. If the sugar in the urine quickly chap.vui., irregular gout. 145 disappear, and if several months elapse before its reappear- ance, then the prognosis is fairly good, and life may con- tinue for many years. Hepatic congestion. — A condition of congestion of the liver, or possibly of subacute parenchymatous hepatitis, popularly known as " gout in the liver," is occasionally met with in gouty subjects, or in those who have inherited a gouty tendency. Pains in the head, chest, abdomen, joints, and other parts, lasting for a few minutes to some hours or even two or three days, are frequently gouty in origin. At times it is difficult to recognise them as forms of irregular gout, but a careful inquiry into the family history and the habits of the patient will often settle the question. Such pains occurring in one who inherits from his family a gouty tendency, or who eats and drinks too much, and at the same time takes too little exercise, are generally indicative of a gouty origin. During the past few years I have noticed in several cases of so-called " hay-fever " a gouty tendency under- lying the local affection. Such cases resisted cure until, in addition to local treatment, attention was paid to the gouty condition, especially with regard to the dietary. These observations confirm those of Karl Grube, who states that in all cases which were treated successfully by him such gouty tendency could be traced to be under- lying the local affection. He also points out the fact that hay-fever, like gout, is more common in England than in any other country. Sir Dyce Duckworth, too, has also noticed the connection between gout and hay-fever. Retrocedent or metastatic gout. — This form of gout occurs when a sudden subsidence of the inflammation in a gouty joint is succeeded by the development of the disease in one or more of the internal viscera, such as the stomach, intestines, heart, or liver. Persons subject to retrocedent gout are generally in a debilitated condition, and of feeble 146 GOUT: .ETIOLOGY AND VARIETIES. [Part ii. constitution. The attacks frequently follow an exposure to cold while suffering from an articular attack, and especially after indiscretion in diet. Attacks of retrocedent gout have also not uncommonly followed the extremely baneful practice of suddenly plunging a gouty foot into cold water. If the attacks rapidly shift their position the affection is termed flying gout. It is quite possible that attacks of retrocedent gout are caused by a deposition of the crystalline sodium biurate in the affected viscus, and that this crystal- line biurate acts as a mechanical irritant, and so produces inflammation of the organ. On the other hand, these attacks may simply be of nervous reflex origin, due to vaso-motor disturbance producing a condition of hyper- aemia or congestion of the affected viscus. The following are the principal forms of retrocedent gout, with the symp- toms indicative of the sudden transference of the attack to the affected viscus. Retrocedent gout of the stomach. — The symptoms are severe pain in the stomach, accompanied usually by vomit- ing and a feeling of general oppression, depression, and faintness. Palpitation may occur. Retrocedent gout of the intestines. — The usual symptoms are severe abdominal pain, vomiting, tympanites, and constipation. Retrocedent gout of the heart. — The symptoms are severe palpitation, pain in the region of the heart, a sensation of constriction of the chest, dyspnoea, a small feeble pulse, and great anxiety. Syncopal attacks may occur. Retrocedent gout of the brain. — Apoplexy is the most frequent symptom. Congestion of the brain or meninges may occur, and may be followed by headache, stupor, convulsions, delirium, and occasionally by maniacal attacks. Transient attacks of aphasia, amnesia, and hemiplegia some- times occur, and are probably due to congestion of the brain. Gouty orchitis and -parotitis of metastatic origin have occasionally been known to occur. CHAPTER IX. DIFFERENTIAL DIAGNOSIS. Differential diagnosis of chronic diseases of the joints — Forms of rheumatoid arthritis — Distinction of gout from rheumatoid arthritis — Distinction of gout from rheumatism — Distinction of gout from various diseases of the joints — Prognosis in gout. Differential diagnosis of chronic diseases of the joints. — The recognition of acute gout is a very easy matter, but the distinction of chronic gout from other chronic diseases of the joints is often a matter of considerable difficulty ; a difficulty which is not diminished by the general desire on the part of our patients to have a dis- ease labelled with some distinctive title. There is much looseness in the diagnosis, and consequently in the treat- ment, of joint affections, due to a great extent to the descrip- tions of joint diseases in text-books not being up to date with the advances of scientific knowledge as to their mode of origin and pathology. Perhaps the best classification of joint diseases is that of Bannatyne, who divides them into three great classes : — (i) the bacterial or toxic arthro- pathies ; (2) the nerve arthropathies ; and (3) the senile degenerative arthropathies. To this division I would add a fourth class — viz. those due to interference with the nutrition of the joints by circulatory changes, such as occur in Raynaud's disease. The term toxic is not meant to be confined to the products of bacterial activity only, but includes those arising from the tissues themselves, or by chemical processes, such as the toxic substance or substances causing gout. 147 148 GOUT : ETIOLOGY AND VARIETIES. [Part ii. Another classification of arthritic cases is into (i) the essential arthropathies — i.e. those in which the joint troubles form the principal or prominent sj^mptom of the disease, such as gout, rheumatism, rheumatoid arthritis, and senile arthritis ; and (2) the accidental arthropathies — i.e. those which, although they may occur in the course of a disease, yet are not essential symptoms of that disease, such as gonorrhoeal, scarlatinal, malarial, tuberculous, syphilitic, pneumococcic, and nerve arthropathies. With regard to the bacterial arthropathies, considerable discussion has arisen as to whether the bacteria or their products are the cause of the symptoms. I think that the balance of evidence is strongly in favour of the joint troubles being due to the micro-organisms themselves, since the micro-organisms of rheumatism, gonorrhoea, pneumonia, and possibly rheumatoid arthritis, have been found in the joint structures and joint fluids. Moreover, in those cases where operative treatment of the joints has been resorted to, the rapid subsidence of the symptoms points to the joints being the seat of bacterial infection, rather than to their being affected by toxic products elaborated elsewhere. Certainly it may be accepted that infection plays a most important part in the production of joint diseases, while a general defect of nutrition underlies many, if not all, of the chronic forms of arthritis. Unfortunately, the term rheumatism has been applied with too much looseness and too generally. Now that it is known that acute rheumatism is itself an infective disease, it is recognised that many cases of arthritis which have been termed rheumatism certainly belong to the infective class. I propose first to consider the differential diagnosis of the three forms of chronic joint disease that are most frequently met with, that are most apt to be confounded, and that therefore offer the principal difficulties in diagnosis — viz. gout, rheumatoid arthritis, and rheumatism. The differential diagnosis of these diseases is a very important Chap. IX.] RHEUMATOID ARTHRITIS. 149 matter, and it is all the more important to direct attention to such diagnosis, because undoubtedly in the past many cases of rheumatoid arthritis have escaped recognition, and have been' diagnosed either as rheumatism or as gout. When it is considered that tlie treatment of these three diseases is quite different, the necessity for a correct diag- nosis is manifest. It is probable that many cases which are diagnosed as chronic rheumatism of the joints are not chronic rheumatism at all ; many of them are cases of rheumatoid arthritis, and a fair number are cases of gout. I believe chronic rheumatism of the joints — chronic arthritic rheumatism — to be a comparatively rare affection ; at any rate, it is not very frequently met with. Cases are frequently diagnosed as cases of chronic rheumatism, in which there are great deformities of the joints, lipping of the cartilages, osteophytic outgrowths, and grating of the ends of the bones. Those are cases of rheumatoid arthritis. In chronic rheumatism, neither lipping of the cartilages nor the osteophytic outgrowths which are so diagnostic of rheumatoid arthritis ever occur. Rheumatoid arthritis — The term "rheumatoid ar- thritis " is objectionable, as suggesting a causal con- nection with rheumatism. If, however, it is employed and understood as merely meaning an arthritis somewhat resembling some forms of rheumatism, the term may be retained, although the name "arthritis deformans" is less open to objection. I propose, however, to retain the term " rheumatoid arthritis," owing to its long usage, as I am afraid that the description of that disease under another and less recognised name may lead to confusion. By rheumatoid arthritis I mean the disease known as " arth- ritis deformans," or " polyarthritis deformans," or " rheu- matic gout." I think that very often the unfortunate name of " rheumatic gout," as applied to rheumatoid arthritis, is a cause of the two conditions being confused. Certainly it is a name which covers a multitude of sins 150 GOUT: ETIOLOGY AND VARIETIES, [part ii. and errors in diagnosis, and it is a term which ought to be abandoned. The cases hitherto grouped together as rheumatoid arthritis undoubtedly include more than one disease. I should define true rheumatoid arthritis as a progressive degeneration of the joints, consisting of changes in the synovial membranes, cartilages, and bones, accompanied by atrophy of some structures and by hypertrophy of others. In chronic cases marked osteophytic outgrowths are peculiar to this disease. Heberden, in 1804, was one of the first to distinguish between this disease and rheu- matism. He pointed out that there was swelling of the affected joint, but little or no fever, no great pain, and no redness of the skin ; that the disease generally attacked joint after joint, and that it was very crippling ; that the fingers and wrists were especially liable to the disease, and that the terminal phalangeal joints of the fingers were liable to become affected with nodosities, which have since become known as " Heberden's nodes." The disease occurs in acute, subacute, and chronic forms. The chronic form may be chronic from the first, or may be secondary to an acute or subacute attack. The acute and subacute forms are characterised by inflammatory changes in the affected joints, by erosion of cartilages and bones, by nerve and trophic phenomena, and by glan- dular enlargement. It is polyarticular, and in its acute and subacute forms occurs especially in children and young adults. The disease usually commences in one joint, commonly one of the metacarpo-phalangeal articulations, and then rapidly spreads to most of the other joints. The symmetrical nature of the affection is usually well marked, and the joints are painful, hot, and present a spindle- shaped enlargement, but no outgrowth or thickening of either cartilage or bone during the acute stage. The chronic forms are characterised by progressive thickening and hardening of all the joint structures, by the formation Chap. IX. RHEUMATOID ARTHRITIS. . 151 of osteophytes, by the lipping of cartilages, and by the development of deformities. The disease may affect several joints, or be confined to one or two. It most commonly occurs in middle life, and in females. Com- paratively slight injuries of a joint, especially of a small joint, may lead to rheumatoid arthritis, and to an extension of the process to other joints in a symmetrical order. The injuries are frequently the outcome of exces- sive work and strain, especially in elderly and enfeebled persons with a diminished power of resistance, increasing with years and with imperfect nutrition. The three divisions of the disease proposed by Charcot constitute the generally adopted classification of the forms of rheumatoid arthritis for a study of their symptoms. They are (i) cases with Heberden's nodes ; (2) the general progressive form ; and (3) the partial or monarticular form. This last-mentioned monarticular form is, however, in my opinion, an absolutely distinct disease from rheuma- toid arthritis, and I shall describe it later among the senile arthropathies. I. Cases with Heberden's nodes. — These cases represent the mildest degree of the disease. The nodes consist of httle hard swellings of the finger joints, affecting almost entirely the terminal phalangeal, and are due to a very chronic form of rheumatoid arthritis. This type is more commonly met with in women than in men, and usually at or after the middle period of life. The nodules are due to enlargement of the ends of the bones, which are frequently covered by a pouch of the projecting synovial membrane, which acts somewhat as a bursa. The joints become swollen and tender. The cartilages are softened, and the ends of the bones are eburnated. The enlarge- ments are osseous in character, but there may be a certain amount of increase of the periarticular fibrous tissues. After a time the disease usually becomes arrested, but the swelHngs remain, and eventually may cause no 153 GOUT : ETIOLOGY AND VARIETIES, [part ii. discomfort. Treatment cannot produce any diminution in size of the bony growths, but may effect a decrease in size of the periarticular tissues referred to. Heberden's nodes are frequently associated with some uterine disturbance. Heberden, in his original paper, particularly noted the fact that the thirty-three cases he described occurred only in women, and in women of middle age. This form of rheumatoid artliritis touches a point of age beyond which the influence of the sexual system is likely to be much diminished, and there is un- doubtedly a direct connection between it and uterine troubles associated with the climacteric. The affection is not commonly very progressive, and never reaches to much deformity ; but, on the other hand, there is no .retrocession of the chronic arthritis. The uterine troubles and the active affection of the joints subside together. Apart from Heberden's nodes, other forms of chronic arthritis are frequently associated with and determined by uterine and ovarian troubles. It has for some time been held that the joint troubles are due to reflex trophic influence, the excessive uterine irritation being reflected from the spinal cord to the joints ; but I cannot help thinking that a more probable explanation is that the diseased uterus becomes the channel by which an infective or septic arthritis, generally leucorrhoeal in origin, is started in the joints. In a similar way a chronic urethral and prostatic affection in men, quite apart from gonorrhoea, may give rise to a chronic arthritis ; such an arthritis may also be started by the use of an imperfectly clean catheter. I have had under me in the course of the past twelve years six cases of severe chronic arthritis, indistinguishable from rheumatoid arthritis, in which the disease followed the removal of both ovaries. Whether in these cases the disease occurred in consequence of the removal of the ovaries, or in association with the diseases requiring their removal, I am unable to say. Chap. IX.] RHEUMATOID ARTHRITIS. 153 2. The general progressive form. — Of this there are two varieties — the acute and the chronic. The acute form has been previously referred to. It may resemble, and certainly has been mistaken for, acute articular rheumatism. It generally starts in one joint, and subsequently involves many. There is not much redness of the affected joints, and only moderate fever. It is most common in young adults and young women. Among the last-mentioned it is often connected with recent delivery, rapid child-bearing, or excessive lactation. Rheumatoid arthritis certainly occurs in children, but very rarely, and even more rarely than the joint disease described by Still, to which refer- ence will presently be made. The chronic form is much commoner than the acute. The joints that have been most especially and actively used, according to the former occupation or employment of the patient, are those which usually show the first signs of the disease. The affection commences with slight swelling and pain on movement. The amount of effusion into the joint is variable, and may be marked or slight. The hands and feet, especially the hands, are most liable to be first affected, and the disease then tends to advance more or less up the limbs towards the trunk, obeying, as Charcot described, " the centripetal law." In extreme cases every joint in the body may be affected. The tem- poro-maxillary articulation becomes the seat of rheumatoid arthritis in about 25 per cent, of the total number of cases. At a later period the articulations of the spine may become involved. The disease usually attacks the cervical vertebrae first, causing pain at the back of the neck, and rendering flexion of the neck and rotation of the head difficult. The dorsal and lumbar vertebrae may be next affected, so that in bad cases the spine may be converted into a rigid column. Pain may be very severe, especially at night ; while, on the other hand, the case may proceed to extreme deformity without pain. 154 GOUT: ETIOLOGY AND VARIETIES, [part n. Very considerable alterations in the shape of the joints may occur from the formation of osteophytes, thickening of the capsules, and retraction of muscles. The cartilages become worn away at the centres, and the ends of the bones become eburnated by attrition and chronic osteitis. In such joints grating is readily obtained by rubbing the eburnated ends of the bones against each other. The locking of the joints, which sometimes ultimately occurs, is not due to true ankylosis, but to the presence of the projecting osteophytes, and to the thickening of the capsules of the joints. True ankylosis only occurs in the spinal column in cases of rheumatoid arthritis. Atrophy of the muscles from disuse is present in bad cases, with contractures tending to flex the thigh or to bend the knee or elbow. There is usually some increase of myotatic irritability, as shown by some exaggeration, frequently but slight, of the knee-jerks. Most patients finally reach a stage in which the disease becomes arrested, so that they are free from pain, and only are troubled with the associated crippling and consequent inconvenience. Rheumatoid arthritis is nearly always associated with a certain amount of anaemia, the patients presenting a sallow appearance. Increased rapidity of the heart's action is a not uncommon accompaniment of the disease in its earlier stages, and cold and moist hands and feet are commonly met with. Subcutaneous fibroid nodules and periosteal nodes are occasionally present, especially in those cases which are secondary to rheumatism ; and a rheumatoid pigmentation of the skin, somewhat resem- bling freckles in appearance, is not unfrequently seen, but is especially present in the acute stage. In a small proportion of cases a neuritis is present, but it probably is always secondary to the arthritis, and may be caused, as suggested by Bannatyne, either by the existing joint inflammatory process, or by the action of toxins circulating in the blood. Spender describes the following collateral Chap, ix] RHEUMATISM. 155 symptoms, one or more of which are commonly present, as aids to diagnosis in doubtful cases : — (i) tachycardia ; (2) pigmentation of the face, and perhaps numerous spots or stains on the arms ; (3) cold and moist hands ; (4) neuralgic twinges in the upper and lower limbs ; (5) per- sistent neuralgic pain over the ball of the thumb and on the ulnar side of the wrist. Rheumatism. — Rheumatism is a disorder which gener- ally manifests itself as acute rheumatism or rheumatic fever ; but in the chronic condition, although it generally manifests itself as an arthritic disorder — that is to say, a disorder affecting the joints — it may not manifest itself that way at all : it may simply show itself by the pro- duction of chorea, or by the production of erythema, or by the production of fibrous nodules, or by the production of endocarditis or pericarditis. Therefore rheumatism is a disorder which does not necessarily show itself as a joint affection ; it may become manifest in some other way. In other words, there is the articular chronic rheumatism and there is the abarticular chronic rheumatism — such as the choreic and erythematous forms. As an assistance in the diagnosis of a chronic articular affection, there is a rough but fairly sure test which is frequently of assistance in diagnosis : it is treatment with salicylate of soda. If the case responds well to this treatment, it is a case of rheumatism. If it does not respond to this treatment, the existence of rheumatoid arthritis or gout is fairly certain, as neither of these affections responds well to salicylates. When I hear the remark about " an obstinate case of rheumatism which has not done well with salicylates," I feel fairly sure that it is a case of gout or of rheumatoid arthritis — more probably the latter. Very many of the cases diagnosed as chronic rheumatism are cases of rheumatoid arthritis, or gout, or some form of infective arthritis or arthropathy. Though much less frequent than is generally supposed, 156 GOUT: .ETIOLOGY AND VARIETIES. [Parx ii. chronic rheumatic affections of the joints do occur, but they never produce that permanent deformity which the other affections may, especially the lipping of the cartilages and the bony outgrowths already referred to. These chronic rheumatic affections of the joints are generally accom- panied by the formation of fibrous nodules over the tendons, by the development of extra-articular fibrous thickening, by the presence of subcutaneous fibres, fibrous nodules (especially on the fingers, elbows, and head), and not un- frequently by the indication of valvular disease of the heart. There is generally a well-marked history of rheu- matism, and the disease is identical with that described as " chronic fibrous rheumatism." It must not be con- sidered that the subcutaneous fibrous nodules occur only in connection with rheumatism. They are fairly frequently seen in cases of rheumatoid arthritis, and less frequently in gout, syphilis, influenza, and other diseases. It should be carefully remembered that chronic rheu- matism is not associated with the formation of bony or cartilaginous deposits in the joints. It shows little sym- metry, and is usually associated with rheumatic pains shifting about from one place to another. It never affects the temporo-maxillary joints. As regards the actual diagnosis of rheumatism, it is usually fairly easy. If a patient complains of pains in the joints, which pain flies about from joint to joint, and generally affects some of the muscles at the same time, and if, in connection with these flying pains, there are indications of the presence of the rheumatic erythema — erythema nodosum — then the diagnosis of rheumatism is obvious. As a rule, the fitful way in which the joints are affected, the fairly rapid subsidence of the swellings of the joints, and the asso- ciation of muscular pains, make the diagnosis a simple matter. Then the response of the disease to treatment by salicylates will settle the diagnosis. The absence of bony thickening and of bony grating distinguishes the Chap, ix] GOUT AND RHEUMATOID ARTHRITIS. 157 disease from rheumatoid arthritis, and in addition the finger-joints are much less frequently affected. Differential diag'nosis of grout and rheumatoid arthritis. — These are the two chronic joint diseases which are most frequently confounded. The following distinguishing characters show how very different the two diseases are. In the first place, rheu- matoid arthritis occurs most commonly in females ; gout occurs mostly in males. Rheumatoid arthritis occurs more commonly amongst the poor and ill-nourished ; gout mostly among the well-to-do and well-nourished. Rheu- matoid arthritis is a disease which is improved by good dieting ; in the case of a gouty person a spare and plain diet is indicated. The onset of rheumatoid arthritis is insidious ; that of gout sudden and obvious. As regards the commencement of the attack, gout most commonly begins in one of the feet, especially in the great toe joint ; rheumatoid arthritis, although ultimately it frequently affects many joints of both hands, nearly always begins in one joint, most commonly selecting one of the joints of the thumb, either the carpo-metacarpal or metacarpo-phalangeal joint, after which it rapidly spreads to the other joints. Then as regards the appearance : in the case of rheumatoid arthritis there is no obvious swelling at first, and no marked redness. In the case of gout, at its commencement there is very obvious swelling, marked redness, and a shiny condition of the skin around the affected joint. In rheumatoid arthritis there is very little pain at first. There is some aching in the joint, but it starts in a very insidious manner. It is this insidious character of the disease which is one of its bad features, for the patients do not seek advice until the affection is fairly advanced. Gout, however, begins in the most marked manner with severe pain, the patient as a rule waking up in the early morning with excruciating pain in the great toe. There- fore, if there is doubt as to whether a particular case is 158 GOUT: .ETIOLOGY AND VARIETIES, [part ii. one of rheumatoid arthritis or of gout, the patient should be questioned as to the commencement of the attack, in order to ascertain whether it began with an obvious out- burst of pain, and with sweUing and redness of the joint, or whether it began very insidiously. Then as to the joint affections : apart from what has been stated as to gout generally beginning in the foot, and rheumatoid arthritis generally in the hand, there is one joint commonly affected in rheumatoid arthritis which is not affected in cases of gout — that is the temporo-maxillary articulation. I have never seen a case of gout in which the temporo-maxillary joint has been affected, whereas in rheumatoid arthritis it is fairly common for that joint to be affected. In rheumatoid arthritis there is a special liability to the affection of the joints of the cervical vertebrae, as evidenced by pain and stiffness at the back of the neck. This is a most useful distinguishing sign. Another dis- tinction is this — and it is perhaps one of the most important distinctions — that in connection with rheumatoid arthritis there is a remarkable symmetry in the affection of the smaller joints of the hands. In gout that symmetry is wanting. It was this symmetrical affection of the joints which led to the idea — which I believe to be absolutely erroneous — that rheumatoid arthritis is a nervous disease. Lastly, in a case of rheumatoid arthritis sodium biurate is found neither' in the joints nor in the blood, whereas in the gouty person sodium biurate exists both in the joints and in the blood. It is not common to get rheumatoid arthritis and gout associated in the same individual. Undoubtedly rheuma- toid arthritis may supervene in joints which have been the seat of any acute infective arthritis. Any affection which impairs the nutrition or weakens the resistance of joints offers a suitable condition for the development of rheu- matoid arthritis. Hence rheumatoid arthritis may follow such diseases of the joints as acute rheumatism, gout. Chap. IX.] STILL'S DISEASE. 159 gonorrhoeal arthritis, etc. This is the only sense in which such diseases are related to rheumatoid arthritis, in that they have by impairment of the joint structures so lowered the vitality as to render the joints more liable to the invasion of the micro-organism or toxin of rheuma- toid arthritis. On the other hand, a person suffering from rheumatoid arthritis, who indulges in rich living for a lengthened period of time, and especially if he takes much wine, may develop gout, and so gouty deposits in the joints of a patient suffering from rheumatoid arthritis may occasionally be met with. This, however, is only a com- plication ; there is no actual relationship between the two conditions, and one disease does not, in the strict sense of the term, predispose to the other. A form of chronic joint disease in children de- scribed by Still. — This is a disease closely resembling the rheumatoid arthritis of adults, and which until recently was always considered to be identical with rheumatoid arthritis, but which, as pointed out by Still, presents such marked differences as to suggest that it has a distinct pathology. The disease consists of a chronic progressive enlarge- ment of joints associated with enlargement of glands and enlargement of the spleen. The onset, which is usually insidious, almost always occurs before the second dentition, and girls are more commonly affected than boys. The enlargement of the joints is smooth and fusiform, and feels like a general thickening of the tissues around the joint, with none of the bony irregularities of the rheumatoid arthritis of adults. There is no redness, and as a rule no tenderness of the joints ; and, although creaking is fre- quently present, there is never any of the bony grating so commonly present in true rheumatoid arthritis, since in this disease there is a complete absence of the cartilaginous changes so characteristic of the latter disease. Limitation of movement, chiefly of extension, is almost always present. i6o GOUT: ETIOLOGY AND VARIETIES, [part ii. There is an absence of the extensive deformities of the hands so frequently present in the rheumatoid arthritis of adults. The affection is symmetrical. The joints earliest affected are usually the knees, wrists, and those of the cervical spine ; the ankles, elbows, and fingers are subsequently affected. There is no tendency to suppuration nor to bony ankylosis. One of the most distinctive features is the affection of the lymphatic glands. The enlargement is general, but affects primarily and chiefly those related to the joints affected. The enlargement of the spleen is roughly proportionate to that of the glands, but does not extend to more than half-an-inch to one inch below the costal margin. The heart shows no evidence of valvular disease. Sweating is often profuse, and a certain amount of pyrexia, generally recurrent in character, may be present. The disease is usually accompanied by a general arrest of bodily development. The disease is not in itself fatal, but, after running a slow course, the joint disease becomes permanently stationary. The four important points in the differential diagnosis of this disease from rheumatoid arthritis are (i) the enlarge- ment of the glands ; (2) the enlargement of the spleen ; (3) the peculiar appearance and feel of the joints, with the absence of bony grating on manipulation, and the absence of osteophytic outgrowths ; and (4) the fact that the disease begins nearly always in the knees or wrists, and affects the fingers much later, whereas rheumatoid arthritis in adults affects the small joints of the hands early, and frequently commences in them. Senile arthropathies. — Senile arthritis in the great majority of cases affects only one joint, usually the hip or shoulder. Occasionally it occurs in the spinal column. This is the form of arthritis frequently known as the monarticular form of rheumatoid arthritis, but it should be regarded as a local degeneration, progressive in its nature. It is, I believe, an entirely different disease from Chap. IX.] GONORRHCEAL ARTHRITIS. i6i rheumatoid arthritis, and is probably not microbic in origin. In the hip the disease is known as " morbus coxae seniHs," and in the spine it is known as " spondyhtis deformans." It occurs in elderly people, and is in the majority of cases started by some local injury, and is common in old persons who have had to carry heavy weights, or who make ex- cessive use of their lower limbs in the course of their occu- pation. The arthritis is persistent, and, if not suitably treated, progressive. Grating is nearly always present, with muscular wasting, shortening of the limb, and limita- tion of movement accompanied by pain. On deep pres- sure over the affected joint pain is always ehcited. The synovial membrane of the joint shows chronic inflammatory changes, along with destruction of cartilages and softening of the articular ends of the bones. The last-mentioned condition is in marked contrast to the eburnation of the ends of the bones in cases of rheumatoid arthritis. Gonorrhoea! arthritis.— This form of arthritis is also known as " gonorrhoeal rheumatism," a term which should be abandoned as being misleading in its character. It is always secondary to a gonorrhceal attack elsewhere. This attack is generally in the urethra, but is not necessarily so, as some cases have followed infection of the conjunctiva. The arthritis is due to the presence of the gonococcus in the joints. It usually appears at the decline of the urethritis, or even when this appears to be cured. It is not, there- fore, directly proportional to the acuteness of the urethritis. It rarely develops before the third week, and its advent may be postponed for several months after the onset of the gonorrhoea. Time is required for the gonococci to reach the glandular tissues of the prostate, whence they are enabled to enter the circulation. This form of arthritis is most liable to affect the larger joints, especially the knees ; the joints that may also be affected are the ankles, elbows, small joints of the feet, shoulders, wrists, small joints of the hands, and the sterno-clavicular joints. I. i62 GOUT: ETIOLOGY AND VARIETIES, [part ii. The disease is apt to be mistaken for subacute rheu- matism, but it may be differentiated by the comparative absence of temperature, and by the non-reaction of the affection to sahcylates. As a rule the diagnosis is rendered easy by the presence of a gonorrhoeal discharge, but this is apt to be overlooked in women, on account of the fre- quency of a leucorrhoeal discharge. The actual condition of gonorrhoeal arthritis may be one of synovial effusion, or it may be limited to thickening of the joint capsule and of the periarticular tissues. If neglected, suppuration may occur in the joint. A form of infective arthritis which is somewhat akin to gonorrhoeal arthritis is that accompanying ophthalmia neonatorum. Rapid recovery always follows on fixation of the affected limb and local treatment of the ophthalmia. Two other forms of septic or infective arthritis somewhat resembling gonorrhoeal arthritis are those which occasion- ally occur in connection with profuse leucorrhoeal dis- charges, and in connection with bronchiectasis. Arthropathies due to infective fevers. — In this chapter I am dealing only with the chronic forms of arthritis, but it is necessary to refer briefly to the forms of arthritis which may occur in connection with any of the infective fevers. As generally seen, these are forms of acute arthritis, but occasionally they persist for a long time, and so become cases of chronic arthritis. These forms of arthritis have been known to occur in connection with scarlet fever, pneumonia, malaria, septicaemia, pyaemia, enteric fever, Maltese fever, measles, influenza, dysentery, glanders, erysipelas, etc. It is, however, only within the last few years that the joint troubles that occasionally occur in the course of the specific diseases have come to be regarded as due to the micro-organisms or poisons of the respective diseases. Formerly they were looked on as manifestations of true rheumatism occurring during the course of the disease. All these forms of arthritis are especially liable Chap, ix.i INFECTIVE ARTHRITIS. 163 to occur in a joint or joints which have been previously damaged, either by disease or by mechanical injury. Scarlatinal arthritis. — This is, perhaps, the best known type of arthritis met with in the various infective diseases. The elbows and knees are the joints most frequently affected ; the smaller joints of the upper extremities follow next. Pneumococcic arthritis. — The occurrence of arthritis during an attack of pneumonia has long been known, but until comparatively recently it was generally ascribed to a concurrent attack of rheumatism, and was not directly connected with the attack of pneumonia. A strong tendency to ankylosis is one of the special characteristics of an in- fective arthritis. Previous damage to a joint, as by injury, rheumatism, or gout, favours the localisation of pneumo- coccic arthritis. The influence of injuries in predisposing joints to attacks of infective or septic arthritis should be carefully borne in mind, as otherwise cases which are really those of infective arthritis may be considered simply traumatic in origin, and so the possibly necessary operative treatment of the joint may never be considered. Malarial arthritis. — The parasite, although different in its life history from a bacterium, yet from the point of view of causation of arthritis may be considered as such. Malarial arthritis due to the parasite is a comparatively rare affection, but rheumatoid arthritis coincident with a malarial attack is not by any means uncommon. Quiet elTusion into knee-joints.— This affection was first described by Sir Wilham H. Bennett, and was stated by him to occur only in girls and women, and to be always associated with menstrual irregularity or uterine trouble. It occurs mainly at the time of puberty, and at the climacteric. A similar condition has, however, been observed in males. The affection consists of a passive effusion into the joint, and rarely occurs in any other joint than the knee. It is unattended by pain, and a large number i64 GOUT: ETIOLOGY AND VARIETIES, [part ii. of the patients are unaware of its existence, unless attention is called to it accidentally. It is best recognised when the patient is standing in the upright position, when the fluid sinks to the lower part of the joint cavity, and sometimes forms a pouch-like overhanging of the synovial membrane at its lower anterior aspect. Attention is generally called to the condition by a slight injury, such as a twist or fall. The joints of the two sides are usually involved at the same time, but the effusion is, as a rule, much more marked on one side than on the other, that on the right side being generally the greater. Nerve deg^enerative arthropathies. — These are joint affections that occur in tabes, ataxy, paraplegia, progressive muscular atrophy, etc. The joint troubles are due to abnormal trophic influences started by affections of the central nerve organs, as the result of which inflammatory troubles, generally of a very chronic nature, are set up, characterised by alterations in the ends of the bones, ulceration of cartilages, and formation of fibrous adhesions. Of all the chronic joint affections these are perhaps the easiest of diagnosis, on account of their association with an easily recognisable disease of the nervous system of a degenerative nature. Tuberculous disease. — The history of the case, both family and personal, is of great assistance in making a diagnosis in this form of joint disease. The swelling is frequently spindle-shaped. When the disease is advanced the joint is in a condition of organised fibrous tuberculosis, and consequently nothing of diagnostic value is to be made out by radiographs. Syphilitic joint disease. — This is commonly chronic. There is effusion with thickening of the capsules of the medium-sized and larger joints, with occasional bony thickening and lipping of the smaller joints, which may at times closely simulate rheumatoid arthritis. The pres- ence of a gumma, and of old iritis and other indications Chap. IX.] DISEASES OF JOINTS. 165 of syphilis, will frequently assist in making a correct diag- nosis. A form of joint disease occurring in the later stages of syphilis has been described by Whitfield, which presents many resemblances to a joint recovering from acute gout. The joint is considerably swollen, the surface shiny, the skin being of a dark red colour, with distended veins cross- ing over the joint. As a rule, it is exquisitely tender to the touch. The diagnosis is, as a rule, rendered easy by the discovery of a periosteal gumma over one of the bones. The joint disease itself is undoubtedly gummatous in nature, the gummatous infiltration starting in the liga- ments and periarticular tissues. Pulmonary osteo-arthropathy. — This is a rare dis- ease. It is secondary to some chronic pulmonary disease, such as phthisis, empyema, and chronic bronchitis. The. disease may possibly be tuberculous, or be due to some toxic agent. It is characterised by considerable enlarge- ment of the hands, wrists, feet, and ankles. It is apt to be mistaken for acromegaly, but may be distinguished by the clubbing of the finger ends and the enlargement of the wrists, which conditions are absent in acromegaly. Joint changes in Raynaud's disease. — The joints are much thickened ; they present little indication of fluid distension of the cavities ; there is a good deal of thicken- ing of the bone, and considerable pain and tenderness. The condition is apt to be mistaken for rheumatoid arthritis, but the diagnosis is rendered easy by .the association with the circulatory changes accompanying Raynaud's disease. Distinction of so-called chronic rheumatism (flbro- sitis) from gout. — Many cases of so-called chronic rheu- matism are frequently confounded with gout. These are cases in which the essential pathological change is an in- flammatory hyperplasia of the white fibrous tissue in various parts of the body, to which the term " fibrositis " has been very aptly applied. The articular structures proper — synovial membrane, cartilage, and bone — are not i66 GOUT: .ETIOLOGY AND VARIETIES. [Part ii. primarily affected, but the parts implicated are the fibrous tissues of the joints, muscles, and bones, especially the aponeuroses and insertions of the muscles, fasciae, the fibrous ligaments of the joints, and the periosteum. Such affections cause pain and stiffness in these structures, are especially apt to recur, and are commonly referred to as rheumatic or even gouty in their origin. This inflammatory hyperplasia of the fibrous tissues occurs in patches, and is started by exposure to wet or cold, by injury, or by some irritant, microbic or toxic, conveyed in the blood. The inflamed and swollen fibrous tissue is tender, painful on pressure or on movement, and can frequently be felt on palpation, or is evident by the consequent elevation of the skin. This fibrositis may completely disappear, but recur- rences are common, and if not suitably treated the thickened fibrous tissue remains as indurations at various parts. The indurations may be widespread but generally are well defined, and vary in size from an eighth of an inch to one inch in diameter. They may be situated in the sub- cutaneous tissue, the muscles, tendons, aponeuroses, and periosteum. The pain is especially aggravated by any sudden movement of the muscles which compresses or stretches the affected fibrous tissues and the sensory nerve filaments. The muscle-spindles, which lie between the bundles of muscular fibres and in the fibrous tissue of the muscle, and each one of which receives one or more narrow muscular fibres, and two or more nerve-fibres, are the only sensory structures in muscle, and it is through them that the pain of so-called muscular rheumatism is felt. Owing to direct pressure of a fibrous nodule on a nerve, or to the involvement of the nerve in the nodule, the pain may be felt over an extensive area, or even be referred to a part of the body which is not the seat of the fibrositis. Etiology. — Local fibrositis may result from several causes, of which the following are the commonest : — (i) Cold, damp, and wet. — In a very large number of Chap, m FlBRQSlTlS. 167 cases the only assignable cause of the fibrositis is a history of exposure to cold and wet. Sometimes the attack comes on acutely a few hours after the exposure, as in many cases of lumbago, stiff neck, intercostal " rheumatism," and other forms of so-called muscular " rheumatism." At other times stiffness gradually develops after the exposure, and passes on to the condition of chronic fibrositis generally known as chronic rheumatism. The exposure may be due to draughts, remaining in wet clothes, lying or sitting on damp ground or some cold substance, or the simple advent of damp or cold weather. Many persons are readily affected by the approach of rain, and by a lowering of the barometric pressure. Longstreth states that the painful symptoms do not correspond to rain, but to the fall of barometric pressure, and Stockman suggests that possibly the atmospheric changes may increase or lessen the lymph-pressure in the body, and so increase or lessen the tension in the affected fibrous tissues. A very common cause of lumbago from exposure to a local draught is sitting on a draughty privy or water-closet ; this, no doubt, accounts for the prevalence of that affection in rural districts, combined with the constant strain of the lumbar muscles, amongst so many agricultural labourers. (2) Extremes of heat and cold. — Sudden and considerable variations in temperature constitute by no means an un- common cause of a generalised fibrositis which takes the form of so-called " muscular rheumatism," following on the resulting chill. One of the severest cases of fibrositis (muscular rheumatism) that I have ever seen was the case of a stoker who after working during very hot weather in the engine-room of a steamer on the Red Sea went straight to the refrigerating chamber of the steamer in order to cool himself. The result was a very severe attack of in- flammation of the fibrous tissues over practically the whole of the body, which absolutely prostrated him, and from which he made a very tedious recovery. i68 GOUT : ^ETIOLOGY AND VARIETIES, [pari il (3) Local injuries. — These are responsible for a large number of cases of local fibrositis, so-called " local rheu- matism." The injury is generally caused by muscular over- exertion, such as the strain of lifting a heavy weight, the strain exerted in certain muscles in order to save a sudden fall, and the excessive muscular strain that an athlete may put forth. Golf produces a number of such injuries, the fibrous tissue of the muscles of the arms and back and their attachments being specially affected in this game. If the individual has previously suffered from fibrositis which has not been completely cured, or which has left some fibrous nodules, a comparatively slight wrench may be sufficient to start the aching in the affected part. (4) Absorption of irritating toxins from the gastro-intestinal tract. — It has long been recognised that disorders of the stomach or bowels may give rise to " rheumatic " pains. The aching in the joints and the lumbar region that occa- sionally occurs the day after a lengthy dinner, especially if several wines have been indulged in, is due to irritation of the fibrous tissues by the toxins absorbed from the intestinal tract, and which have been produced there by abnormal fermentation. This pain, whether in the joints or the lumbar region, which follows excessive indulgence at the table is generally attributed to gout, and, as a rule, the champagne, claret, or port is blamed for it. I am convinced, however, that this articular or muscular pain has, in the great majority of cases, no relation whatever to gout, and that it is simply an indication of an inability of the gastro-intestinal tract to deal properly with the various articles introduced into it. (5) Tonsillitis and -pharyngitis. — The aching pains that occur in various parts of the body in connection with these affections are well known, and are doubtless due to toxic absorption and consequent irritation of the fibrous tissues. Chap. IX.] MUSCULAR RHEUMATISM. 169 (6) Influenza. — The majority of us are probably person- ally acquainted with the aches and even severe pains in the muscles, joints, and bones which accompany this disease. These are in all probability due to the librositis set up by the specific microbe or its toxin. It is not uncommon to find fibrous nodules and thickenings left as sequeke of this disease. (7) Fehricula. — A " feverish cold " is generally accom- panied by aching pains in the muscles, joints, and bones. The attack, which is sometimes described as a " rheumatic cold " or an " influenzal cold," is probably microbic in its origin, and the pains are, no doubt, due to irritation of the fibrous tissues by the microbe or its toxin. Various forms of fibrositis. — Muscular rheumatism. — This affection is always a fibrositis. Any of the muscles may be affected. Affection of the muscles of the lumbar region constitutes one of the forms of lum- bago ; affection of the muscles of the neck constitutes stiff neck ; affection of the deltoid muscle consti- tutes " deltoid rheumatism ; " affection of the inter- costal muscles constitutes " intercostal rheumatism." Tlae pain at first is generally dull, but in anything like severe cases soon becomes sharp and shooting, and is aggravated by damp weather. It is usually worse when the patient becomes warm in bed, and is generally felt severely on waking in the morning and on rising from bed. Brachial fibrositis is especially apt to be of long duration, and inter- feres with sleep on account of the difficulty of getting the arm into an easy position. To some extent it wears off with exercise or on rubbing the affected parts. It is always accompanied by a feeling of stiffness. Lumbago. — This is a very typical form of fibrositis. As just mentioned, it may be an affection of the fibrous elements of the lumbar muscles, but more commonly it starts as a localised affection of the insertions of the muscles in the vicinity of one or both of the sacro-iliac joints. It 170 GOUT : ETIOLOGY AND VARIETIES. [Parx n. spreads by continuity of the fibrous tissue, as is manifested by its affecting the tendinous attachments of the neigh- bouring muscles, by its affecting the sacro-ihac joint itself, and by its often spreading through the joint and reaching the sheath of the sciatic nerve. This explains the very frequent association of some degree of sciatica with an attack of lumbago. It is astonishing to find in a very large number of cases of lumbago that a careful examination of the back reveals no pain or tenderness on pressure over the various muscles, but that as soon as one or both sacro-iliac joints are pressed upon, acute pain is complained of and the patient refers his appreciation of the pain to that region. I am convinced that in the majority of cases of lumbago the affection is not in the quadratus lumborum, nor even in the deeper muscles of the back, but is in the fibrous tissues directly over the sacro-iliac joint, and in the joint itself. The production of the pain of lumbago is usually sudden, the patient frequently ascribing it to a sudden strain or rick, especially on rising in the morning, but although the production of the pain is generally sudden, yet the condition on which it depends has been gradually developed. Rheumatic neuralgia. — This is a fibrositis of the nerve- sheaths, and is a common cause of sciatica, especially accom- panying lumbago of the sacro-iliac joints. The affected nerve is painful on pressure or when stretched. The symptoms are numbness, tingling, " pins and needles," and pain, all of which are due to slight compression of the nerve. Dupuytren's contraction. — This is a localised fibrositis caused by habitual postural use of the hand. It is frequently ascribed to gout, but, according to my experience, the con- dition has no connection with that disease. Certainly I have never seen any gouty deposits in the thickened tissues, nor is the affection commoner amongst gouty subjects. Chap. IX.] PROGNOSIS. I7I Prognosis in g-out.— If no complications arise, if the attacks are not too frequent, and if no serious amount of albuminuria occurs, the disease is not likely materially to shorten life, especially if the patient is amenable to proper treatment and discipline. PART III INVESTIGATIONS OF CERTAIN POINTS CONNECTED WITH THE TREATMENT OF GOUT. CHAPTER X. SOLUBILITY OF SODIUM BIURA.TE. Influence exerted by the mineral constituents of meat, milk, and vegetables respectively on the solubility of sodium biurate — Relative effects exerted by the mineral constituents of various vegetables on the solubility of sodium biurate — Influence exerted by the mineral constituents of various vegetables in retarding the conversion of sodium quadriurate into sodium biurate — The vegetables most beneficial to gouty subjects. It is well known that the excessive consumption of rich nitrogenous food, combined with excesses in wine and malt liquors, both induces and excites gout. The com- parative immunity of females and young people from gout is mainly explained by the absence of such determining causes of the gouty attack, combined with, in the case of young people, the absence of predisposing cause, and also the fact that the secreting functions are in full activity. The subjects of gout are generally persons who live well and consume a large amount of animal food. Budd, speaking from a long and extensive professional con- nection with a large rural district, states that he never knew an instance of gout occurring among agricultural labourers. Though uric acid is not the primary cause of gout, 172 CAr.x.] VEGETABLE ASHES. 173 yet its deposition as sodium biurate and its subsequent absorption are materially influenced by various conditions. As it is quite possible that the different saline constituents of animal and vegetable foods might very materially affect the solubility of sodium biurate and therefore influence its precipitation, I thought it advisable to ascertain if the saline substances contained in different articles of diet appreciably affected the solvency of sodium biurate at the temperature of the human body, as obviously the subject might have both a pathological and therapeutical bearing. The following experiments were therefore carried out. Influence of the mineral constituents of meat, milk, and vegretables respectively on the solubility of sodium biurate at 100*^ F. — A series of experiments was under- taken, operating upon the ash respectively of lean beef, milk, and mixed vegetables (potatoes, spinach, and French beans). The experiments were carried out in the following manner : — The contents of a number of bottles, each containing 100 c.c. of distilled water, were mixed with known quantities of the different ashes and placed in the warm chamber until their contents were at a temperature of 100° F., when an excess of sodium biurate was added to each. The bottles were kept at 100° F. for five hours, during which period they were frequently agitated. At the end of that time the contents of the bottles were filtered and refiltered through double filters until perfectly clear filtrates were obtained. The arnount of uric acid in each of the filtrates was then estimated by adding an excess of strong sulphuric acid, and titrating with the standard potassium permanganate solution ; the quan- tity of uric acid found was subsequently calculated into terms of sodium biurate. The results thus obtained are shown in the following tables. The solubility of sodium biurate in distilled water is placed at the head of each table for comparison. 174 GOUT: INVESTIGATIONS. [Part III. TABLE XVI. Showing the influence of the mineral constittients of meat {lean beef) on the solubility of sodium biurate at ioo° F. Solvent. Water Water containing- i.o per cent, of meat ash . 0.5 0.2 o. I 0.05 0.02 O.OI Sodium biurate dissolved. 1 . 10 per 1,000 0.93 0.76 0.56 0.32 0.15 O. II 0.85 From the above table it is seen that the mineral con- stituents of meat, in all proportions between i.o and o.oi per cent., diminish the solvency of sodium biurate. The effect is most marked when the proportions are between o.i and 0.02 per cent., which are proportions that may certainly be present in the blood after eating a few ounces of meat. It is therefore quite possible that the well- known influence of excessive meat-eating on the hastening or maturing of an attack of gout may, in part at least, be due to the action of the mineral constituents of the meat. TABLE XVII. Showing the influence of the mineral constituents of milk on the solu- bility of sodium biurate at 100° F. Solvent. Water Water containing- i.o per cent, of milk ash 0.5 0.2 0.1 0.05 0.02 0.01 Sodium biurate dissolved. 1 . 10 per 1,000 0.62 0.58 0.49 0.44 0.72 0.90 ,, 0.94 Chap. X.] VEGETABLE ASHES. 175 The foregoing table shows that the mineral consti- tuents of milk in all proportions diminish the solvency of sodium biurate. The effect is most marked when o.i per cent, of milk ash is present. It is extremely unlikely that such a proportion could be present in the blood un- less a person were exclusively fed for some time on milk. To introduce o.i per cent, of the mineral constituents of milk into the blood would require that all the mineral constituents of about twenty-two ounces of milk should be introduced at one moment into the blood of an adult of average weight. These experiments therefore seem to indicate that the mineral constituents of milk can exer- cise no appreciable influence in hastening or maturing an attack of gout. TABLE XVIII. Showing the influence of the mineral constituents of vegetables {potatoes, spinach, and beans) on the solubility of sodium biurate at 100° F. seven.. ^tTjiT' Water T . 10 Der 1. 000 Water containing — i.o per cent, of vegetable ash 0.5 0.2 ,, ,, O.I 0.05 0.02 O.OI ,, 2.15 1.70 1-35 1. 15 1. 10 1. 10 1. 10 From Table XVI I L it is seen that the mineral consti- tuents of vegetables in quantities of 0.1 per cent, and above very appreciably increase the solvency of sodium biurate. In quantities below 0.1 per cent, the solutions exercise the same solvent power on the biurate as distilled water. These experiments indicate that the mineral con- stituents of vegetables, if taken in sufficient quantities, would increase the solvency of sodium biurate, and would also exert a solvent effect on gouty deposits. 176 GOUT: INVESTIGATIONS. [Partiii. From the results of these prehminary experiments it appears probable that if the mineral constituents of vegetables were present in sufficient quantities in the fluids of a gouty person, they would not only increase the solu- bility of the sodium biurate present in these fluids, but would also, by their increased solvent effects on uratic deposits, facilitate the removal of the latter. I have therefore carried out a long series of experiments with the mineral constituents of all the vegetables in ordinary use, in order to elucidate the two following points : — (i) The relative effects exerted by the mineral constituents of various vegetables on the solubility of sodium biurate at the temperature of the human body, and therefore presumably on uratic deposits ; and (2) the influence, if any, exerted by these constituents in retarding the conversion of the sodium quadriurate into the sodium biurate. Obviously the elucidation of these points would have a material bearing on the treatment of gout.* The solvent effects exerted by the mineral con- stituents of various veg-etables on sodium biurate. — The method of carrying out these experiments was similar to that previously described. I operated separately on the mineral constituents of certain vegetables, viz. Spinach, Brussels sprouts, potato, asparagus. Savoy cab- bage, French beans, lettuce, beetroot, winter cabbage, celery, turnip tops, turnip, carrot, cauliflower, seakale, and green peas. The results obtained are shown in the following sixteen tables, which are arranged in the order of the average solvent effect exerted by the mineral con- stituents of the various vegetables, commencing with those exercising the greatest influence. The solubihty of sodium biurate in distilled water is placed at the head of each table for comparison. * The results of these experiments were first communicated to the Royal Medical and Chirurgical Society of London in a paper read on June 14th, 189S. Chap. X.J VEGETABLE ASHES. 177 TABLE XIX. Showing the infltience of the mineral constituents of spinach on the solubility of sodium biurate at 100° F. Solvent. Sodium biurate dissolved. Water 1 . 10 per 1,000 1 . per Water containing — cent, of spinach ash .... .S..36 0.5 2.76 0.2 2. 12 0. 1 I .90 0.05 1.52 0.02 I. 21 O.OI I. 18 TABLE XX. Showing the influence of the mineral constituents of Brussels sprouts on the solubility of sodium biurate at 100° F. Solvent. Water Water containing — ■ i.o per cent, of Brussels sprouts ash 0.5 0.2 o. I 0.05 0.02 O.OI Sodium biurate dissolved. 1 . 10 per 1,000 3.06 2.21 1.68 1 .62 1.52 1.30 1.23 TABLE XXI. Showing the influence of the mineral constituents of potato on the solubility of soditim biurate at 100° F. Solvent. Water Water containing- i.o per cent, of potato ash 0.5 0.2 o. I 0.05 0.02 O.OI Sodium biurate dissolved. 1 . 10 per 1,000 2.49 2. 17 92 47 36 12 10 178 GOUT: INVESTIGATIONS. [Part III. TABLE XXII. Showing the influence of the mineral constituents of asparagus on the solubility of sodium hiurate at 100° F. Solvent. Sodium biurate dissolved. Water 1 . 10 2.77 2.09 1.58 1.45 1-33 1. 12 1 .10 per 1,000 Water containing — 1.0 per cent, of asparagus ash . 0.5 0.2 0.1 0.05 ,, ,, 0.02 ,, ,, 0.01 ,, ,, TABLE XXIII. Showing the influence of the mineral constituents of Savoy cabbage on the solubility of sodium biurate at 100° F. Solvent. Sodium biurate dissolved. Water I . 10 per 1,000 Water containing — 1.0 per cent, of Savoy cabbage ash . 2.32 0.5 92 0.2 77 0.1 S7 0.05 34 0.02 ,, ,, 13 0.01 ID TABLE XXIV. Showing the influence of the mineral constituents of French beans on the solubility of sodium biurate at 100° F. Solvent. Sodium biurate dissolved. Water I. ID 2.48 1.87 1.68 1.56 1.28 1. 16 1. 10 per 1,000 Water containing— 1.0 per cent, of French beans ash 0.5 0.2 0.1 0.05 0.02 o.oi ,, ,, Chap, X.] VEGETABLE ASHES. 179 TABLE XXV. Showing the influence of the mineral constituents of lettuce on the solubility of sodium biurate at 100° F. Solvent. Water Water containing- i.o per cent, of lettuce ash 0.5 0.2 o. I 0.05 0.02 O.OI Sodium biurate dissolved. I . 10 per 1,000 .72 .92 •57 •53 .21 . ID .09 TABLE XXVI. Showing the influence of the mineral constituents of beetroot on the solubility of sodium biurate at 100° F. Solvent. Sodium biurate dissolved. Water Water containing — i.o per cent, of beetroot ash .... I . 10 2.46 per 1,000 0.5 0.2 82 60 0.1 0.05 0.02 45 34 15 O.OI 10 TABLE XXVII. Showing the influence of the mineral constituents of winter cabba^ on the solubility of sodium biurate at 100° F. Solvent. Sodium biurate dissolved. Water Water containing — 1.0 per cent, of cabbage ash 0.5 0.2 0.1 0.05 0.02 O.OI „ 1 . 10 2.30 2.14 1.63 I-3I 1.23 1 . 10 1 . 10 per 1,000 GOUT: INVESTIGATIONS. [Part III. TABLE XXVIII. Showing the inflvience of the mineral constituents of celery on the solubility of sodium biurate at ioo° F. Solvent. Water Water containing- o per cent, of celery ash . 5 2 I O o O. I 0.05 0.02 O.OI Sodium biurate dissolved. I . 10 per 1,000 2.20 1.84 1-53 1.44 1.30 1 . 10 1 .06 TABLE XXIX. Showing the influence of the mineral constituents of turnip tops on the solubility of sodium biurate at 100° F. Solvent. Water Water containing — - i.o per cent, of turnip tops ash 0.5 0.2 o. I 0.05 0.02 O.OI Sodium biurate dissolved. 1 . 10 per 1,000 2.16 1.82 1.58 1.42 ,, 1.20 I -13 I . II TABLE XXX. Showing the influence of the mineral constituents of turnips on the solubility of sodium biurate at 100° F. Solvent. Sodium biurate dissolved Water Water containing- i.o per cent, of turnip ash . 0.5 0.2 o. I 0.05 0.02 O.OI 1 . 10 per 1,000 2.04 1.78 1.50 1.42 1-32 1. 14 Chap. X.] VEGETABLE ASHES. I5I TABLE XXXI. Showing the influence of the mineral constituents of carrot on the solubility of sodium biurate at ioo° F. Sodium biurate dissolved. Solvent. Water Water containing— I . o per cent, of carrot ash 0.5 0.2 0. 1 0.05 0.02 O.OI 1 . 10 per 1,000 63 53 47 45 3?) 13 II TABLE XXXIL Showing the influence of the mineral constituents of cauliflower on the solubility of sodium biurate at 100^ F. Solvent. Water Water containing — • i.o per cent, of cauliflower ash 0.5 0.2 o. I 0.05 0.02 O.OI Sodium biurate dissolved. 1 . 10 per 1,000 52 50 42 34 28 09 09 TABLE XXXIII. Showing the influence of the mineral constituents of seakale on the solubility of sodium bivirate at 100° F. Solvent. Sodium biurate dissolved. Water 1 . 10 per 1,000 1-49 Water containing — 1.0 per cent, of seakale ash 0.5 1-47 0-2 1-35 o-i 1-23 0.05 1 . 10 0-02 1 . 10 O.OI 1. 10 l82 GOUT: INVESTIGATIONS. [Part IIL TABLE XXXIV. Showing the influence of the mineral constituents of green peas on the solubility of sodium hiurate at ioo° F. Solvent. Water Water containing — i.o per cent, of green peas ash 0.5 0.2 o. I 0.0s 0.02 ,, O.OI Sodium biurate dissolved. 1 . 10 per 1,000 0.99 1 .01 1 .04 1 . 10 1 . 10 1 . 10 1. 10 From the results detailed in these tables it is evident that 0.05 per cent, and over of the mineral constituents of nearly all the vegetables very appreciably increases the solubility of sodium biurate. The solitary exception is in the case of the mineral constituents of green peas, which practically exert no influence whatever on the solubility of the biurate. As I considered that these solvent effects of the mineral constituents of most vegetables on the biurate might have some bearing on the treatment of gout, I next en- deavoured to ascertain whether these effects were due to the alkalinity of the vegetables ashes, or whether they could be referred to any one saline constituent of the vegetables. Experimental proof that the solvent effects of the mineral constituents of vegetables on sodium biurate are not due to their degree of alkalinity. — That the solvent effect exerted respectively by the mineral consti- tuents of each vegetable on the sodium biurate was not proportional to the alkalinity of the ash was very easily determined. I made estimations of the alkalinities of the different vegetable ashes, and calculated the percentages of alkalinity in terms of sodium carbonate. The alkalinity Chap. X.] VEGETABLE ASHES. 183 of the ashes was due to potassium and sodium carbonates ; none of the ashes contained either potassium or sodium hydrate. The following table shows a comparison of the solubility exerted by the mineral constituents of vegetables on sodium biurate, and the alkalinity of those constituents : — TABLE XXXV. Showing that the solvent effect on sodium biurate of the rnineyal con- stituents of vegetables is not dependent on the alkalinity of those constituents. Vegetables arranged in order of solvent effect of their mineral con. stituents on sodium biurate. Commenc- ing with those exert- ing the greatest effect. Spinach Brussels sprouts Potato Asparagus Savoy cabbage French beans Lettuce Beetroot Cabbage Celery- Turnip tops Turnip Carrot Cauliflower Seakale Green peas Vegetables arranged in order of the alkalinity of their ashes, and showing percentages of alkalinity- reckoned as sodium carbonate. Commencing with the most alkaline. Spinacli 26.00 Celery 20.80 Turnip 20.80 Potato 17-55 Beetroot 1 5 • 60 Cauliflo-wer 13-20 Carrot 1 3 - 00 Brussels sprouts 12.35 French beans 12.35 Turnip tops 1 1 . 70 Lettuce ir.05 Asparagus 8-45 Cabbage 5-85 Green peas 5 • 20 Savoy cabbage 4-55 Seakale 1.95 It is evident from a glance at this table that the solvent effect of a vegetable ash on sodium biurate, with the ex- ception of spinach ash, bears no relationship, either of a direct or an inverse ratio, to the alkalinity of the ash. For instance, it can be seen that the solvent effect on the biurate of the ash of Brussels sprouts is high, while its i84 GOUT: INVESTIGATIONS. [partHl alkalinity is low ; on the other hand, the solvent effect on the biurate of the ash of celery is low, while its alkalinity is high. In other words, it is evident that the order in which the vegetables are arranged as regards the solvent effect of the mineral constitu- ents . on the biurate is neither the order nor the inverse order of their relative alkalinities. These results support the conclusions I arrived at from some experiments made with blood serum, and described in the " Goulstonian Lectures " of 1897. I then showed that a diminution in the alkalinity of blood serum did not cause a diminution in the solvent power of the serum for biurate, and, conversely, that an increase in the alka- linity of the serum did not increase its solvent power for the biurate. Experimental proof that the solvent effects of the mineral constituents of vegetables on sodium biurate are not due to any single constituent. — The next problem to solve was whether the effect exerted by the mineral constituents of vegetables in increasing the solubility of sodium biurate is due to any one constituent. With regard to this point, it appeared probable beforehand that such would not prove to be the case, since Sir William Roberts had shown that sodium, calcium, and magnesium salts diminish the solvent power of water on sodium biurate, and that potassium salts exercise no influ- ence, one way or the other, on the solubility of the biurate. Now it can easily be demonstrated that the solvent effect is not due to the potassium salts. The next table contains a comparison of the solvent powers exerted by the mineral constituents of vegetables on sodium biurate, and the proportions of potassium salts present. C..AP.X.] POTASSIUM SALTS IN VEGETABLES. 185 TABLE XXXVI. Showing that the solvent effect on sodium biurate of the mineral con- stituents of vegetables is not dependent on the amounts of potassium salts present. Vegetables arranged in order of solvent effect Vegetables arranged in order of the proportions of of their mineral con- potassium salts present, and showing tlie )er- stituents on sodium centages of potassium salts present in the ashes, biurate. Commenc- reckoned as potassium oxide. Commencing with ing with those exert- those richest in potassium salts. ing the greatest effect. Spinach Potato 56 03 Brussels sprouts Turnip • 54 05 Potato Carrot 53 2^ Asparagus Lettuce . . 48 01 Savoy cabbage French beans - 46 50 French beans Asparagus 39 21 Lettuce Green peas . 38.96 Beetroot Beetroot . 38 22 Cabbage Cabbage . 27 71 Celery Brussels sprouts 35 00 Turnip tops Celery 23 14 Turnip Turnip tops . 30 55 Carrot Savoy cabbage 26 82 Cauliflower Cauliflower . ^2 46 Seakale Spinach . 23 43 Green peas Seakale . 2 59 It is evident from this table that the solvent effect of the mineral constituents of vegetables on sodium biurate bears no relationship, either of a direct or an inverse ratio, to the proportions of potassium salts present. For in- stance, it can be seen that the solvent effect on the biurate of the ash of spinach is high, while the proportion of potas- sium salts is low ; on the other hand, the solvent effect on the biurate of the ash of turnips is low, while the pro- portion of potassium salts is high. It can also be demonstrated that the increased solubility of the biurate effected by the mineral constituents of vegetables is not due to the sodium salts. Table XXXVII. contains a comparison of the solvent powers exerted by i86 GOUT: INVESTIGATIONS. [Part III. the mineral constituents of vegetables on sodium biurate, and the proportions of sodium salts present. TABLE XXXVII. Showing that the solvent effect on sodium biurate of the mineral con- stituents of vegetables is not dependent on the amounts of sodium salts present. Vegetables arranged in order of solvent effect of their mineral con- stituents on sodium biurate. Commenc- ing with those exert- ing the greatest effect. Spinach Brussels sprouts Potato Asparagus Savoy cabbage French beans Lettuce Beetroot Cabbage Celery Turnip tops Turnip Carrot Cauliflower Seakale Green peas Vegetables arranged in order of the proportions of sodium salts present, and showing the percentages of sodium salts present in the ashes, reckoned as sodium oxide. Commencing with those richest in sodium salts. Seakale 33-84 Spinach 3 1 • 42 Beetroot 31 -17 French beans 30.50 Celery 19-33 Asparagus 16.79 Carrot 14 -17 Savoy cabbage 13-86 Brussels sprouts 12.60 Lettuce 1 1 . 80 Cauliflower 10.87 Turnip 6- 37 Green peas 5 - 20 Turnip tops 4- 19 Cabbage 2.39 Potato 2.18 This table shows that the solvent effect of the mineral constituents of vegetables on sodium biurate bears no relationship, either of a direct or an inverse ratio, to the proportions of sodium salts present. For instance, it can be seen that the solvent effect on the biurate of the ash of potato is high, while the proportion of sodium salts is low ; on the other hand, the solvent effect on the biurate of the ash of seakale is low, while the proportion of sodium salts is high. In like manner it can be demonstrated that the increased solubility of the biurate effected by the mineral constituents chap.x.] calcium salts in vegetables. 187 of vegetables is not due to the calcium salts. The following table contains a comparison of the solvent powers exerted by the mineral constituents of vegetables on sodium biurate, and the proportions of calcium salts present : — TABLE XXXVIII. Showing that the solvent effect on sodium biurate of the mineral con- stituents of vegetables is not dependent on the amounts of calcium salts present. Vegetables arranged in order of solvent effect of their mineral con- stituents on sodium biurate. Commenc- ing with those exert- ing the greatest effect. Spinach Brussels sprouts Potato Asparagus Savoy cabbage French beans Lettuce Beetroot Cabbage Celery Turnip tops Turnip Carrot Cauliflower Seakale Green peas Vegetables arranged in order of the proportions of calcium salts present, and showing the percentages of calcium salts present in the ashes, reckoned as calcium oxide. Conunencing with those richest in calcium salts. Turnip tops 37 • 1 5 Seakale 27.56 Cauliflower 23.33 French beans 17-48 Cabbage 17 -14 Lettuce 15.02 Savoy cabbage 14-83 Turnip 13.38 Celery 13 -06 Spinach 10.64 Carrot 6.88 Brussels sprouts 6.16 Potato ........ 5.46 Asparagus S-^S Green peas 4-98 Beetroot 2.58 It is clear from this table that the solvent effect of the mineral constituents of vegetables on sodium biurate bears no relationship, either of a direct or an inverse ratio, to the proportions of calcium salts present. For instance, it can be seen that the solvent effect on the biurate of the ash of potato is high, while the proportion of calcium salts is low ; on the other hand, the solvent effect on the biurate of the ash of seakale is low, while the proportion of calcium salts is high. Similarly it can be shown that the increased solvent GOUT: INVESTIGATIONS. [Part III. effect on the biurate exerted by the mineral constituents of vegetables is not due to either the magnesium or iron salts present. It can also be demonstrated that the increased solu- bility of the biurate is not due to the phosphates present in the vegetables. The following table contains a com- parison of the solvent powers exerted by the mineral con- stituents of vegetables on sodium biurate, and the pro- portions of phosphates present : — TABLE XXXIX. Showing that the solvent effect on sodium biurate of the mineral con- stittients of vegetables is not dependent on the amounts of phos- phates present. Vegetables arranged in order of solvent effect Vegetables arranged in order of the proportions of of their mineral con- phosphates present, and showing the percentages stituents on sodium of phosphates present in the ashes, reckoned as biurate. Commenc- phosphoric anhydride. Commencing with those ing with those exert- richest in phosphates. ing the greatest effect. Spinach Green peas 35-62 Brussels sprouts Cauliflower . 22. 14 Potato Asparagus 21.93 Asparagus Potato . . 15-99 Savoy cabbage Carrot 15.02 French beans Celery 14-39 Lettuce Brussels sprouts 14.20 Beetroot Savoy cabbage 13-19 Cabbage French beans 12.21 Celery Cabbage . 11.99 Turnip tops Lettuce . 9.62 Turnip Turnip 9.26 Carrot Spinach . 8.56 Cauliflower Beetroot . 8.25 Seakale Seakale . 8.00 Green peas Turnip tops . 6.15 It is manifest from this table that the solvent effect of the mineral constituents of vegetables on sodium biurate bears no relationship, either of a direct or an inverse ratio, to the proportions of phosphates present. For instance, it can be seen that the solvent effect on the biurate of the ClIAP. X.] SULPHATES IN VEGETABLES. 189 ash of spinach is high, while the proportion of phosphates is low ; on the other hand, the solvent effect on the biurate of the ash of green peas is low, while the proportion of phosphates is high. It can also be demonstrated that the increased solu- bility of the biurate is not due to the sulphates present in the vegetables. The following table contains a com- parison of the solvent powers exerted by the mineral constituents of vegetables on sodium biurate, and the proportions of sulphates present : — TABLE XL. Showing that the solvent effect on sodium hiurate of the mineral con- stituents of vegetables is not dependent on the amounts of sulphates present. Vegetables arranged in order of solvent effect Vegetables arranged in order of the proportions of of their mineral con- sulphates present, and showing the percentages stituents on sodium of sulphates present in the ashes, reckoned as biurate. Commenc- sulphuric anhydride. Commencing with those ing with those exert- richest in sulphates. ing the greatest effect. Spinach Seakale . 19-78 Brussels sprouts Turnip tops 15.27 Potato Cauliflower . 14. 16 Asparagus Savoy cabbage . 12.85 Savoy cabbage Turnip 12.47 French beans Brussels sprouts 8.31 Lettuce Cabbage . 7.28 Beetroot French beans 6.82 Cabbage Potato . . . 5.60 Celery- Asparagus 5 -40 Turnip tops Carrot 5.20 Turnip Spinach . . 4.44 Carrot Green peas . 4-36 Cauliflower Lettuce . 3-92 Seakale Beetroot 2.41 Green peas Celery 1. 10 This table makes it evident that the solvent effect of the mineral constituents of vegetables on sodium biurate bears no relationship, either of a direct or an inverse ratio, to the proportions of sulphates present. For instance, it igo GOUT: INVESTIGATIONS. [Part III. can be seen that the solvent effect on the biurate of the ash of spinach is high, while the proportion of sulphates is low ; on the other hand, the solvent effect on the biurate of the ash of seakale is low, while the proportion of sulphates is high. Finally, as disposing of all the mineral constituents of any importance in vegetables, it can be demonstrated that the increased solubility of the biurate is not due to the chlorides present in the vegetables, as seen in the following table : — TABLE XLI. Showing that the solvent effect on sodium biurate of the mineral con- stituents of vegetables is not dependent on the amounts of chlorides present. Vegetables arranged in order of solvent effect of their mineral con- stituents on sodium biurate. Commenc- ing with those exert - Vegetables arranged in order of the proportions of chlorides present, and showing the percentages of chlorides present in the ashes, reckoned as chlorine. Commencing with those richest in chlorides. ing the greatest effect. Spinach Celery 22.14 Brussels sprouts Beetroot 18.13 Potato Seakale . 15.46 Asparagus Cabbage . 9.09 Savoy cabbage Lettuce . 8.80 French beans Spinach . 7.78 Lettuce Savoy cabbage 7-53 Beetroot Turnip tops 7-3Z Cabbage Asparagus 6.62 Celery Turnip 5.06 Turnip tops Cauliflower . 4-83 Turnip Carrot 3-70 Carrot Brussels sprouts 3.00 Cauliflower Potato . . 2.50 Seakale French beans 2.50 Green peas Green peas , 2. 10 From this table it is clear that the solvent effect of the mineral constituents of vegetables on sodium biurate bears no relationship, either of a direct or an inverse ratio, to the proportions of chlorides present. For instance, it can be seen that the solvent effect on the biurate of the chap.x] artificial and natural ash. 191 ash of Brussels sprouts is high, while the proportion of chlorides is low ; on the other hand, the solvent effect on the biurate of the ash of seakale is low, while the propor- tion of chlorides is high. These results collectively show that the solvent effect exerted on sodium biurate by the mineral constituents of vegetables is not due to any one constituent. Experimental proof that an artificially prepared ash does not react to sodium biurate in the same manner as a natural vegretable ash.— I next endeavoured to ascertain whether an artificially prepared ash of the same composition as the natural ash of one of the vegetables would exercise a similar effect in increasing the solubility of the sodium biurate to that possessed by the natural ash. For this purpose I selected the spinach ash, which has the greatest solvent effect on the biurate. An artificial ash was prepared, which was made with the same propor- tions of potassium, sodium, calcium, sulphates, phosphates and chlorides as those present in the natural spinach ash, and also of precisely the same degree of alkalinity. Ex- periments were carried out with this artificial ash and the biurate in a similar manner to that employed in working with the natural vegetable ashes. The following table shows the results of these experiments : — ■ TABLE XLII. Showing the influence of artificial spinach ash on the solubility of sodium biurate at 100'' F. Solvent. Water Water containing — i.o per cent, of artificial spinach ash 0.5 0-2 0.1 0-05 0.02 „ O.OI Sodium biurate dissolved. 1 . 10 per 1,000 0.20 0.34 0.62 0.86 0.96 1 .04 1 .06 192 GOUT: INVESTIGATIONS. [Part III. These results are very remarkable, as they indicate that the artificial ash exercises in all proportions a deterrent effect on the solubility of the biurate. This deterrent effect is well seen by contrasting the results with those of the natural ash, which show the marked solvent effect exerted by the latter on the biurate. TABLE XLIII. Shoiving the different influences exerted by artificial and by natural spinach ashes on the solvency of the biurate at 100° F. Solvent. Water Water containing- i.o per cent, of ash 0.5 0.2 0.1 0.05 0.02 O.OI Sodium biurate dissolved in 1,000 parts. Artificial spinach ash. 0.20 0.34 0.62 0.86 0.96 1 .04 1 .06 Natural spinach ash. 2.76 2. 12 1 .90 1.52 1 .21 1. 18 The only explanation that I can offer of these remark- able results is that in the natural ash there is some com- bination of the mineral constituents which cannot be arti- ficially imitated, and that upon this natural combination of the salts is dependent the increased solvent effect exerted on the biurate by the mineral constituents of most vege- tables. If this view be correct, then modern science is but confirming the correctness of the practice of those ancients who employed vegetable ashes in the treatrhent of gout. It is well to make here a brief reference to the experi- ments previously described, which show that the mineral constituents of meat exercise a marked deterrent effect on the solubility of sodium biurate ; and that this effect Chap. X.] VEGETABLES AND GOUT. 193 is most marked by proportions of the mineral constituents which may certainly be present in the blood after eating a few ounces of meat. The following table shows in con- trast the effects exercised respectively by the mineral constituents of lean beef and spinach on the solubility of the biurate. TABLE XLIV. Showing the respective effects exercised by the mineral constituents of beef and spinach on the solubility of sodium biurate at 100° F. Solvent. Sodium biurate dissolved in 1,000 parts. Water Water containing- i.o per cent, of ash 0.5 0.2 0.1 0.05 0.02 o.oi Expepimental inquiry to ascertain the effect exerted by the mineral constituents of various veg-etables on the conversion of sodium quadriurate into sodium biurate. — It is well known from the researches of Bence Jones and of Sir William Roberts that sodium quadriurate is an unstable body, and is gradually converted by combination with the sodium carbonate of the blood into sodium biurate, which latter body, on account of its comparative insolubility, deposits in the tissues and thus constitutes the gouty uratic deposit. This gradual con- version of the quadriurate into biurate is known as the maturation process. It is obviously of therapeutical importance to know whether the mineral constituents of any of the vegetables, 194 GOUT: INVESTIGATIONS. [Partiii. in addition to exerting an increased solvent effect on the biurate, possess the power of delaying this maturation process ; or, in other words, of inhibiting the conversion of the quadriurate into the biurate. In order to ascertain this, I conducted a series of experiments. In all these experiments I employed Sir William Roberts's standard solution, as being a more convenient medium to work with than blood serum. This standard solution contains 0.5 per cent, of sodium chloride and 0.2 per cent, of sodium bicarbonate dissolved in distilled water. Sir William Roberts found that this solution is a. fairly exact represent- ation of blood serum, in so far as its saline ingredients are concerned, and that it reacted with uric acid and the urates in the same manner as blood serum itself, and in the same manner as a solution comprising all the salines of the serum in their due proportions. The experiments were conducted in the following way. Pure sodium quadriurate was prepared by shaking for one minute ten grammes of uric acid with a litre of a boiling-hot 5 per cent, solution of sodium acetate. This was filtered hot, and the filtrate was then rapidly cooled on ice. The quadriurate, which falls down, was at once collected on a filter, washed with absolute alcohol, and dried at 100° F. Ten milligrammes of pure sodium quadri- urate were well rubbed with ten drops of the standard solu- tion, and the mixture was placed in a small corked bottle in the warm chamber and kept at 100° F. Every half- hour a small quantity of the mixture was examined under a high power of the microscope, and the time at which crystals of sodium biurate first appeared was noted. This represented the time occupied by the maturation process when the standard solution was saturated with sodium quadriurate. Similar experiments were conducted with the same amount of sodium quadriurate in the same quan- tity of standard solution containing respectively o . i per cent, of the mineral constituents of each of the vegetables Chap. X.] VEGETABLES AND GOUT. 195 in ordinary use. The results are shown in the following table : — TABLE XLV. Showing the effects exerted by the mineral constituents of vegetables on the conversion of sodium quadriurate into sodium biurate. Solvent. Crystals of sodium biurate first appeared in — Standard solution ' . 2 hours Standard solution containing — 0. 1 per cent. of potato ash cauliflower ash . 2 2 lettuce ,, 2 carrot ,, 2 asparagus beetroot 2|- , 3 . green peas ,, celery Brussels sprouts ash cabbage turnip tops turnip Savoy cabbage ,, seakale 3h . l\ . 4 4 , 4 , 4 . 4 4 French beans 4i , spinach ,, 5 . These results show that the mineral constituents of some of the vegetables — notably spinach, Brussels sprouts, French beans, cabbage, turnip tops, and turnips — very considerably delay the conversion of sodium quadriurate into sodium biurate. The inference is that if such mineral constituents were present in suitable proportions in the blood of gouty subjects, the elimination of that body might be secured without the occurrence of any precipi- tation of the biurate in the tissues. Moreover, it must be borne in mind that these experiments were conducted under very stringent conditions, in that they were all carried out with a saturated solution of the quadriurate, and it is extremely unhkely that the fluids of the body are ever, in gouty subjects, saturated with so soluble a 196 GOUT: INVESTIGATIONS. [Partiii. compound as the sodium quadriurate ; therefore, it is but fair to infer that, with smaller proportions of the quadriurate in solution, the inhibitory effects of the mineral constituents of vegetables would extend over much longer periods than actually occurred in the carrying out of these experiments. Results of the experimental inquiry. — The net re- sults of all the experiments described indicate that the mineral constituents of most vegetables increase the solu- bility of sodium biurate, and also, in several cases, delay for considerable periods the conversion of the sodium quadriurate into the biurate. On the other hand, the mineral constituents of meat diminish the solubility of sodium biurate, and exercise but little effect in delaying the conversion of the quadriurate into the biurate. I wish it to be clearly understood that I do not attri- bute the different effects of animal and vegetable diets on gouty subjects to the saline constituents alone. I think, however, that the results of these experiments clearly show that it is to the different mineral constituents of animal and vegetable foods, and to the different physical effects they exercise on the quadriurate and biurate, that we must look for a partial explanation of the known facts that an excessive diet of the one tends to produce gout and of the other tends to retard it. A reference to some of the tables previously given will show that certain vegetables stand out prominently with regard to the effect exercised by their mineral con- stituents both in retarding the conversion of the sodium quadriurate into the biurate, and in increasing the solu- bility of the latter. These vegetables are spinach, Brussels sprouts, French beans, winter cabbage, Savoy cabbage, turnip tops, turnips, and celery. These are the vegetables which I consider are likely to prove most beneficial to gouty subjects. Of these, in so far as the effects produced by their mineral constituents are concerned, spinach occupies chap.x] vegetables and gout. 197 the lirst place, both as regards inhibiting the decomposition of the quadriurate and increasing the solubihty of the biurate. Spinach has the further advantage of being extremely rich in mineral constituents, since it contains 16.27 P^^ cent, of mineral matter as compared with 8.50, which is the average percentage of the mineral constituents of all the vegetables experimented with. It may be urged that a drawback to the employment of spinach is that it cannot be obtained fresh throughout the year. Very excellent spinach is, however, now obtainable in the desic- cated and compressed state, and when cooked makes a dish which is practically indistinguishable from the fresh vegetable. General conclusions drawn from the investigfations. 1. The solubility of sodium biurate is markedly increased by the presence of the mineral con- stituents of most vegetables. 2. The mineral constituents of certain vegetables delay the conversion of sodium quadriurate into the biurate. 3. The vegetables most useful to gouty subjects are spinach, Brussels sprouts, French beans, winter cabbage, Savoy cabbage, turnip tops, turnips, and celery. CHAPTER XI. SOLUTION OF GOUTY DEPOSITS. Reasons for believing that the removal of gouty deposits by alkalies is erroneous — Experimental investigation of the value of the various alkalies, piperazine, and lysidine as solvents of gouty deposits — Experimental investigation of the value of salicylates as solvents of gouty deposits. For a considerable period of time two methods of treat- ment which have for their professed object the ehmination of uric acid from the system have been more or less em- ployed by medical men. They are the treatment of gout by means of alkalies, and by means of salicylates. These two methods of treatment I consider owe their popularity to the entirely erroneous supposition that uric acid is present as such in the fluids and deposits of gouty patients, whereas the uric acid is always present as sodium quadri- urate or biurate, and the chemical and physical behaviour of these substances is entirely different from that of uric acid. The plea for the treatment of gout by means of alkalies is mainly based on the following assumptions : — (i) That uric acid is present in the blood and tissues, and is rendered soluble by the administration of alkalies ; (2) that the biurate deposited in joints is rendered soluble by means of alkalies ; and (3) that there is a general acidity of the system which is neutralised and removed by alkalies. It will be seen that these assumptions do not stand the test of experimental inquiry. With regard to the first assump- tion, it is now well known that in gouty subjects uric acid is never present as such in the blood and tissues, but is always combined with sodium as the quadriurate or biurate, Chap. XL] ALKALIES AND GOUT. 199 and possibly in some organic combination as well. The only way in which alkalies could beneficially affect the quadriurate would be to delay its conversion into the biurate. In order to test this point, I conducted a series of experiments so as to ascertain the effect of artificial blood serum, to which different alkalies had been added, on the decomposition of sodium quadriurate. In all the experiments the artificial blood serum employed was Sir William Roberts's standard solution. This was employed instead of blood serum in order to obviate the objections that have been raised to the use of blood serum in such experiments, viz. the tendency to variation in its alkalinity. Moreover, as shown by Sir William Roberts, this standard solution reacts with uric acid and with the quadriurates and biurates in the same manner as blood serum itself. Objects of conducting- the experiments with sodium quadriurate. — These experiments were undertaken in order to ascertain whether any of the drugs ordinarily employed in the alkaline treatment of gout possess any power, when introduced into the circulation, of restraining the precipitation of sodium biurate from the quadriurate contained in the blood. Such experiments would show whether any such drugs would be of use in lessening the formation of gouty deposits. When sodium quadriurate is mixed with water it is decomposed into a uric acid moiety and a sodium biurate moiety, the uric acid appearing, immediately it is set free, in the form of ovoid or spindle-shaped crystals. These crystals appear in a very short time after the contact of the quadriurate with water — generally in from one to five minutes — whilst the sodium biurate passes into the gela- tinous form, which, if sufficient water be present, is dis- solved. If, instead of water, an alkaline medium be em- ployed to decompose the quadriurate, such as blood serum or artificial blood serum, at the temperature of the human body, then as long as free alkaline carbonate is present 2o6 'GOUT: INVESl'lGATIONS. [PARxiit. the uric acid moiety of the quadriurate, instead of crystal- hsing out as uric acid, unites with tlie sodium carbonate to form sodium biurate, which first assumes the amor- phous form. After a time this amorphous biurate becomes gradually converted into the needles of the crystalline biurate. The time, therefore, that elapses between the saturation of the blood serum with sodium quadriurate, and the first appearance of needle-shaped crystals of sodium biurate, represents the inhibitory influence of the medium on the crystalline precipitation of sodium biurate. The next paragraph describes how the experiments to ascertain the effect of drugs employed in the alkaline treatment of gout were conducted. Method of conducting" the experiments with sodium quadriurate, — Ten milligrammes of sodium quadriurate were well rubbed with ten drops of a o.i per cent, solution of the drug in artificial blood serum, and the mixture was then placed in a small corked tube and kept at ioo° F. Every half-hour a small quantity of the mixture was re- moved and examined under a high power of the microscope, and the time at which crystals of the sodium biurate first appeared was noted. A similar experiment, for purposes of comparison, was made with the quadriurate and artificial blood serum alone. I experimented separately in this way with potassium bicarbonate, potassium citrate, lithium carbonate, lithium citrate, sodium bicarbonate, sodium phosphate, piperazine, and lysidine. The results are set out in Table XLVI. They show that none of the drugs mentioned in the table exercises the slightest effect in delaying the conversion of the quadriurate into the biurate, even when present in far larger proportions than could possibly be introduced into the blood by the medicinal administration of the drugs. Therefore it appears that the treatment of gout by alkalies and salts of the alkalies does not delay the conversion of the quadriurate into the biurate. Chap. Xl.] Alkalies and gout. TABLE XLVI. 201 Showing the influence exerted on the decomposition of sodium quadri- urate by artificial blood serum alone, and by artificial blood serum containing o . i per cent, of various drugs in solution. Solvent. Sodium biurate crys- tals appeared after the lapse of — Artificial blood serum. „ containing o. I per cent, of potassium bicarbonate ,, containing o. i per cent, of potassium citrate . ,, containing o. i per cent, of lithium carbonate „ containing o. I per cent, of lithium citrate ,, containing o. i per cent, of sodium bicarbonate . ,, containing o. i per cent, of sodium phosphate ,, containing o . i per cent, of piperazine .... ,, containing o . i per cent, of lysidine .... 2 hours Does the treatment of grout by alkalies increase the solubility of sodium biurate ? — With regard to the second assumption, that the administration of alkalies increases the solubility of the biurate deposited in the joints and tissues, Sir William Roberts * has shown that sodium bicarbonate and sodium phosphate diminish the solubility of sodium biurate, while potassium bicarbonate exercises no influence whatever on its solubility. That the administration of alkalies might increase the solubility of the biurate appeared at one time to be probable from the results of some experiments performed by Sir Alfred Garrod. He immersed small pieces of cartilage infiltrated with sodium biurate for forty-eight hours in aqueous solutions of the carbonates of lithium, potassium, and sodium respectively. At the end of that time he found Croonian Lectures, 1892. 202 GOUT: INVESTIGATIONS. [partiii. that the cartilage immersed in the lithium solution was restored to its natural condition ; that in the potassium solution was much acted upon, while that in the sodium solution appeared to be unaltered. These results are somewhat in opposition to those of Sir William Roberts, and as neither the experiments of Sir Alfred Garrod nor those of Sir William Roberts represent the conditions under which alkalies, when introduced into the circulation, would act on sodium biurate, I thought it desirable to re-investigate the subject, as far as possible under such conditions. Investigration of the effects of various alkaline drug's on the solubility of sodium biurate. — These experiments were undertaken in order to compare the solubility at 100° F. of sodium biurate in artificial blood serum, and in artificial blood serum containing different proportions of the various drugs. The experiments were carried out in a similar manner to those previously described. I experi- mented separately with the following drugs, viz. potassium bicarbonate, potassium citrate, lithium carbonate, lithium citrate, sodium bicarbonate, sodium phosphate, piperazine, and lysidine. Much greater proportions of the drugs were employed than could possibly be introduced into the blood by medicinal administration. The results are shown in the following tables : — TABLE XLVII. Showing the solubility at ioo° F. of sodium biurate in artificial blood serum alone, and in artificial blood serum containing different proportiovis of potassium bicarbonate. Solvent. Artificial blood serum Artificial blood serum containing o.oi per cent, of potassium bicarbonate Artificial blood serum containing o.io per cent, of potassium bicarbonate Artificial blood serum containing 0.20 per cent, of potassium bicarbonate Sodium biurate dissolved. o. II per 1,000 0.10 ,, 0.10 o. II ALKALIES AND GOUT. 203 HAP. XI.] These results show that potassium bicarbonate would not in the slightest degree increase the solvent power of the blood for gouty deposits. TABLE XLVIII. Showing the solubility at 100° F. of sodium biurate in artificial blood serum alone, and in artificial blood serum containing different proportions of potassium citrate. Solvent. Artificial blood serum Artificial blood serum containing o.oi per cent, of potassium citrate Artificial blood serum containing o.io per cent, of potassium citrate Artificial blood serum containing 0.20 per cent, of potassium citrate Sodium biurate dissolved. o . 1 1 per 1 ,000 0.10 ,, 0.10 o. I I These results show that potassium citrate would not in the slightest degree increase the solvent power of the blood for gouty deposits. TABLE XLIX. Showing the solubility at 100° F. of sodium biurate in artificial blood serum alone, and in artificial blood serum containing different proportions of lithium carbonate. Solvent. Sodium biurate dissolved. Artificial blood serum - 0. 1 1 per 1,000 Artificial blood serum containing 0.005 per cent, of lithium carbonate . 0. 1 1 Artificial blood serum containing o.oi per cent, of lithium carbonate . 0. II Artificial blood serum containing 0. 10 per cent, of lithium carbonate . 0.15 These results show that lithium carbonate would not in the slightest degree increase the solvent power of the blood for gouty deposits, even when present in far larger proportions than could be introduced into the blood by medicinal administration. Lithium salts are usually given 204 GOUT: INVESTIGATIONS. [Part III. in doses of one to five grains three times a day, whereas to get o.oi per cent, of a hthium salt into the blood it would be necessary to introduce lo grains of the salt at once into the circulation of an adult man of average weight. TABLE L. Showing the solubility at ioo° -F. of sodium biurate in artificial hlood serum alone, and in artificial hlood serum containing different proportions of lithium citrate. Solvent. Sodium biurate dissolved. Artificial blood serum . 1 1 per 1 ,000 O.II Artificial blood serum containing 0.005 cent, of lithium citrate .... per Artificial blood serum containing o.oi cent, of lithium citrate .... per O.II Artificial blood serum containing o.io cent, of lithium citrate .... per O.II These results show that lithium citrate would not in the slightest degree increase the solvent power of the blood for gouty deposits. TABLE LI. Showing the solubility at 100° F. of sodium biurate in artificial blood serum alone, and in artificial blood serum containing different proportions of sodium bicarbonate. Solvent. Sodium biurate dissolved. Artificial blood serum Artificial blood serum containing o.oi per cent, of sodium bicarbonate .... Artificial blood serum containing o.io per cent, of sodium bicarbonate .... Artificial blood serum containing o . 20 per cent, of sodium bicarbonate .... O.II per 1,000 O.IO ,, o . 09 0.08 These results show that sodium bicarbonate would slightly decrease the solvent power of the blood for gouty deposits. Chap. XI.] PIPERAZINE AND GOUT. TABLE LII. 205 Showing the solubility at 100° F.-of sodium biurate in artificial blood serum alone, and in artificial blood serum containing different proportions of sodium phosphate. Solvent. Sodium biurate dissolved. Artificial blood serum Artificial blood serum containing o.oi per cent, of sodium phosphate Artificial blood serum containing o.io per cent, of sodium phosphate Artificial blood serum containing o . 20 per cent, of sodium phosphate o . 1 1 per 1 ,000 o. I I O. II O. II These results show that sodium phosphate would not in the slightest degree increase the solvent power of the blood for gouty deposits. TABLE LIII. Showing the solubility at 100° F. of sodium biurate in artificial blood serum alone, and in artificial blood serum containing different proportions of piperazine. Solvent. Sodium biurate dissolved. Artificial blood serum Artificial blood serum containing o.oi per cent, of piperazine Artificial blood serum containing o.io per cent, of piperazine Artificial blood serum containing o . 20 per cent, of piperazine o . II per 1 ,000 0.09 O.II 0.13 These results show that piperazine would not in the slightest degree increase the solvent power of the blood for gouty deposits, even when present in far larger proportions than could be introduced into the blood by medicinal administration, Piperazine is usually given in doses of five grains three times a day, whereas to get o.io per cent, of piperazine into the blood it would be necessary to 2o6 GOUT: INVESTIGATIONS. [Partiii. introduce lOO grains of the drug at once into the circula- tion of an adult man of average weight. TABLE LIV. Showing the solubility at ioo° F. of sodium biurate in artificial blood serum alone, and in artificial blood serum containing different proportions of lysidine. Solvent. Sodium biurate dissolved. Artificial blood serum Artificial blood serum containing o.oi per cent, of lysidine Artificial blood serum containing o.io per cent, of lysidine Artificial blood serum containing 0.20 per cent, of lysidine o . 1 1 per 1 ,000 o . 09 0.10 0.10 These results show that lysidine would not in the slight- est degree increase the solvent power of the blood for gouty deposits, even when present in far larger proportions than could be introduced into the blood by medicinal admin- istration. Lysidine is given in doses of from 30 to 120 grains three times a day, whereas to get 0.20 per cent, of lysidine into the blood it would be necessary to intro- duce 200 grains of the drug at once into the circulation of an adult man of average weight. Further experiments as to the influence of potas- sium and lithium salts on the solvency of grouty deposits. — As it appeared to me that the experiments of Sir Alfred Garrod, previously referred to, as to the solvent effect of potassium bicarbonate and lithium car- bonate on gouty deposits, were scarcely comparable with what occurs when those drugs are acting via the blood and other fluids of the body, I thought it desirable to repeat the experiments under different conditions. I therefore investigated the solvent action on gouty deposits of artificial blood serum impregnated with quantities of potassium bicarbonate and lithium carbonate respectively ; Chap. XI.] ALKALIES AND GOUT. 207 the quantities of the drugs used were as nearly as possible equal to those which would be present in the fluids of the human body when full doses are being administered. The artificial blood serum impregnated with potassium bicar- bonate contained o.oi per cent, of that drug. The artificial blood serum impregnated with lithium carbonate contained 0.0015 P^r cent, of that drug. The experiments were carried out in the following manner. Method of ascertaining- the solvent effects of potas- sium bicarbonate and lithium carbonate on g-outy deposits. — A piece of cartilage well and uniformly infil- trated with sodium biurate, which had been removed from a gouty joint at a post-mortem examination, was divided into three equal pieces. One piece was suspended in a bottle containing 100 c.c. of artificial blood serum, the second piece in a bottle containing 100 c.c. of artificial blood serum impregnated with potassium bicarbonate, and the third piece in a bottle containing 100 c.c. of artificial blood serum impregnated with lithium carbonate. The bottles with their contents were kept throughout the ex- periments at the blood heat, and every twenty-four hours fresh supplies of fluid were introduced, so that the first piece of cartilage was constantly bathed in artificial blood serum at the blood heat, the second piece in artificial blood serum impregnated with potassium bicarbonate, and the third piece in artificial blood serum impregnated with lithium carbonate. By this method of procedure it was considered, as regards any solvent effect that the drugs might exert on the gouty deposit, that the results would be fairly comparable with what occurs when potassium or lithium salts are medicin- ally administered. The pieces of cartilage were removed every twenty-four hours and examined by means of a lens, and the experiments were continued until all the sodium biurate was dissolved out of the cartilage. The solution of the sodium biurate from the cartilage proceeded 2o8 GOUT: INVESTIGATIONS. [Partiii. at the same pace in the three pieces, and was in no way accelerated by the presence of the potassium bicarbonate or the Hthium carbonate. The sodium biurate was com- pletely dissolved from the three pieces of cartilage on the fifteenth day. These experiments indicate that the quantities of potassium bicarbonate and lithium carbonate that could, by ordinary dosage, be introduced into the fluids of the body can exercise no influence on the solvency of gouty deposits, and the results obtained support the view of Sir William Roberts that potassium bicarbonate and lithium carbonate exercise no influence on the solubility of sodium biurate. The net result of all these experiments is that the treatment of gout by alkalies or by piperazine or lysidine does not increase the solubility of the biurate deposited in the joints and tissues. Levison * holds very similar opinions with regard to the alkaline treatment of gout. He considers that the administration of the ordinary alkalies, of lithium salts, or of piperazine with the object of either dissolving sodium biurate or of preventing its deposition is decidedly useless. He also found that the administration of piperazine exerts no influence upon the amount of uric acid excreted. J. Fawcett,t as the result of his investigations on the treatment of gout by piperazine, arrives at an unfavour- able conclusion as to its efficacy in gout. He found that in acute cases it did not relieve the pain, nor was there any constant increase in the excretion of uric acid under its use. Mordhorst J also considers that piperazine and lysidine are useless in the treatment of gout. A g-enepal acidity of the system not associated with gout. — The third assumption, that in connection with gout there is a general acidity of the system which * "The Uric Acid Diathesis," 1894. t Guy's Hosp. Reports, 1895. J Therap. Monats., x., 1896. ... CAP. XI.] ALKALINITY OF BLOOD. 209 causes a diminished alkalinity of the blood, is opposed to the results of recent investigations on the subject. The experiments of Klemperer and my own experiments show that the alkalinity of the blood of gout is not diminished, and that variations in the alkalinity of the blood may frequently be met with in healthy individuals. More- over, the experiments previously described demon- strate that a diminution in the alkalinity of blood serum containing uric acid in solution does not facilitate the deposition of sodium biurate from it, nor does a diminution in the alkalinity of blood serum diminish its solvent power for sodium biurate. It appears therefore that there is no ground whatever for the assumption that the treatment of gout by alkalies tends to neutralise a so-called general acidity of the system, and so renders the blood a better solvent of gouty deposits. No relationship between the acidity of the urine and the alkalinity of the blood. — The idea that a general acidity of the system is associated with gout has, in my opinion, arisen from observations of the fact that the urine of gouty patients is acid. These observations are generally made on small samples of the urine, although when the total acidity of the urine for the twenty-four hours is determined, it is frequently found to be below that of the normal acid output in the urine for that period of time. It is certain that the erroneous assumption has been made by some writers that variations in the acidity of the urine can be taken as a gauge of corresponding variations in the alkalinity of the blood, and that therefore a fall of acidity in the urine means an increased alkalinity of the blood, and vice versa. That this assumption is quite wrong is shown by reference to the next table (Table LV.), in which are arranged side by side the determinations that I made on the same days of the alkalinity of the blood and of the total acidity of the urine for each twenty- four hours of an adult patient suffering from subacute 210 GOUT: INVESTIGATIONS. [Part III. gout. The total acidity of the urine was determined by collecting the whole of the urine for the twenty-four hours, and then titrating a portion of the urine by the process described by Lepinois.* The estimations were made mostly on alternate days throughout the duration of the attack. TABLE LV. Shoiving the absence of any constant relationship between the alkalinity of the blood and the acidity of the urine of a patient during an attack of subacute govit. Alkalinity represented as Acidity of total urine for Dates of percentage of anhy- the 24 hours, reckoned as determinations. drous sodium carbon- ate present in the blood. grammes of hydrochloric acid. Feb. 4th. 0. 167 1.392 , 6th. 0. 167 953 , 8th. 0. 167 096 , loth. 0. 156 374 , 1 2th. 0. 167 583 , 15th. 0.158 529 1 , , 17th. 0.158 629 , 19th. 0. 167 581 , 22nd. 0. 180 602 , 24th. 0.173 Alkaline I , 26th. 0. i6r Alkaline , 28th. 0.179 0.608 Mar. 2nd. 0. 167 0.622 This table shows that no constant relationship existed in this case of gout between the alkalinity of the blood and the acidity of the urine, and moreover that on those days when, owing to treatment with citrate of potassium, which was administered from February 19th to 28th, the urine remained alkaline, there was no corresponding rise in the alkalinity of the blood. These determinations of the alkalinity of the blood and the acidity of the urine of this case of subacute gout are shown in curves in the following diagram, a glance at * Jonrn. Pharm., 1896 (6), iii., 8-16. Chap. XI.] SALICYLATES AND GOUT. 211 which at once demonstrates that no constant relationship existed between the alkahnity of the blood and the acidity of the urine. Reasons for believingr the treatment of g'out by sali- cylates to be erroneous. — Just as the treatment of gout by means of alkalies is based on the entirely erroneous supposition that uric acid is present as such in the fluids and deposits of gouty patients, so the main reason for A A \, / \ y y ^-«> ^ / ^ \ / "'v y B / ""*■". ''' ~~' '"" I • \ '" \ 1 1 \ / — \ \ Mi iuL \'cili ^ of Ur tne \ / ~^" PiLM ■•""■ ^^ JIL *^ ^^ • Diagram showing the absence of any constant relationship between the alkalinity of the blood and the acidity of the urine of a patient during an attack of subacute gout. A, Alkalinity of blood. B, Acidity of urine. giving a salicylate in gout is based on the assumption that it unites with uric acid throughout the system, and so effects its removal from the system and its elimination in the urine. That sodium salicylate does cause an in- creased elimination of uric acid in the urine, at all events in the early stages of its administration, is undoubted. This is shown by the following daily determinations that I made of the total uric acid excretion of a healthy man before, during, and after treatment with sodium 212 GOUT : INVESTIGATIONS. [partiii. salicylate. The diet was of the same nature throughout the experiment. TABLE LVI. Showing the daily excretion on successive days of uric acid by a healthy man before, during, and after treatment with sodium salicylate. Daily excretion of uric acid in grammes. /O.S47 Before taking salicylate '0.589 ( 0.731 Average 0.622 [-0.852 Fifteen grains of sodium salicylate taken . Jo. 942 three times a day ] 0.826 t 0.784 Average 0.851 r 0.340 jo. 581 Salicylate left off J^ 0.543 0.677 0.686 Average 0.565 That this increased elimination of uric acid is due, however, to the removal of ready-formed uric acid stored in the system is, in my opinion, incorrect. In the first place it must be remembered that any uric acid deposited in any of the organs or tissues of gouty subjects is deposited in the form of sodium biurate, and the results of the follow- ing experiments show that artificial blood serum contain- ing sodium salicylate, in much greater proportions than could be introduced into the blood by the medicinal Chap. XI] SALICYLATES AND GOUT. 213 administration of the drug, has not the shghtest increased solvent effect on the biurate. TABLE LVII. Showing the solubility at 100° F. of sodium biurate in artificial blood serum alone, and in artificial blood serum containing different proportions of sodium salicylate. Solvent. Sodium biurate dissolved. Artificial blood serum 0. 1 1 per 1,000 Artificial blood serum containing 0.003 per cent, of sodium salicylate . O.II Artificial blood serum containing 0.006 per cent, of sodium salicylate O.II ,, Artificial blood serum containing o.oi per cent, of sodium salicylate O.II „ Artificial blood serum containing o.io per cent, of sodium salicylate O.II These results show that sodium salicylate would not in the slightest degree increase the solvent power of the blood for gouty deposits, even when present in far larger proportions than could be introduced into the blood by medicinal administration. Sodium salicylate is usually given, in the treatment of gout, in doses of fifteen to twenty grains three times a day, whereas to get o.i per cent, of sodium salicylate into the blood it would be necessary to introduce 100 grains of the drug at once into the circu- lation of an adult man of average weight. J. Fawcett,* who likewise finds that sodium salicylate produces an increased uric acid excretion, considers it improbable that the increase can be explained by a mere clearing out of retained uric acid. I also find that artificial blood serum containing sodium salicylate in far larger proportions than could be intro- duced into the blood by medicinal administration has no effect whatever in delaying the conversion of sodium quadri- urate into the biurate, as is shown in the following table : — * Guys Hosp. Reports, 1895. 214 GOUT: INVESTIGATIONS. [PariIII. TABLE LVIII. Showing the influence exerted on the decomposition of sodium quadri- urate by artificial blood serum, and by artificial blood serum containing o.i per cent, of sodium salicylate in solution. Solvent. Sodium biurate crys- tals appeared after the lapse of — Artificial blood serum Artificial blood serum containing o . i per . cent, of sodium salicylate 2 hours. 2 hours. It therefore appears from the results of the experiments given in Tables LVII. and LVIII. that sodium salicylate has no direct action either in delaying the decomposition of sodium quadriurate or in effecting a solvent action on deposits of sodium biurate. The erroneous supposition as to salicylates possessing a solvent power on gouty deposits probably arose from the faulty deduction that increased elimination of uric acid in the urine after the administration of a salicylate was necessarily due to the solvent effect of the salicylate on uratic deposits. The correct explana- tion of this increased elimination of uric acid is, I believe, to be found in the known fact that salicylic acid unites readily with glycocine to form salicyluric acid, and that it thus brings an increased amount of glycocine to the kidneys, where by the combination of that body with urea an increased amount of uric acid may be formed. General conclusions drawn from the investigrations. 1. The administration of the ordinary alkalies, of lithium salts, of piperazine, and of lysidine, with the object of removing gouty deposits, appears to be useless. 2. No general acidity of the system is associated with gout. 3. No relationship exists between the acidity of the urine and the alkalinity of the blood. 4. The administration of salicylates with the object of removing gouty deposits appears to be useless. PART IV. THE TREATMENT OF GOUT AND OF GOUTY CONDITIONS. CHAPTER XII. ACUTE AND CHRONIC GOUT: TREATMENT AND DIET. General principles of treatment — Examination of the urine — Treatment of acute gout — The action of colchicum — Diet in acute gout — Treatment of subacute and chronic gout — Preventive treatment of gout — Local treatment of gouty- joints — Electric light and superheated-air baths — Cata- phoresis. General principles on which the treatment of gout is based. — In the first place it should be borne in mind that no routine treatment can be adopted which is suit- able to all cases. The nutritional condition of the patient, his habits, surroundings, and mode of life constitute factors that must necessarily modify the treatment of individual cases, and with gout, as with so many other diseases, it will be found that each individual case requires separate study, and frequently special treatment. Quite apart from the treatment of an attack of gout, which is a comparatively simple and easy matter, must be con- sidered the treatment of the condition or conditions which led up to the attack. In connection with this point it must be remembered that the gouty individual is one whose general metabolism is unstable, and that this in- stabihty may be present in one or more of the great physiological systems — the digestive, the nervous, the 215 2i6 GOUT: TREATMENT. [Parxiv. circulatory, etc. The question which of these systems is primarily and mainly at fault should always be a matter for patient investigation, and one must then endeavour to improve the metabolism of that system by suitable medicinal, dietetic, and hygienic treatment. The treatment of gout should have for its aim the following objects : — (i) The treatment of the gouty paroxysm in cases of acute gout, and the relief of the pain as speedily as possible ; (2) the treatment of the subacute or the chronic condition, and prevention of the recurrence of an attack ; (3) the treatment of the affected joint, or joints, with the object of removing the uratic deposits, and of preventing permanent deformity ; and (4) the treatment of the various forms of irregular or abarticular gout. Examination of the urine. — In all cases of gout a very careful examination of the urine should be made. The indications that the kidneys are not performing their proper functions are the existence of a certain amount of polyuria, a low specific gravity of the urine — usually from 1007 to 1016 — the presence of a small quantity of albumen, which, however, may disappear for some time and then reappear, the presence of a few granular casts if a careful microscopical examination is made after centri- fugalising the urine, and a diminished daily excretion of uric acid and generally of urea. It is most important care- fully to examine the urine for traces of albumen, and for the presence of casts. For the latter purpose the centrifugal machine should be used, as the casts, when present, are usually present in but small numbers, and are otherwise very slow to settle. This examination for casts should always be made in those cases where there is a suspicion of organic renal disease, even though there may be a complete absence of albuminuria. It is a common occurrence to find gouty individuals with marked signs of renal inadequacy passing urine of fairly low specific CHAP.xii] TREATMENT OF ACUTE GOUT. 217 gravity and quite free from albumen, but in such cases a careful examination of the urine will always reveal the presence of granular and frequently hyaline casts. It is desirable before commencing treatment, and from time to time during treatment, to know the amount of uric acid that is being daily eliminated in proportion to the body-weight of the patient. This determination of the amount of uric acid eliminated must be made on a sample of the mixed urines of twenty- four hours. The mere determination of the percentage of uric acid in a sample of the urine is useless, as it constitutes no guide to the actual amount of uric acid that is being excreted. It is absolutely necessary to determine the total uric acid elimination for the twenty-four hours, and that can only be done by examining a sample of the mixed urines of that period. Similarly the determination of the percentage of urea in a sample of the urine is no guide to the amount of nitrogenous elimination that is taking place from the kidneys. To ascertain that factor the total output of urea for the twenty-four hours must also be determined. Treatment of acute gout. — In order to arrest the abnormal intestinal fermentation, to remove the excessive numbers of intestinal bacteria, and to relieve the catarrh of the intestinal mucosa, all factors in the development of abnormal intestinal toxins, the bowels should be freely opened with four grains of calomel or " blue pill," followed by a saline aperient. For the first twenty-four hours it is preferable that no food should be taken, but water should be drunk freely. For the treatment of the gouty paroxysm the limb should be placed in the horizontal position, or slightly elevated above the level of the body, and a cradle should be arranged so as to take the weight of the bed-clothes from the affected part. To alleviate the severe pain felt in the affected joint, warm packs should be arranged round it, consisting of cotton-wool saturated with a soothing 2i8 GOUT: TREATMENT. [Parxiv. lotion, and then lightly covered with oil-silk, I have found the following lotion most useful in relieving the local pain : — Sodii Carb. . . . . . • 5 "J- Linim. Belladonnae . . . . . § ij. Tinct. Opii . . . . . . ^ ij. Aq. ad ....... 3 viij. A small portion of the lotion should be mixed with an equal quantity of hot water, and then poured on cotton- wool previously arranged round the joint. The pack should be changed every four hours. In connection with the acute paroxysm, no attempt at local depletion, such as the application of leeches to the inflamed joint, blistering, or incisions, should on any account be made, owing to the great liability of thereby extending the inflammatory condition, and so producing subsequent ankylosis or deformity. For the internal treatment of acute gout, colchicum is one of the most valuable drugs that we possess. It should be especially used for acute gout, and for subacute attacks supervening on chronic gout. If it is used con- tinuously, tolerance is apt to be acquired, and then the drug ceases to act. At the commencement, a large dose of thirty to forty minims of colchicum wine should be given, followed by a mixture containing in each dose fifteen to twenty minims of the wine, with from forty to sixty grains of citrate of potassium, which should be admin- istered three times a day. The citrate of potassium, which is given for its combined properties of acting as a diuretic and of diminishing the acidity of the urine, may, if desired, be given as an effervescing mixture, using thirty grains of potassium bicarbonate to twenty grains of citric acid. Colchicum reduces the gouty inflammation, relieves the pain, and shortens the attack. It should only be taken under medical advice, and should never be given in such doses as to produce extreme depression ; after the CHAr.xii] COLCHICUM AND GOUT. 219 inflammation of an acute attack has subsided, the doses of colchicum should be gradually diminished until the drug is left off. A very useful method of administering col- chicum is in the form of its active principle, colchicine, which may be given in doses of one-fiftieth to one-eightieth of a grain three or four times a day immediately after food. Only a few patients will tolerate doses of one-fiftieth of a grain, the contra-indication of such a dose being the pro- duction of diarrhoea and intestinal griping. The following constitutes a very useful pill : — Colchicinae . Ext. Nucis Vom. Ext. Hyoscyami Ext. Gentianae gr. k IT. 2" gr- ]■ After the initial free purgation, as previously mentioned, it is not desirable to produce too free an action of the bowels. All that is necessary is to have a sufficient action to relieve portal congestion and intestinal catarrh. The following pill effects this purpose, in most cases, very well. It is administered at night, and is followed up, when neces- sary, by a dose of saline in the morning. Leptandrin . . . . . . gr. j. Iridin . . . . . . . gr. j. Ext. Hyoscyami . . . . . . gr. j. Ext. Colocynth Co. . . . . . gr. ij. If the pain of an acute attack of gout is so severe as to prevent sleep, seven grains of veronal, or ten grains of trional may be given, or a full dose of extract of hyoscyamus will, in some cases, act as a very useful anodyne. The administration of opium or morphine should, if possible, be avoided owing to the risk of its deficient elimination, and also on account of its diminishing the amount of urine, and its tendency to derange digestion and to check hepatic metabolism. Action of colchicum. — For the past few years my thoughts have been directed with increasing intensity 220 GOUT: TREATMENT. [Partiv. to the view that the intestinal tract is a very powerful factor, if not the primary factor, in the development of gout. My attention was first directed to this view as the result of some clinical observations which I was making in an attempt to explain the action of colchicum in cases of gout. I happened at that time to see some cases of acute colchicum poisoning, which in many respects re- sembled acute arsenical poisoning. In toxic doses, colchicum is first a gastro-intestinal irritant ; it produces nausea, vomiting, choleraic diarrhoea, and rice-water stools, just as arsenical poisoning does. It also, in sufficient toxic doses, produces cardiac depression, and a bilateral neuritis, similar to that produced by arsenic. If, then, in therapeutic doses, the main action of colchicum is upon the gastro-intestinal canal, its rapid efficacy, in cases of gout, is possibly due to its effect upon those abnormal intestinal changes which constitute the primary factor in that disease. Colchicum increases the secretion from the intestinal mucous membrane, and so either prevents the formation, or effects the destruction, of the intestinal toxin which, when absorbed into the circulation, is re- sponsible for the development of gout. It is probable that the drugs that are of most value in the treatment of gout owe their efficacy chiefly to their power of checking intestinal putrefaction, as well as to preventing the absorption or promoting the elimination of the products of such intestinal putrefaction. Diet in acute gout. — As previously mentioned, it is preferable that no food be taken for the first twenty- four hours of an acute attack of gout, but water should be drunk freely. During the acute attack the patient should be restricted to a milk diet, which may consist of milk, bread and milk, and tea made with boiling milk instead of with water. Weak tea with cold toast thinly buttered may also be taken. The free drinking of hot or cold water, of salutaris water, or of some simple mineral water, should CHAr.xii] TREATMENT OF CHRONIC GOUT. 221 be encouraged. The milk diet should be continued until the acute inflammation is subsiding, which stage is indi- cated by the lessening of the pain, and by the pitting on pressure of the affected parts. No alcohol in any form should be given during this stage, unless there are strong reasons for its administration, such as a weak action of the heart and a feeble, irregular pulse, when a little well- matured whisky diluted with salutaris water will prove the best form of alcohol. Beef tea and any of the meat extracts or essences should be avoided at all times by gouty patients, owing to the tendency they have to irritate the kidneys, and to the fact that they are loaded with waste nitrogenous products. With the subsidence of the acute attack the patient may return to a more liberal diet, but care should be taken to avoid anything indigestible. The dietary suitable for gouty subjects after the acute attack has subsided is fully dealt with in the chapter on diet in gout. Treatment of subacute and chronic g-out. — In addition to colchicum, which may be given in small doses, guaiacum may very usefully be administered as an alter- ative which stimulates the metabolism of the liver, and also affords relief to the portal system. From five to ten grains of guaiacum resin should be given in cachets two or three times a day, according to the effect on the bowels, since guaiacum sometimes acts as a laxative. The method of administering the powdered guaiacum resin in cachets is far preferable to giving the tincture of guaiacum in a mixture, as, in the latter form, a nauseous medicine is produced, and the precipitated resin tends to cling obstin- ately to the tongue and fauces. In cases of chronic gout, the colchicum may be very conveniently administered in the form of the colchicine pill, given three times a day. In order to encourage the elimination by the kidneys of the toxic agents of gout, citrate or bicarbonate of potassium should be employed as a diuretic, which increases the volume 222 GOUT: TREATMENT. [Partiv. of the urine, and, at the same time, diminishes its acidity. The use of the potassium salt may with' advantage be pushed until moderate alkalinity of the urine is produced, as, by such means, the tendency to the deposition of uric acid, or sodium biurate, in the kidney-tissues is removed. Free diuresis should also be encouraged by the drinking of sufficient quantities of water. Of the beneficial effects of employing a potassium salt in conjunction with col- chicum in the treatment of acute and subacute gout I am fully assured, and my experience is that, of the various potassium salts, the citrate is the most useful. If given in sufficiently large doses, it tends, by its conversion in the kidneys into the carbonate, to diminish the acidity of the urine, which is generally high in connection with the gouty paroxysm, while, at the same time, it increases the solvent power of the urine for the uric acid salts, and so assists their elimination. In cases of sluggish action of the liver, of gastro-intestinal catarrh and torpor, of gouty dyspepsia, and of other forms of irregular gout, in which there are no appreciable uratic deposits in the joints, mineral waters containing sodium salts are undoubtedly beneficial, owing to the action of those salts as hepatic and gastro-intestinal stimulants. As regards the use of lithium salts in the treatment of gout, my opinion is that they are not so useful as the potassium and sodium salts. The principal objection to their use is their greater toxicity, and depressing action on the heart, as compared with the potassium salts. They consequently have to be given in such small doses that I am very doubtful whether, in such doses, they possess any remedial effect at all. On the other hand, 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. The enlargement and tenderness of the gouty joints is Chap. XII.] TREATMENT OF CHRONIC GOUT. 223 due to two causes, the deposition of sodium biurate in the cartilages and fibrous structures, and a chronic inflamma- tory thickening of the fibrous tissues. For the reduction of this thickening, as well as for painful gout of the sole of the foot, and for gouty neuralgic affections, iodide of potassium, given internally, is a useful remedy. In cases of gout associated with the contracted granular kidney, as evidenced by slight albuminuria and high arterial tension, the administration of iodide of potassium is also most beneficial. I usually prescribe it in doses of ten grains three times a day, and continue its use over a period of six or eight weeks. My experience is that it seems to act more beneficially when given in combination with the compound decoction of sarsaparilla. In the treatment of the gouty state associated with disturbance of the functions of the liver, the most important consideration is the restoration of that organ to its normal state of activity, and here the alkaline sodium salts are especially useful. There is no better treatment at the outset than a dose of blue pill or calomel at night, followed by a dose of Epsom salts or Carlsbad salts in the morning. Subsequently a pill containing a small dose of " blue pill " or calomel combined with euonymin and colocynth will be found most useful. In such cases of gouty hepatic inadequacy a mixture which I have found most beneficial as regards its stimulating effect on the metabolism of the liver, and also of the gastro-intestinal tract, is one containing sodium bicarbonate, gentian, and nux vomica, taken a quarter of an hour before meals. The indulgence in high living by gouty subjects induces arterial plethora and a rise of blood pressure. The conse- quent strain on the arterial walls produces arterial disease if continued long enough, but in the early stages of such rise in blood pressure the administration of "blue pill" and careful attention to diet will always prevent the incidence of arterial disease. Gouty subjects are more prone to the injurious 224 GOUT: TREATMENT. [Partiv. effects of constipation of even a slight degree than non-gouty individuals. So-called " Solvents of uric acid," — Uric acid can- not be " washed out " of the system. Substances that dissolve uric acid in the test tube are of little or no use in increasing the output of uric acid in the body. When drugs do increase or diminish the uric acid excretion, they act by directly affecting the cellular processes of the body, and not by dissolving out the uric acid deposits. In no case is there a possibility of converting the uric acid in the deposits into a more soluble condition by the addition of potassium or lithium salts. The only possibility of converting a sparingly soluble primary urate into a more soluble compound is to remove the primary uric acid ions from the solution. That can be done by addition of strong alkaline solutions which convert the primary uric acid ions into secondary ions ; but that is obviously a method in- applicable in therapeutical practice. Some years ago a solvent of uric acid seemed to have been found in urea. It was apparently shown by Rudel that a water solution of urea, as well as urine, would dissolve very considerable quantities of uric acid or urates. One litre of a 2 per cent, urea solution was said to dissolve at the normal temperature about 0"5 gramme of uric acid, and a 10 per cent, solution more than 2 grammes, while a litre of water dissolves only 0.0253 gramme. Moreover, compounds of the urea with uric acid were said to have been isolated, and these observations excited much interest in regard to the treatment of gout and stone formation. Careful repe- tition of Rudel's experiments has, however, led to directly opposite conclusions, and it may be confidently stated that urea does not affect the solubility of uric acid in water. Neither does its presence in a water solution sensibly counter- act the separation of uric acid from its salts. Nor could any compounds of uric acid and urea be obtained. Con- sequently, since urea has no influence upon the relations CHAP. XII.] . PREVENTIVE TREATMENT. 225 of solubility and equilibrium of uric acid or its salts, the proposed treatment with urea is destitute of any scientific foundation. I have deemed it advisable to make no reference to the employment of any of the numerous preparations which are so constantly being introduced to our notice as infallible solvents of uric acid, and as specifics for gout. It is not that I have not made trial of them, but such trials have always led to disappointment, and have sent me back with renewed confidence to the drugs of our Pharmacopoeia. I have witnessed, and doubtless shall again witness, the rise and fall in popularity of many a so-called solvent of uric acid, which has been introduced with exaggerated praise, and with the usual undeserved laudation born of insufficient experience. Preventive treatment of gout. — After convalescence, as much exercise as possible, short of fatigue and discomfort, should be taken in the open air. Cycling is an excellent exercise for the gouty, since it furnishes good muscular movement in the open air without the gouty joints having to bear the weight of the body. I have now had a considerable experience of the pro- phylactic effects of guaiacum resin, and I must confess that I know of no drug which is more useful in the preventive treatment of gout. Its action is probably due to its stimu- lating effect on intestinal and hepatic metabolism. The form in which I prefer to give it is that of the powdered resin in cachets, commencing with doses of 5 grains three times a day after meals, and gradually increasing the dose to one of 10 or 12 grains. In this form it can be taken without any discomfort to the patient, whereas if admin- istered in the form of the tincture in a mixture a most nauseousl'medicine results. To prevent, as far as possible, the recurrence of gout the patient should also give careful attention to diet on the fines laid down in the chapter on diet. Regular habits 226 GOUT: TREATMENT. [Partiv. of life, with even and sufficient exercise, should be encour- aged, and constipation should be zealously avoided. Briefly stated, the individual who is subject to gout, and who wishes to prevent a recurrence of the disease, should lead an active and an abstemious life. Local treatment of gouty joints. — If much swelling of a joint persists, the limb should be elevated as much as possible, and a light flannel bandage applied to the joint. If the oedema persists, the hot douche followed by sponging with a cold strong solution of common salt will be found serviceable. The application of the so-called solvents of uric acid externally to affected joints is useless, as they are not solvents of sodium biurate. Careful massage and gentle exercise of the stiffened joints should be employed, but only when convalescence is fairly established ; massage and muscular movement increase the flow of lymph in the lymph channels, and so tend to promote the removal of uratic deposits, and to increase general metabolism. A free movement of the lymph in the lymph channels is essential to oxidation and metabolism, and therefore massage and muscular movements exercise an important influence on account of the pumping action produced in the lymph-spaces by both forms of exercise. Muscular movements and respiration are almost the only means by which the circulation is ordinarily carried on in this system, as it has no motor mechanism with the exception of the vis-a-tergo of the heart and arteries, and, if these latter are in default, delay and defective metabolism must result if muscular exercise is not taken. This is an argument, from the physiological side, in proof of the fact that a sedentary life and deficient exercise conduce to gout. Massage should never be resorted to in cases of acute gout, as it not only aggravates the disease at that stage, but also causes severe pain ; it should be reserved for the more chronic cases. Massage produces an increase in the amount of blood and lymph passing through the tissues concerned, cHAP.xii.j TREATMENT OF JOINTS. 227 at the time and afterwards. This improves the nutrition of the affected tissues, promotes absorption of deposits, and restores physiological activity. In subacute or chronic cases, where the joints remain swollen and cedematous, and are the seat of considerable deposits, much benefit is frequently derived from massage and galvanism. Each of the affected joints should be massaged for a few minutes, and then galvanism (5 to 10 milliamperes) applied for a few minutes with the negative pole over the affected region, to be again followed by massage. Under this combined treatment the oedema and deposits frequently disappear rapidly. Probably the beneficial effects are due mainly to the increased circulation of blood and lymph induced, and the consequent absorption that takes place. The Scotch douche is very useful in the treatment of chronically affected joints. A good-sized stream is thrown with considerable force upon the affected joint, cold water being first employed for half a minute, and then hot ; the latter should be as hot as the patient can bear, and should be continued for one minute. This process is repeated for fifteen or twenty minutes. The repeated alternations of temperature produce a stimulating effect upon the circula- tion about the joint, and so increase tissue change, and favour absorption. Massage of the joint should be resorted to immediately after the douching, as the tissues are then in a relaxed condition. In many cases of chronic articular gout the salt pack is efficacious. It consists of flannel soaked in a warm saturated solution of common salt, which is wrapped round the affected joint, covered with oiled silk and a bandage, and kept on all night. It should be repeated nightly as necessary. For the stiffness and thickening of joints, careful rubbing with iodide of potassium and soap liniment or with the compound camphor liniment may be resorted to. The thermal baths of Bath, Buxton, Harrogate, Strathpeffer, Llandrindod Wells, Aix-les-Bains, and other spas and 228 GOUT: TREATMENT. [partiv. mud-baths, are useful in the treatment of cases of chronic articular gout. Treatment by means of baths should, however, be avoided by patients suffering from acute gout, by elderly patients, and by those suffering from any serious cardiac affection. Electric lig-ht and superheated-air baths. — I have found in many cases that a decidedly beneficial influence on gouty joints is produced by electric light baths, followed by electrical treatment in the form of cataphoresis to the affected joints. Electric light and superheated-air baths promote the oxidative processes within the body, as is shown by the increased elimination of carbon dioxide from the lungs, and also by the increased metabolism of the body in general. They also stimulate the circulation of both the blood and the lymph in the affected joints and so lead to improved nutri- tion of the parts. This curative action undoubtedly con- tinues after the treatment has been left off. Such treatment therefore is better given intermittently — say, six baths on alternate days ; then intermit for two or three weeks and so on. These baths improve the atrophic condition of the muscles. They cause a temporary elevation of the body- temperature, marked reddening of the skin of the part treated, profuse local or even general perspiration, quickened pulse, lowered arterial tension, and generally considerable amelioration of the pain, and in some cases complete dis- appearance of it for a time. Radiant heat has a greater penetrative effect than other forms of heat, and, in my opinion, the effect is more stimulating. In cases of acute or subacute gout the pain, as a rule, recurs at varying intervals after a bath, but usually with diminished severity ; and in favourable cases a progressive reduction of the pain occurs after the use of subsequent baths. Undoubtedly many cases of chronic gout do not show much improvement after the use of electric light or super- heated-air baths, and I have frequently experienced great Chap. XII.] ELECTRIC LIGHT BATHS. 229 difficulty in selecting the cases most likely to be benefited by it. As a general rule my experience "has been that cases of chronic gout of long standing, with considerable deposits in the joints, do not derive much benefit from these baths. For such cases undoubtedly much more good can be done by the employment of vapour baths, followed by massage of the affected joints, a method of treatment which is frequently most useful in producing softening and absorption of the deposits. It should, however, be borne in mind that electric light baths seem to set up improved circulatory and trophic changes in the joints, which apparently are maintained for a prolonged period after the baths have been discontinued. Certainly I have seen in several cases, after a course of twelve to eighteen electric light baths had resulted in but slight improvement, and the baths had been abandoned in despair, a progressive improvement maintained for weeks and even months after the discon- tinuance of the baths, an improvement which in some cases has issued in more or less complete cure. If only one limb is the seat of gout, the question arises as to whether that limb should be locally treated by being placed in a small specially-constructed bath, or whether the " entire body " bath should be used. My experience is that the " whole body " bath is in all cases the most useful, with, in the case of the electric light bath, an extra localisation of the heat and light rays on the affected part. That means, according to my experience, that the more extensive the surface to which the heat and light rays are applied the better is the result. When the ordinary electric light or superheated-air baths are not obtainable, very good results may be obtained at home by the use of an ordinary blanket-tent with a small opening at the top to let out the hot air saturated with moisture. The hot air is supplied by a ring bunsen gas-burner, or by a large spirit-lamp with a flue passing through an opening in the blanket at the foot of the tent. 230 GOUT: TREATMENT. ipartiv. In the acute or subacute stage of gout, or when a shght attack of gout has just started, I consider the use of the Turkish bath most undesirable. I have known of its em- ployment in such cases being followed by an exacerbation of the attack and extension to joints not at the time affected. This is a point which should be borne in mind by medical men, as many patients on the first appearance of an attack of gout are apt to have immediate recourse to the Turkish bath, and it is well that they should be warned of the danger they thereby incur. Cataphoresis. — Cataphoresis is useful in many cases of chronic gout with considerable deposits in the joints. By cataphoresis is meant electric osmosis, or the transfer through porous partitions from anode to cathode. The joint may be treated either by immersion in a local bath of the fluid which is to be introduced, the positive electrode being placed in the bath and the negative on the back, or the positive electrode may be kept thoroughly wet by frequent applications of the fluid. The negative electrode should be a large one, about eight inches by five inches, made of zinc and protected by a flannel cover. It is well moistened with warm water, and applied to the lumbar or dorsal region. At the positive pole either potassium bicarbonate or lithium iodide may be introduced into the affected joint. In the former instance the positive electrode is kept thoroughly wet with a saturated solution of potassium bicarbonate ; in the latter the joint is painted over with iodine liniment, and a pad of lint soaked in a saturated solution of lithium carbonate is laid over the iodine surface ; on the lint the positive electrode, which should be a large flat one, is placed, and closely applied to it. Care must be taken to have everything in situ before turning on the current, so as to avoid any shock, and to give an easy, steady flow of current. Although it is not possible to absorb gouty deposits through the skin by means of alkaline baths, yet it seems Chap. XII.] CATAPHORESIS. 231 probable that such a result can be effected by means of electrolysis. Edison, in 1890, suggested electrolysis for the introduction of lithium into gouty tissues, and since his time several medical experimenters have noted the good effect of this form of treatment. More recently Bordier repeated these experiments, also using as electrode a bath containing a solution of lithium, and made a series of appli- cations to a patient with large gouty deposits in the hands. He was not only able to demonstrate the presence of lithium in the patient's urine, as had been done before by others, but, and this is even more striking, he detected the presence of uric acid in the liquid of the arm baths, thus proving both the introduction of the cathion lithium and the extraction of the anion uric acid at one operation. There was also a marked change for the better in the condition of the patient's gouty deposits as a result of the experiments. CHAPTER XIII. TREATMENT OF IRREGULAR GOUT. The treatment of the various forms of irregular gout — Gouty- dyspepsia — Hyperchlorhydria — The gouty heart — Neuritis — Insomnia — Gouty eczema — Gouty glycosuria and diabetes — Retrocedent or Metastatic Gout. Gouty dyspepsia and acidity. — In addition to the usual remedies, such as bismuth subcarbonate, sodium bicarbonate, bitters, etc., taka-diastase is a most useful drug in the treatment of gouty dyspepsia. It is made up in the form of tablets containing two and a half grains in each tablet, and one of these should be taken immediately before each meal. The taka-diastase encourages the digestion of the carbohydrate elements of the food, and so prevents the development of fatty acids, which, by their irritating effects, are so common a factor in the development of gouty dyspepsia. Hyperchlorhydria. — The treatment of this condition consists in a proper regulation of the diet by cutting off any excess of the proteid articles of diet, and by neutralising the superfluous acid by the administration of some alkali. A drug that I have found most useful in the treatment of this hyperchlorhydria is hopogan (the magnesium peroxide). It not only gives immediate relief of the pain and discomfort by its neutralising effect on the excess of acid, but it also parts with one-half of its oxygen, and acts as an internal antiseptic. It is a most valuable drug in many abnormal gastric and intestinal fermentations. It is a white tasteless powder, and is best given in a little milk in doses of twenty to thirty grains three or four times a day taken one hour 232 Chap. XIII.] HEPATIC TORPOR. 233 after meals. If it exerts too great a purgative effect, tlie dose should be diminished. It is also very useful in allaying the irritation in many cases of gouty pruritus, which are probably due to absorption of a toxin or toxins from the intestinal tract. In cases of ordinary neurotic dyspepsia, associated with flatulence, the drug is, in my experience, of no value whatever. Hepatic torpop. — A very common form of irregular gout is due to defective metabolism of the liver, and is known as hepatic torpor, or hepatic inadequacy. In this form, the faeces are pale, generally very offensive, and, as a rule, constipation occurs. Slight jaundice is usually present, as evidenced by a yellowish conjunctiva and muddy complexion, and the urine is highly coloured, of high specific gravity, and very acid. In the treatment of this form of irregular gout the most important consideration is the restoration of the liver to its normal state of activity, and here the alkaline sodium salts are especially useful. There is no better treatment at the outset than a dose of " blue pill " or calomel at night, followed by a dose of Epsom salts or Carlsbad salts in the morning. Subsequently, a pill containing a small dose of " blue pill " or calomel, combined with euonymin and colocynth, will be found most useful. In such cases of gouty hepatic inadequacy a mixture which I have found most beneficial as regards its stimulating effect on the metabolism of the liver, and also of the gastro-intestinal tract, is the following, which should be taken a quarter of an hour before meals : — Sodse Bicarb. . gr. xij. Tinct. Nucis. Vom. n X. Tinct. Gentian Co. . 5 ss. Sp. Chloroformi . . n xij. Aq. Menth. Pip. . ad 5J. Gouty heart is associated with fatty degeneration of the cardiac walls. The treatment should be rest in the re- cumbent position, and a small dose of " blue pill " or calomel. 234 GOUT: TREATMENT. ipartiv. followed by a purge of Epsom salts, should be administered. If the pulse is of low tension a mixture containing convallaria and strychnine will be suitable. If anginal attacks occur, nitroglycerine or erythrol tetra-nitrate may be given by the mouth, or inhalations of nitrite of amyl employed. Iodide of potassium is also a very useful drug when there is much pain. The patient must be carefully dieted, and graduated exercise, at first of a passive nature, such as the Schott treatment, and later of an active nature, may be very beneficial. The action of the bowels should be properly regulated, and entire abstention from tobacco smoking, or extreme moderation in its use, should be advised. The anginal and syncopal attacks that occur in connec- tion with the gouty heart do not prove fatal, but care must be taken not to overtax the heart, and, at first, only gentle outdoor exercise on the level should be allowed. Ang'ina pectoris. — In anginal attacks in gouty subjects the pulse is generally one of high tension without the existence of any necessary association of atheroma of the vessels. For the immediate relief of the actual attacks nitroglycerine is the best drug to employ, although in rare cases nitrite of amyl may be found more efficacious. Stim- ulants and morphine administered hypodermically should also be employed if necessary. For some days after an attack nitroglycerine in doses of one-hundredth of a grain should be given two or three times a day. If organic cardiac mischief exist, the condition must be suitably treated on general principles. In cases of anginal attacks occurring in gouty subjects, as soon as the severe pain has been relieved by the administration of nitroglycerine, a pill containing one grain of the acetic extract of colchicum and three grains of " blue pill " should be given at night and should be followed by a dose of Epsom salts in the morning. When the administration of nitroglycerine is discontinued citrate of potassium and iodide of potassium should be given for some time thrice a day. Chap. XIII.] GOUTY PHLEBITIS. 235 Pseudo-ang-ina pectoris. — For the treatment of this affection a dose of hot brandy and water should be given at once, and a mustard leaf should be applied to the epigas- trium. On the subsidence of the severe symptoms a pill containing one grain of the acetic extract of colchicum and three grains of " blue pill " should be given at night, and should be followed by a dose of Epsom salts in the morning. Gouty phlebitis. — For the treatment of this fairly common form of irregular gout the patient sliould be kept in the recumbent position, and any sudden movement of the affected limb must be prevented, on account of the danger of detaching a portion of thrombus and the occur- rence of consequent embolism of the pulmonary artery. Equal parts of glycerine and extract of belladonna should be smeared over the affected part, arid a linseed poultice with some of tlie glycerine and extract of belladonna spread on the surface should be applied and renewed every six hours. In addition to this the ordinary treatment of the gouty state must be resorted to. Gouty sciatica. — For the treatment of this painful affection the patient must be kept in the recumbent posi- tion, and in severe cases the pain should be relieved by a hypodermic injection of morphine. Ammonium chloride, given in doses of thirty to forty grains three or four times a day, is a very useful drug in the treatment of this form of irregular gout. Two grains of salicylate of quinine should also be given in a pill two or three times a day. These measures should be supplemented by the ordinary treat- ment of the gouty state. Gouty neuritis. — Blistering along the course of the affected nerve-trunk is the most rapid way of relieving this painful affection. If such a mode of treatment should not be considered desirable, then iodine liniment may be painted along the course of the nerve-trunk, and hot linseed poultices applied as soon as the iodine is dry, and kept in position by a bandage loosely applied. Internally, iodide of potassium 236 GOUT: TREATMENT. [partiv. combined with small doses of perchloride of mercury should be given. Insomnia in gouty subjects. — Many gouty persons complain of insomnia or restlessness when in bed. This is frequently either toxic in its origin, or is due to a state of high tension in the cerebral arteries. As a rule, the insomnia is not complete, but consists of restlessness, interspersed with varying intervals of light or broken slumber. In such cases, careful attention should be given to the state of the pulse, the heart, and the condition of the urine. In many cases it will be found that the pulse is of high tension, and is associated with accentuation of the aortic second sound, perhaps reduplication of the first sound in the vicinity of the apex of the heart, and a slight degree of albuminuria. In such cases the insomnia is best relieved by the adminis- tration at night of small doses of " blue pill " or calomel, combined with full doses of the extract of hyoscyamus. Bromide of ammonium may also be given as a sedative, •and as a drug which reduces arterial tension, but, with such patients, it is most undesirable to resort to the use of the ordinary hypnotic drugs. Irritable temper. — For the treatment of the irritable temper of gout. Sir Lauder Brunton recommends the admin- istration of twenty grains of bicarbonate of potassium and ten to twenty grains of bromide of potassium. Renal calculi. — For the treatment of uric acid renal calculi citrate of potassium should be given in full doses, so as to produce a moderate alkalinity of the urine. By this means the further deposition of free uric acid in the kidneys is prevented, and the alkaline urine, moreover, gradually carries into solution the uric acid already deposited. The free drinking of ordinary water or of one of the mineral waters of the simple kind should be advised. Gouty eczema. — Of the purely internal causes of eczema, disorder of the gastro-intestinal tract should, in my opinion, be placed first. The gouty person is one who Chap. XIII.] GOUTY ECZEMA. 237 is not only liable to such disorder and to faulty assimilation of food, but is also particularly vulnerable to inflammations of the synovial and mucous membranes, and of the skin. In the treatment of this form of irregular gout special attention should be given to two details. One is to see that the bowels are freely opened, which at the outset may be secured by the administration of " blue pill " or calomel followed by a saline ; the other point is that entire abstention from alcohol is most desirable, at all events during the treatment and persistence of the eczema. It is best that any form of alcohol should be abstained from, but the pro- hibition applies more especially, in my experience, to the red wines. I have met with several cases occurring among gouty individuals past the middle age of life in whom two or three glasses of claret or burgundy will in the course of a few hours cause the development of an eczema. During the irritative stage of dry gouty eczema I have found the application of a lotion consisting of liquor plumbi sub- acetatis 5J, liquor carbonis detergens 5J, aqua sambuci ad Oj, most soothing, especially if followed by the use of a simple dusting-powder, such as cimolite powder. For the acute moist type of eczema a similar lotion, but with a preparation of opium replacing the tar-solution, is advisable. When the eczema is in a chronic condition much benefit is usually experienced from immersion in sulphur-baths, such as those of Harrogate, Strathpeffer, Aix-les-Bains, etc. After the bath the skin should be carefully dried. and a dusting-powder such as cimolite powder freely applied. In cases of gouty eczema and gouty pruritus a careful dietary must be enforced, care being taken to forbid all articles which the experience of the patient in the past has shown to produce dyspepsia. Persons who are subject to attacks of gouty eczema should avoid such acid fruits as strawberries, gooseberries, apples and pineapples ; rhubarb also should be excluded from the dietary. As 238 GOUT: TREATMENT. [part iv. regards the medicinal treatment of gouty eczema, my experience is that it is not necessary to give the ordinary anti-gout remedies, such as colchicum, etc. It is much more important to treat the dyspepsia and the catarrhal condition of the gastro-intestinal tract, which are generally present as associated or causative conditions, by the admin- istration of subcarbonate of bismuth with the bicarbonate of sodium or the bicarbonate of potassium. In cases of gouty pruritus, or, as it is sometimes termed, latent gouty eczema, the severe itching is frequently relieved by the use of carbolic-acid lotion, or the itching attending pruritus and urticaria may be relieved by the application of the following lotion : — Liq. Plumbi Subacet. . . . . 5ij- Tinct. Opii ...... 5iv. Aq. Rosae ad ..... . ^viij. Rubbing the skin with a menthol cone moistened with water is frequently useful in relieving the irritation. For the treatment of dry skin eruptions Sir William Roberts recommends the skin to be rubbed with a piece of smooth hard paraffin night and morning, so as to leave on the skin a delicate coating, which then probably acts by pro- tecting the cutaneous surface from the air. Treatment of g-outy grlycosuria and gouty diabetes. — Dietetic treatment. — Careful dietetic treatment should be resorted to, without, however, restricting the diet too much. An excessively nitrogenous diet is to be avoided as tending to accentuate the gouty condition, but no hard and fast rules as to the amount of diet can be laid down. Each case must be treated by ascertaining what amount of proteids, fats, and carbohydrates is best borne by the individual. Toasted bread, milk, and milk puddings made with rice, sago, and tapioca are generally permissible in this form of glycosuria. The best test of the suitability of the diet is the fact that the weight of the patient is not diminishing, while, at the same time, the excretion of sugar CHAP.xiii] RETROCEDENT GOUT. 239 is becoming less. The patient should, therefore, be weighed once a week, and the whole of the urine for twenty-four hours should be collected once a week, measured, and the quantity of sugar determined in a sample of the mixed urines, so that the total output of sugar for the twenty- four hours may be known. Medicinal treatment. — A pill containing one grain of " blue pill," one grain of acetic extract of colchicum, and two grains of euonymin should be given every other night. A mixture containing thirty grains of ammonium chloride and fifteen minims of dilute nitro-hydrochloric acid in each dose should be taken three times a day ; this mixture acts as a stimulant to hepatic metabolism. Opium and its alkaloids are best avoided. A list of the mineral waters best suited for the treatment of gouty glycosuria and gouty diabetes is given later on. Treatment of retrocedent or metastatic g-out. — Immediate treatment. — If the symptoms are urgent some brandy should be immediately given, and, if necessary, a hypodermic injection of morphine should be administered, provided marked albuminuria does not exist. If the metastatic seizure is a severe one, and especially if it affects either the heart or brain, it may be desirable to reinduce an attack of articular gout by placing the feet in a hot mustard- and-water bath, containing a full tablespoonful of flour of mustard to a gallon of water. Treatment of the gastro-intestinal form. — A mustard leaf should be applied to the epigastrium, and a mixture containing bismuth subcarbonate, sodium bicarbonate, and hydrocyanic acid should be given. If there is much depression suitable stimulants must be employed. Treatment of the cardiac form. — Heart tonics, such as digitalis, convallaria, or strophanthus, and brandy, should be administered. A mustard leaf may be applied to the epigastrium. If an anginal attack occurs, then, in addition to this treatment, a dose of nitroglycerine should be given 240 GOUT: TREATMENT. [Partiv. at once, or an inhalation of nitrite of amyl employed, and, if necessary, a mustard leaf should be placed over the prsecordial region. For the treatment of syncopal attacks the patient should be immediately placed in the recumbent position, with the foot of the sofa or bed raised ; some hot brandy and water should be given, warmth and friction applied to the extremities, and a mustard leaf placed over the epigastrium. Treatment of the cerebral form. — If the patient is plethoric, and if the pulse is hard, and stupor or coma supervenes, venesection should be performed, and from eight to sixteen ounces of blood withdrawn ; in less urgent cases six leeches may be applied to the mastoid region. Five grains of calomel should afterwards be administered by the mouth, and a turpentine enema given. CHAPTER XIV. DIET IN GOUT. General principles of dieting — Digestibility of food — Chittenden's views — Animal food — Purin - free diet — Vegetable food — Starchy and saccharine foods — Fruits — Beverages — Simplicity of meals — The Salisbury diet — Plan of diet for gouty subjects. General principles of dieting*. — No hard-and-fast lines as to dietary can be laid down in the treatment of gout. Each individual must be carefully considered as regards his habit of body, his capacity for the digestion of different articles of food, the amount of exercise he is able to take, and the nature of his work. Derangements of the gastro-intestinal tract constitute a most important factor in the development of acute, chronic and irregular gout ; in all forms of gout, whether regular or irregular, there is one invariable symptom, viz., digestive disturbance. It is, therefore, of the utmost importance to secure and maintain a healthy condition of the gastro-intestinal mucous membrane, and a normal daily evacuation, in order to guard against auto-intoxication, which is un- doubtedly an early factor in the development of the gouty condition. The individual who is subject to gouty attacks can certainly diminish the number and severity of the attacks, and in many cases can prevent their recurrence, by careful attention to diet, to the quality and the quantity of fluid taken, to exercise, and to a sufficient daily action of the bowels. Gouty people may for the purposes of the con- sideration of diet be roughly grouped into three classes i e 24L 242 GOUT: TREATMENT. [Partiv. (i) those who suffer from more or less frequent attacks of acute gout ; (2) those who have never suffered from an acute attack, but who are constantly subject to some chronic form of regular or irregular gout, especially after slight indiscretion in diet ; and (3) those who are only affected with gouty symptoms (generally of the irregular kind) when they eat or drink certain articles, and who therefore in order to avoid these gouty symptoms have to be specially watchful over their diet. As Mouillot has observed, it will usually be found that patients in classes 2 and 3 are the offspring of those who have suffered from acute gout. In advising as to the diet of any particular gouty in- dividual the personal factor is a most important one to consider, and it is wise to gain some knowledge as to the likes and dislikes of the individual with regard to food. In this connection it is well to remember the saying of Sydenham, that " more importance is to be attached to the desires and feelings of the patient, provided they are not excessive, than to doubtful and fallacious rules of medical art." It is well known that the excessive consumption of rich nitrogenous food, combined with excesses in wine and malt liquors, both induces and excites gout. The com- parative immunity of females and young people from gout is mainly explained by the absence of such determining causes of the gouty attack, combined, in the case of young people, with the absence of predisposing cause, and also with the fact that the secreting functions are in full activity. The subjects of gout are generally persons who live well and consume a large amount of animal food. Budd, speak- ing from a long and extensive professional connection with a large rural district, states that he never knew an instance of gout occurring in an agricultural labourer. Dig'estibility of food. — Gout, which is a toxaemia originating to a great extent in the alimentary tract, derives its toxic products from the improper digestion of food-stuffs. Chap. XIV.] DIET. 243 Whatever articles of food can be properly digested by the gouty are therefore suitable articles for their dietary. The physical condition of an article of food to a very great extent determines its digestibility. By digestibility is meant not necessarily the extent to which it is absorbed into the blood, but the power of disposing of the food by the stomach, without the production of discomfort or pain. The digestibility of the various kinds of fish, and of the flesh of birds and animals, depends on the length of the muscular fibres, and on the amount of fat deposited between the fibres. The shorter the fibres, and the smaller the amount of fat deposited between them, the more digestible will the article of food be. If an article of food tends to be swallowed in a solid lump, such for instance as new bread or new potatoes, so as to prevent the ready permeation of the substance by the digestive juices, it tends to be indigestible purely by virtue of its physical condition. If such articles were first reduced to minute subdivision by thorough mastication and insalivation, their indigestibility, as far as ordinary individuals are concerned, would dis- appear. It is not so much a matter of importance to know whether or not any particular article of food contains uric acid or its antecedents, as to know what are its proper- ties as regards digestibility and as regards its influence on the processes which are concerned in the conversion of food-stuffs into body-stuffs. The researches of Pawlow have shown that the food value of any particular article of diet must depend to a large extent upon the amount of energy necessary for its digestion. If gouty persons partake of meals of too complex a character, then, owing to the abnormal intestinal and hepatic metabolism of such subjects, excessive production and im- perfect elimination of toxic products may result. Although both excessive production and imperfect elimination of these abnormal products of digestion go more or less 244 GOUT: TREATMENT. [pahtiv. together, yet it is a matter of fairly frequent observation that some gouty persons seem to be especially the victims of excessive production of toxic products, and others to be mainly affected by defective elimination. In regulating diet it is very important to bear in mind that it is in many cases not advisable to change too suddenly the diet to which the patient is accustomed. The com- position of the various digestive secretions is adapted to the food they have to digest, so that the individual who habitually eats an excess of proteid comes in time to have gastric and pancreatic secretions which will digest proteid well, and if the carbohydrates of the food have been limited he will also have a limited capacity for their digestion ; so that if a sudden change of diet is ordered, it takes a little time for the constituents of the digestive secretions to adapt themselves to the altered food, and in the meantime the patient may feel worse for the change of diet which will ultimately benefit him. The diet suitable to any patient will depend on the digestive capability of that patient, and should be regulated accordingly ; it is important to remember to treat the individual as well as the disease. Maintenance of a healthy alimentary tract. — If, as is probably the case, the toxin or toxins of gout are produced in the intestinal tract, it is obvious that the first efforts at treatment should be directed to obtaining a healthy alimentary tract, and to modifying those habits of living which have caused gastro-intestinal derangement. Before deciding how these objects can be attained, it is first necessary shortly to consider some points in the diges- tive processes which take place in the small intestine. Under normal conditions bacterial decomposition does not take place in the upper part of the small intestine, as the duodenum and upper portion of the jejunum are practically sterile. The conditions which favour increased bacterial growth in the intestine are (i) increase in the amount of proteid food (the number of bacteria in the intestine varying Chap. XIV.] DIET. 245 directly with tlae amount of proteid food), and (2) the reaction of the intestinal contents. As long as the contents are acid, bacterial growth is inhibited, but when, owing to gastric or intestinal dyspepsia, the intestinal secretion is changed, the reaction of the intestinal contents changes, and great increase in the number of intestinal bacteria takes place, while at the same time their pathogenicity is increased. Therefore, the growth of bacteria in the intestinal tract and their pathogenicity will vary directly with the amount of proteid food and the amount of catarrh present. These facts obviously have a great bearing on the treat- ment of gout, and explain how it is that excess of proteid food, and those forms of alcohol which tend to produce intestinal catarrh, have such a strong influence on the production of gout. As regards the amounts of proteid, fat, and carbo- hydrate that the ordinary individual of average body weight needs during the twenty-four hours to satisfy the normal nutritive requirements of the body, it may be answered in a general way that he requires enough of these foodstuffs to establish physiological and nitrogenous equilibrium, suffi- cient, that is, to keep up the strength of body and mind that is essential to good health, to maintain the highest degree of physical and mental activity with the smallest amount of friction and the least expenditure of energy, and to pre- serve and heighten if possible the ordinary resistance of the body to disease germs. Chittenden's opinion is that the smallest amount of food that will accomplish these ends is the ideal diet. There must be enough to supply the true needs of the body, but any great surplus over and above what is really called for may in the long run prove an undesirable addition. It is therefore necessary to have definite and precise knowledge of the amount of proteid, and of the total calorific value, needed to maintain the body in the highest state of ef&ciency, before any very 246 GOUT: TREATMENT. [partiv. exact estimate of what constitutes over-nutrition or under- nutrition can be formed. It must be understood that no diet contains an adequate amount of proteid food that does not keep up a condition of nitrogenous equihbrium. If the nitrogen output per- sistently exceeds the nitrogen intake, it is obvious that the body is feeding on its own tissue, which means that the proteid of the food is insufficient in amount. On the other hand, a diet that suffices to maintain body weight, with estabhshment of nitrogen equilibrium, should, so far as our present knowledge goes, be quite adequate to meet all the wants of the body for proteid matter. Chittenden considers that the daily consumption of proteid food far beyond the amount required to maintain health, strength, mental and physical vigour, body weight, and nitrogen equilibrium, constitutes a form of over-nutrition as serious in its menace to the health and welfare of- the human race as many other evils more striking in character. He believes that there are more people suffering to-day from over-eatmg and over-nutrition than from the effects of alcoholic drink. He maintains that if people, as shown by experiments, can maintain nitrogen equilibrium and body weight, gain in strength, show greater freedom from muscular fatigue, lose their rheumatic and gouty symptoms, regain a smooth and soft skin, exhibit greater freedom from colds, retain the normal haemoglobin content of their blood, and in every recognisable way manifest a good condition of health on a low proteid diet, there should be no hesitation in accepting the teaching which the scientific data point to. Chittenden's experiments show that it is quite possible to maintain body weight, and keep up nitrogen equilibrium, and preserve strength, vigour, and good health on from 34 grammes to 56 grammes of proteid matter per day. My own experience is that, on a diet containing this amount of proteid, gouty persons maintain their nitrogen equilibrium and body weight, become free Chap. XIV.] DIET. 247 from most of their gouty symptoms, and generally enjoy a good condition of health. Animal food. — As regards the question of meat, it must be remembered on the one hand that animal foods constitute to the majority of people the most attractive and appetising forms of diet, and are therefore likely to be taken in excess ; hence the necessity for limiting the amount to be taken. But, on the other hand, it must be borne in mind that it is most desirable to increase the combustion and the oxidative powers within the tissues. In my opinion it is absolutely erroneous to exclude from the dietary of the gouty such articles as meat, fish, and tea, because they are assumed to contain uric acid. The so-called estimations of uric acid in those articles of diet are not, as I have elsewhere pointed out, estimations of uric acid at all. Moreover, the deduction is an erroneous one that because uric acid is a nitrogenous body, it must therefore be directly derived from nitrogenous constituents of the food, the consumption of which must consequently be avoided. The contention that a meat diet is poisonous to the human body, on account of the uric acid that it contains, or produces, is preposterous, in view of the facts that many races have maintained robust health on such a diet, and that, for centuries, the beef-eating Englishmen have man- aged to spread and advance knowledge and civilisation, and to acquire territory in all parts of the world. Surely, if meat is the poison which a certain class of enthusiasts and fanatics maintains it to be, we as a nation should have ceased to exist long ere this. Harry Campbeh, in his interesting series of articles on " The Evolution of Man's Diet," has shown that man has evolved from the ape on a highly animalised diet, and that it was on such a diet that the intehectual faculties, and the faculty of language, which distinguish him from the beast, were developed. It is interesting to note that the recent remarkable advance 248 GOUT: TREATMENT. [^ARxrv. of the Japanese to the position of a first-class Power amongst the nations is concurrent with the adoption of a more animal- ised diet by them. The fact that many races in the past have been largely carnivorous as regards their diet, and that some are so even at the present time (Esquimaux, Andamanese, etc.), shows that the assumption that animal foods are necessarily poisonous to man is an entirely erroneous one.. No class of food-stuff gives so great an amount of energy and produces so much heat as animal food, and none is more easily digested by the majority of gouty people. On the other hand, the tendency with most people in this country, as I shall have occasion to remark later on, is to eat too much, and to masticate too little, and this applies to the consumption not only of meat but of all other solid articles of diet. On the whole, it may be stated that animal food, such as fish, chicken, game and meat, is best suited to the majority of gouty cases, whilst foods of the farinaceous class are most likely to disagree. White meats, such as chicken and fish, are more digestible than red meats. The quantity of meat, and especially of red meat, must be restricted in those cases in which the kidneys are imperfectly performing their eliminating functions, as evidenced by a pale urine, of low specific gravity, and deficient in urea and purin- bases. Pupln-free diet. — A purin-free diet is one selected from milk, cheese, butter, white bread, cereal foods, nuts, and fruit. Milk suits gouty people very well, and milk has a special effect in reducing the number of intestinal bacteria, their number being less with a milk diet than with any other. It is true that a purin-free diet has proved of benefit in certain cases of disease, but there is every reason to believe that in such cases an equal benefit would be obtained by a mixed diet, in which the proteid consumption is kept down to a minimum. So long as temperance in the ingestion tHAP. XIV.] DIET. 249 of proteid is observed, it matters but little from what source the proteid is derived. From Walker Hall's experiments it would appear reasonable to administer sweetbread to gouty patients, since its nuclein portion is only slightly absorbed, for thymus sweetbread contains principally adenin, which is rapidly excreted, and pancreas sweetbread contains mainly guanin, an amino-purin incapable of increasing the urinary purin output and of exerting any injurious effects upon the tissues. Vegetable food. — A fair proportion of vegetable food should be taken with two meals each day. The choice of vegetables will depend upon the digestive capacity of the patient ; but, excepting the potato, as a rule those vegetables that grow above ground are preferable to root vegetables. Whereas the mineral constituents of meat exercise a marked effect in diminishing the solubility of a gouty deposit, the mineral constituents of most vegetables exercise a marked power in increasing its solubility. The vegetables, the mineral constituents of which I find are most efficacious in this respect, are spinach, Brussels sprouts, potatoes, cabbage, and French beans. At the same time, it must be borne in mind that with certain patients some of these vegetables may tend to produce some form of dyspepsia ; and I must again insist that in the dieting of the gouty no hard-and-fast rules can be laid down, but the idiosyncrasy of each patient to various articles of diet must be made the subject of careful observation and study. Due consideration should also be given to the patient's experience of what articles of diet disagree or agree with him. Starchy and saccharine foods. — A diet that too largely consists of bread and starchy material Jeads to gravel in a number of cases. The frequency of uric acid gravel and stone among the rice-fed Hindoos is well known. Starchy articles of food should be especially limited in 250 GOUT: TREATMENT. (partIV, amount in those gouty individuals who are subject to gastric hyperacidity (hyperchlorhydria). This condition is not due to gastric fermentation, but to an excessive secretion of hydrochloric acid by the gastric glands, and is a common cause of dyspepsia, and ultimately of gastric dilatation. It is due to an acid dyscrasia, as the result of which the secretion of gastric juice does not cease with the digestion of the proteid materials of the food, but continues after they have been disposed of. The result is that a considerable portion of the starchy materials is kept back in the stomach, and this retained starch keeps up the gastric secretion, without at the same time giving it any work to do. When intestinal fermentation and putrefaction occur, as evidenced by a sense of discomfort after a meal, I attach great importance to the reduction of the starchy articles of food, but not to the total exclusion of what I believe to be comparatively harmless, the potato. It is remarkable how frequently one hears from gouty patients the emphatic statement, " I never eat potatoes." I must confess that I do not know of any good and sufficient reason for a wholesale condemnation of this common article of diet. Undoubtedly amongst those gouty patients who suffer from an inability to digest starchy articles of diet — in other words, who suffer from amylaceous dyspepsia — a reduction for the time in the amount of starchy foods taken, including potatoes, is desirable ; but the recognition of the existence of amylaceous dyspepsia is a fairly easy matter, and when present it can be suitably treated. Certainly those who are gouty and fat should be very sparing in the use of potatoes, as of other carbohydrate forms of food. I wish, however, to protest against the too general exclusion from the food of the gouty of so popular and useful an article of diet as the potato. The best form in which potatoes can be taken by the gouty is the crisp form, which requires thorough mastication and insalivation. Boiled new potatoes should be absolutely interdicted to the gouty. Chap. XIV.] DIET. 251 Equally wrong, in my opinion, is the total exclusion of sugar from the dietary of all gouty individuals. Undoubtedly in certain individuals sugar may do harm, as in the cases of gouty persons who are fat, or who suffer from glycosuria, or who are prone to attacks of eczema ; and in such it should be cut off ; but that is no reason for the exclusion of it from the dietary of all gouty patients. I know of many gouty individuals who take sugar with absolute impunity. Some gouty subjects undoubtedly digest very badly all starchy articles of diet, and in such fats may well take the place of starches. Fat bacon, properly cooked, is generally well digested by gouty individuals. Subjects who are both gouty and fat should avoid sugar, but undoubtedly sugar may be taken with advantage by those who are gouty and thin, and such subjects may also take in moderation marmalade and wholesome jams. Bread may advantageously be given as crisp toast, or in the form of rusks, or in the " Zwieback " or twice-baked form, as in these conditions it requires thorough mastication and insalivation. In those cases in which it is desirable to reduce the carbohydrate intake, such restriction may be achieved (i) by cutting off sugar, and all articles containing any form of sugar ; (2) by carefully graduating (by weight) the daily intake of starch-containing foods, so as to attain the minimum consistent with adequate nutrition in each individual case ; (3) by similarly graduating the intake of fats if necessary ; and (4) by throwing the onus of nutrition to a considerably greater extent than previously upon fish, lean meat, green non-starchy vegetables, and gelatinous soups. Fruits. — Any fruit which from experience is known to agree with the individual may be taken by gouty subjects. Apples and oranges generally agree best. Uncooked fruit should never be taken at a meat meal, and is best consumed fasting fairly early in the day, as between breakfast and lunch. 252 GOUT: TREATMENT. [p^rtiv. It should always be thoroughly masticated. Strawberries are frequently avoided by the gouty owing to their pro- ducing in some subjects a certain amount of temporary irritation of the skin, but such irritation generally passes off in a short time. In a few subjects strawberries produce eczema or some other rash, but such cases merely represent idiosyncrasy to the special fruit, and necessarily such individuals, whether gouty or not, should not eat straw- berries. I am, however, strongly of opinion that the indiscriminate banishment of strawberries from the dietary of the gouty is unnecessary. Except in those cases in which there is an idiosyncrasy to their use they constitute a good article of diet for the gouty, on account of their delicious flavour, their antiscorbutic properties, and their richness in potassium salts. It is, however, very necessary that they should be ripe and fresh. They are soon prone to decomposition, and in such a state they aid in the development of those intestinal fermentations which are so inimical to the gouty. Beverag"es. — It is my custom to question closely each gouty patient that I see, not only as to the nature of the beverages taken, but also as to their amount ; and my general experience is that the great majority of people suffering from gout take an insufficient quantity of water to drink. Consequently there is an inadequate flushing of the liver, kidneys, and other organs and tissues, and there- fore imperfect removal of waste and toxic products. More especially does one find this insufficient consumption of fluid among female patients, in many cases due to the absurd and erroneous belief that a diminution in the amount of fluid taken tends to keep down the body-weight and to prevent the occurrence of obesity. Taking from my case- books ten consecutive cases of gout occurring in ladies whom I carefully questioned as to the amount of fluid con- sumed per diem, I find that amongst these ten the amount averaged only 26 fluid ounces ; this included all fluid, Chap. XIV.] DIET. 253 whether taken as water, tea, coffee, soup, wine, ale, etc. The amount is obviously insufficient for the proper flushing of the system. For the treatment, as well as for the pre- vention, of the gouty condition the free consumption of water apart from meals is most desirable. Only a small quantity of fluid should be taken during meals, but during the day from two to three pints of some pure water should be taken. In many cases the ordinary tap-water answers perfectly well ; but if it should happen to be too hard a water, or of doubtful purity, then some simple water such as still Salutaris, Contrexeville, etc., may be taken. " Imperial drink " constitutes an excellent febrile drink for the gouty, and in cases of chronic gout may advantageously be taken when the urine is high-coloured and when it deposits amorphous urates on cooling. It is made by dissolving a teaspoonful of powdered cream of tartar (potassium bitartrate) in an imperial pint of water or barley-water, and then sweetening to taste with loaf- sugar which has been flavoured by rubbing against . the rind of a fresh lemon. In place of the sugar, an ounce and a half of syrup of lemon may be added to the pint of liquid. In cases of obese individuals the drink should be sweetened with saccharin or saxin in place of the sugar. The question of alcohol is fully dealt with in the next chapter. Simplicity of meals. — The diet of gouty patients should be simple, that is, the meals should not be made up of too many articles. Simplicity of food means facility of digestion. Moderation in both eating and drinking is perhaps one of the most essential points to insist on in the dietary of the gouty. Certainly meat, even red meat, should not be excluded from the diet. No class of food-stuff, as I have said, is so pro- ductive of energy as animal food ; and as most cases of chronic gout are suffering from lowered vitality and want of tone, animal food, at all events in moderate quantity, 254 GOUT: TREATMENT. [partiv. is distinctly indicated. My experience supports the truth of this view, as I advise, in the great majority of cases of chronic gout, the taking of one meat-meal a day. The exclusion of any article of diet or of any class of food, without taking into account the surroundings of the case and the peculiarities of the individual, is unscientific. Those articles of diet that are known in the individual to favour intestinal fermentation and putrefaction should be avoided, and, speaking generally, a sense of discomfort after a meal indicates that some article or articles of food have been taken which are not beneficial to the indi- vidual in his present condition. If the gouty symptoms are due to over-production of toxic material from faulty intestinal and hepatic meta- bolism, and if at the same time the kidneys are sound, then a diet which mainly consists of animal food is in- dicated, and in extreme cases of this class even the so- called " Salisbury diet " may be useful. If, on the other hand, the symptoms are due to defective elimination on account of diseased kidneys, then a diet which is more vegetarian will be best. The value of the so-called " Salis- bury diet " consists in the small amount of energy necessary for the digestion of so simple a diet, and in the fact that it contains little which can set up intestinal fermentation or putrefaction. On the other hand, a strictly vegetarian diet requires more digestive energy than a purely animal one, and a much larger quantity of vegetable food must be taken to produce an equal nutritive effect. In connection with the question of the amount of food necessary for the maintenance of the most perfect health, it is very important to bear in mind the necessity of adopting the habit of thorough mastication and insali- vation of food. This applies not only to the gouty, but to everyone. The thorough mastication and insalivation of food has a very striking effect upon the appetite, lead- ing to the choice of a more simple dietary and enabling Chap. XIV.] DIET. 255 it to be satisfied with a diet which is considerably less in amount than the ordinary habit of incomplete mastication demands. If, during the treatment of gout, an attack of gouty dyspepsia should at any time intervene, then a milk diet should be employed until the dyspeptic symptoms have abated. The "Salisbury diet." — As previously stated, as little complexity as is possible in the meals is the main desider- atum in the dietary of the gouty, and in a few intractable cases of chronic gout it may even become necessary to reduce the dietary for a time to the simplest possible form, namely, to two articles of food — lean meat and water. There are a few cases of chronic gout which un- doubtedly improve, and even recover, on an exclusive diet of red meat and hot water. These are generally cases of chronic gouty arthritis which have failed to yield to the ordinary methods of treatment, and which are accom- panied by dyspepsia, flatulence, acid eructations, pyrosis, and offensive stools. I have successfully treated a few such carefully-selected cases of chronic gout by the employ- ment of this, the so-called " Salisbury " treatment. It is essential, before placing a patient on such diet, that the urine should be carefully examined, as any advanced condition of kidney disease contra-indicates the employ- ment of such a dietary. If the evidence of kidney derange- ment is only slight, the adoption of the dietary is not contra-indicated ; but the urine must be carefully exam- ined every two or three days, as any considerable increase in the albuminuria would at once be an indication for the discontinuance of this special diet. Gouty patients suffer- ing from organic heart-disease with any failure of com- pensation should never be placed on this dietary. The dietary consists in the patient drinking from three to five pints of hot water daily, the water being taken from one hour to one hour and a half before each meal, and half an 256 GOUT: TREATMENT. [partiv. hour before retiring to rest, and eating from two to four pounds of beefsteak daily. The meat should be freed from fat, gristle, and connective tissue, thoroughly minced, mixed with a little water, and then warmed through with gentle heat until it becomes brown in colour. A little salt and pepper may be added, and the meat eaten in this form or made up into cakes and cooked on the grill. Later on in the treatment, part of the steak may be taken grilled, or a grilled lean mutton-chop may be substituted for one of the daily meals. The course of treatment should last for from four to twelve weeks, after which a gradual return to ordinary diet should be made. Articles of diet to be avoided by the g-outy.— Rich meat-soups — ox-tail, turtle, mock turtle, kidney, mulligatawny, hare, giblet. Salmon, mackerel, eels, lobster, crab, mussel, salted fish, smoked fish, preserved fish, tinned fish. Duck, goose, pigeon, high game. Meats cooked a second time. Hare, venison, pork, lean ham, liver, kidney ; salted, corned, or cured meats, pickled meats, preserved and potted meats ; sausages ; all articles of food pickled in vinegar ; all highly-seasoned dishes and rich sauces. Tomatoes, beetroot, cucumber, rhubarb, mushrooms, truffles. Rich pastry, rich sweets, new bread, cakes, nuts, dried fruits, ices, ice-cream. Diet in chronic grout and for grouty subjects.— The following plan gives an indication of the diet to be recommended to gouty subjects : — Morning. — Half a pint to a pint of hot water, flavoured with a slice of lemon-peel, should be slowly sipped imme- diately on rising. Breakfast. — A selection may be made from the follow- ing articles of diet, according to the taste of the patient : — Porridge and milk, whiting, sole, or plaice, fat bacon. Chap. XIV] DIET. 257 eggs cooked in various ways, dry toast or " Zwieback bread," thinly buttered, and tea infused for three minutes and then strained from the leaves. Fat bacon is digestible when grilled, but less so when boiled. Eggs should not be taken hard-boiled. Lunch and Dinner. — Soups suitable for the gouty are vegetable purees, and soups made by boiling beef or mutton bones with vegetables, and subsequently removing the fat which separates on cooling. These soups should not be thickened with farinaceous substances. The varieties of fish most suitable to the gouty are whiting, sole, turbot, plaice, smelt, flounder, grey mullet, and fresh haddock. The birds that are admissible as articles of diet are chicken, pheasant, turkey, and game (not high). Butcher's meat, mutton, lamb, and beef should be taken at only one meal in the day, and then in moderate quantity. Two vegetables may be taken at both lunch and dinner. Any of the ordinary vegetables may be taken, except those previously mentioned as best avoided ; but those that I consider most likely to prove beneficial to gouty subjects are spinach, Brussels sprouts, French beans, winter cabbage, Savoy cabbage, turnip tops, turnips, and celery. Potatoes may also be taken in moderate quantities. Stewed fruits, or baked apples or pears, may be taken every day at one meal. Green vegetables as salads may be taken, provided oily dressings are avoided. A simple savoury may, if desired, be taken at the end of dinner, or a small quantity of cheese, if well masticated, and if free from the penicillium fungus or mould. Night. — Half a pint to a pint of hot water, flavoured with a slice of lemon-peel, should be slowly sipped before retiring to bed. With regard to persons who are disposed to gout, but are not actually suffering from it, the usual mixed diet 258 GOUT: TREATMENT. [Partiv. may be taken, but they should hmit the starchy articles of food, and should avoid all rich sweets, rice, tapioca, and sago. Thin and ill-nourished subjects require modi- fications in their diet as compared with people who are stout, while those who take plenty of exercise can take food forbidden to the sedentary. Individuals who especially benefit by a reduction of diet, both as regards quantity and quality, are those over- fed people who are past middle life. CHAPTER XV. ALCOHOL IN GOUT. Alcoholic drinks — Acidity and gout -inducing power of wines and beers — Cause of the inducement of gout by wines and beers — Wines least injurious to the gouty — Cider — Perry. Alcoholic drinks. — Stated as a general principle, a person who is subject to gout is better without alcohol in any form. There are, however, some who require a little alcohol, either to aid digestion or to enable them to get through their work ; and here I am entirely in accord with the advice given by Goodhart, that, if a man requires any stimulant at all, it is a matter he must decide by experi- ment for himself, for no medical man can tell him. If alcohol is necessary or desirable, the form in which it is to be taken is frequently a matter whjch the patient can decide better than the medical man ; but I would insist upon the importance of definitely limiting the amount to be taken, and of restricting its consumption absolutely to meals. Some patients find that a little whisky or brandy suits them best ; others find a light still Moselle preferable ; a few, but in my opinion only a very limited number, find a light claret agrees best with them. Champagne is a wine which is seldom suited to the gouty, especially if taken daily. In elderly people or in the feeble, a moderate amount of pure whisky undoubtedly docs good ; but the indiscriminate ordering of whisky to gouty subjects is, I am sure, wrong. It is well known that certain alcoholic drinks injuriously affect the gouty process, whilst others exert a less injurious 259 26o GOUT: TREATMENT. [partiv. influence. Alcoholic drinks which have been obtained by fermentation, but which have not been submitted to dis- tillation, such as wines and beers, appear to exercise a more harmful influence than if the same amount of alcohol be consumed in the form of one of the distilled spirits, such as whisky, brandy, etc. Sir Alfred Garrod considers that the reason for the prevalence of gout in the south of England and its rarity in Scotland is chiefly to be found in the difference between the beverages drunk in the two countries. Acidity of wines and beers. — Distilled spirits contain little or no acid, whilst wines and beers are distinctly acid ; and to the acids contained in these drinks many physicians have attributed, and still do attribute, their gout-producing properties. The acids present are tartaric, succinic, malic, acetic, formic, propionic, butyric and oenanthic. The acidity of wines is mainly due to tartaric, malic, and suc- cinic acids. The amount of free acid in sound wine, reckoned as tartaric acid, varies between 0.3 and 0.7 per cent. I found the acidity of some 1847 port, reckoned as tartaric acid, to be 0.6 per cent. Cider owes its acidity mainly to malic acid. Its total acidity is usually o.i per cent. If we arrange the various wines in (a) their order of acidity and (b) the order of their gout-inducing power, we find that the most acid wines are not those which most predispose to gout (Table LIX.). The arrangement of wines and beers in the order of acidity, beginning with the most acid, is that given by Bence Jones, while the arrangement in order of their gout-inducing power is that given by Sir Alfred Garrod. Hock, Moselle, and the weaker kinds of ales have com- paratively little gout-inducing power. The acidity of alcoholic liquors cannot have much influence in determining an attack of gout, as port, sherry and malt liquors, which are the most powerful predisposing agents, are amongst the least acid, whilst the more acid Chap. XV] ALCOHOL. 261 wines are comparatively harmless in this respect ; more- over, it must be remembered that the organic acids and their salts contained in wines are converted in the body into alkaline compounds, and are excreted in the urine as such. TABLE LIX. wines and beers arranged in order of acidity and gout-inducing power. (a) Acidity (beginning with the (b) Gout-inducing power (beginning most acid). with the most powerful). Moselle Port Rhine wines Sherry Burgundy Other stronger wines Madeira Champagne Claret Stout and porter Champagne Strong ales Port Claret Sherry Hock Malt liquors Moselle Weaker kinds of ales Gout-inducing" properties of alcoholic drinks. — The question is — To what constituent or constituents of wines and beers are their gout-inducing properties due ? They are not due to the alcohol alone, for in countries such as Scotland, Norway, Sweden and Poland, where distilled spirits are, or were, freely consumed, gout is almost un- known. Moreover, several experiments that I have made indicate that alcohol, in such quantities as are ever likely to be present in the blood, has no effect either upon the con- version of sodium quadriurate into biurate or on the solu- bility of the latter. The gout-inducing properties are most probably not due to the acids of the wines and beers, for the reasons which have already been given. It is also very doubtful whether the sugar present in wines is per se harmful ; but as a rule the sweet wines are fortified wines, while the natural wines are generally dry. It is very probable that the sweet fortified wines are prone to produce 262 GOUT: TREATMENT. [partiv. fermentative and catarrhal changes in the gastro-intestinal tract, and are on that account harmful to the gouty. The gout-inducing properties are certainly not directly due to the cenanthic ether and other ethereal salts of wines exerting any effect either on the rate of decomposition of the sodium quadriurate or on the solubility of the biurate. To demonstrate these points, I have extracted from old port wines the ethereal salts to which the bouquet of the wines is due, and have experimented with these ethereal com- pounds on the quadriurates and biurates. Using quantities far in excess of those likely to be present in the blood after the moderate, or even immoderate, consumption of such wine, I find that none of these volatile constituents exercises the slightest effect either in hastening the decomposition of the sodium quadriurate or in diminishing the solubility or hastening the precipitation of sodium biurate. As to the modus operandi of certain wines, such as port, etc., in hastening an attack of gout, I incline to the opinion that the influence of wines on the development of gout is in great part due to the effect they exercise in producing fermenta- tive and catarrhal changes in the gastro-intestinal tract, and in also injuriously affecting hepatic metabolism. At the same time, it must be remembered that those accus- tomed to drink wine are also able to indulge in other luxuries of the table which greatly favour the development of gout. As Woods Hutchinson has pointed out, the experiments of Boix appear to have shown that, in the case of alcohol, it is not the direct toxic effect of the drug, so much as the catarrhal and other irritative changes set up by it in the intestines, which produce the poisonous products that are carried to the liver and cause the irritation and degenera- tion of that organ. In other words, unless alcohol is taken in sufficient amounts to disturb gastric and intestinal digestion, it will not produce the hob-nail liver. Another consideration to be borne in mind is the rapidly fermentable fruit and malt sugars, esters, and higher alcohols, Chap. XV.j ALCOHOL. 263 which are also present in wines and beers, and which experi- ence in gout shows are more closely concerned with fer- mentative changes in the stomach and intestines than is the alcohol itself. Port is a wine which is especially unsuited to the majority of gouty subjects. The gout-inducing properties of the wine are, I believe, mainly dependent upon the ethereal com- pounds which give the aroma or bouquet to the wine, although these bodies do not act directly on either the quad- riurate or biurate of sodium. If this view is correct it would explain the well-known fact that old and matured ports are much more provocative of gout than comparatively new ports taken direct from the wood. The development of the ethereal compounds in the wine extends over many years, and especially progresses after the wine is laid by in bottles. In a few cases of asthenic gout, especially in old people, a moderate amount of comparatively new port taken direct from the wood undoubtedly does good. In my opinion the wines which are least injurious as a rule to gouty subjects to whom it is found necessary to order a small amount of wine are the light still white wines, such as Moselle, certain French wines, certain Austrian wines, hock, and a few of the lighter Austrahan and Calif ornian wines. These last, owing to their greater alcoholic strength, should be taken diluted with water or some mineral water. Gouty subjects suffering from glycosuria or diabetes should entirely abstain from alcoholic drinks, unless marked debihty and loss of appetite necessitates the restricted administration of them. Gouty persons subject to attacks of eczema are also much better without alcohol in any form. " Rough " cider, that is the completely fermented apple- juice, taken in moderation, agrees well with most gouty subjects. It contains but a small percentage of alcohol, is free from sugar, and its acidity is chiefly due to malic acid, which passes into the circulation in the form of alkaline malates, which in their turn are converted in the kidneys 264 GOUT: TREATMENT. [Partiv. into alkaline carbonates and excreted as such, thereby increasing the elimination of urates. The bottled or " champagne " cider, which is imperfectly fermented, should never be used by gouty individuals, owing to its undoubted liability to set up gastro-intestinal fermenta- tions. Dry or " rough " cider mixed with an equal quantity of an aerated water is an excellent beverage for the gouty. Dry perry is also a suitable drink for the subjects of gout. CHAPTER XVI. SPA, BALNEOLOGICAL, AND CLIMATIC TREATMENT. Spa treatment — Ionic theory and Radio-activity — The uses of mineral waters in the treatment of gout — Classification of mineral waters — The simple waters — Simple alkaline waters — Alkaline sulphated waters — Alkaline muriated waters — Common salt or muriated waters — Sulphur waters — Hot and cold mineral waters — Choice of a spa — Balneology —Climatic Treatment. Spa treatment. — The free employment of water in the treatment of gout dates from ancient times. At the Temples of Asklepios at Epidaurus and Athens water was used extensively both internally and externally, and active gymnastic exercise, riding, friction of the skin, massage, and counter-irritation were prescribed. Spa treatment is a complex treatment made up of several factors, and on the correct apportionment of these different factors depends much of the successful issue of the treat- ment. These several factors are (i) hydrotherapy, which includes the taking of, and the bathing in, the waters ; (2) diet ; (3) exercise ; and (4) accessory forms of treat- ment, such as electric light baths, electrical treatment, massage, etc. With regard to the drinking of a water at a spa there is a tendency with some medical men to consider that the efficacy of a natural mineral water is due solely to its watery constituent — in other words, that its one therapeutic use is that of a flushing agent. Even so astute a physician as the late Sir William Roberts appears to have held this view. In his Croonian lectures, referring to the employment of the waters of certain spas in the 265 266 GOUT: TREATMENT. [partiv. treatment of gout, he said : — " Now there can be no reason- able doubt that the efficacy of these springs has nothing to do with their scanty mineral ingredients but depends on their watery constituent. . . . Their action would be to temporarily dilute the blood and lower its percentage of urates and sodium salts. This effect would tend to re- tard or prevent uratic precipitation, and thus give the defective kidneys additional time to overtake their arrears in the task of ehminating uric acid." Ionic theory and radio-activity. — If the efficacy of a natural mineral water depended solely on its watery constituent I do not for one moment think that the resort of sufferers to the various natural springs would have successfully stood the test of centuries as it undoubtedly has. The fact is that in judging of the effect of natural mineral waters we have been too much under the domination of analytical chemistry, and that our deductions from these results have been consequently biased and cramped. The more I consider the therapeutic effects of the natural mineral waters the more convinced I am that chemical analysis, although it can inform us what are the mineral constituents of the natural waters, is yet unable to deter- mine exactly the state of the salts dissolved in them. The " ionic or electrical dissociation theory " and the exist- ence of the mineral constituents of natural waters as " ions " are leading our thoughts to a new and, I believe, correct appreciation of the therapeutic values of these waters. An element or a group of elements divorced from the rest of the original molecule is an " ion." According to the ionic theory metallic salts in very dilute solutions are completely split up into their " ions," so that all the properties of these solutions must be the sum of the properties of the separate " ions." In concentrated solutions much of the salt remains in the undissociated state and only a small proportion in the form of dissociated " ions," whereas in most of the natural mineral waters, which are weak solutions of salts, the Chap. XVI.] IONIC THEORY. 267 mineral constituents are mainly, if not entirely in many waters, in the form of " ions," and in this form the thera- peutic effects and potency may be quite different from those of the undissociated salts. Ionic dissociation does not, there- fore, alter the percentage composition of a salt, but may very materially alter its therapeutic properties, so that in all probability the " ions " rather than the salts are responsible in great part for the effects of mineral waters. In intimate relation with this aspect of the matter is the question of radio-activity in hydrotherapy. Our conception of the atom as an indivisible and finite body is disappearing, and, in view of the recent discoveries that have been made in connection with radio-activity, the atom must be conceived as consisting of an aggregate of corpuscles, and each atom has associated with it a definite charge of electricity, such an electrically charged atom being an " ion." The smallest unit of electric charge is known as an " electron," and the atom is charged with a number of these electrons, which are in a state of vigorous motion among themselves within the atom. Radio-activity consists in the flinging away with great violence of actual atoms. The substance left is also radio- activity, and ultimately one of the residues seems to dis- charge electrons instead of atoms of matter, thus effecting a transmutation of matter. Now, most, if not all, of the natural mineral waters which have been examined have been found to be distinctly radio-active, and the lower the mineralisation of the water the more intense is its radio-activity. In this, I think, lies the explanation of the fact that an artificially prepared mineral water, although it may be made identical in chemical composition with the natural one, does not possess the same therapeutic effects as the natural water, since it is lacking, at all events to any appreciable extent, in the property of radio-activity. A natural water at the moment of its discharge from the earth is radio-active, whereas an ordinary drinking water does not possess this property in an 268 GOUT: TREATMENT. tPARtiV. appreciable degree. Hence also the desirability of drinking the water at its source, since by the bottling and keeping of a natural water the radio-activity is to a great extent lost. When we consider the marked influence of radio-active emanations on new growths and various morbid tissues, is it too remarkable to conceive that a radio-active mineral water will exercise a potent effect on those morbid changes within the body which are connected with abnormal tissue metabolism ? Uses of mineral waters in the treatment of gout.— If gout is primarily due to the absorption of toxins from the intestinal canal dependent upon a catarrh of the intes- tinal mucosa, many of the natural mineral waters must be efficacious in altering the catarrhal condition and in im- proving the digestive processes ; also the secondary effect of increasing the flow of bile and of thoroughly washing out all the tissues, so as to get rid of toxic accumulation, is impor- tant. The value of a given mineral water in the treatment of gout depends greatly on the main object with which it is taken. For instance, it may be taken to remove gouty deposits, or to stimulate the action of a sluggish liver and to relieve portal congestion, or for the treatment of gouty dyspepsia, or to relieve the bowels in cases of torpor and gastro-intestinal catarrh, or to act on the kidneys, or to relieve gouty affections of the skin. Now it is mani- fest that any one mineral water is not likely to produce all these effects, and it is also obviously conceivable that a mineral water which might be most useful to effect one of these purposes might prove injurious if employed to effect another. No doubt considerable error has arisen from indiscriminately sending gouty patients to a particular spa, without giving due consideration to the question as to whether the water of that spa is suitable for the treatment of the specific gouty disorder from which the patient is suffering. It is well to bear in mind that a patient should chxp.xvi] mineral waters. 269 not be sent to a spa during the acute stage of gout, nor if suffering from marked organic disease of the heart or kidneys. It is especially in cases of chronic gout, of gastro-intes- tinal catarrh and torpor, of gouty dyspepsia, sluggish action of the liver, gouty eczema, gouty glycosuria, and of other forms of irregular gout, that mineral waters prove so valuable, whilst the various baths, combined with massage, are very useful in producing softening and absorption of the deposits in the joints and other tissues. The explanations given as to the modus operandi of a particular mineral water must sometimes be received with a certain amount of caution. For instance, the advocates of one mineral water will extol its efficacy in the treatment of gout on account of the lime salts con- tained in it and its freedom from sodium salts, whilst, on the other hand, the advocates of another mineral water will insist that the large quantities of sodium salts present in it and the absence of lime salts are the potent factors in its usefulness in the treatment of gout. With regard to the presence of lime salts, a mineral water containing such does not exercise, by virtue of those lime salts, either a deleterious or a beneficial action on the gouty deposits of sodium biurate. The only objection to a water containing a large quantity of lime salts is the tendency to produce digestive disturbances and to cause constipation. CLASSIFICATION OF MINERAL WATERS. The various mineral waters used in the treatment of gout may be classified according to their chemical composi- tion into the six following groups : — 1. The simple waters, or waters comparatively free from sodium salts. 2. The simple alkaline waters. 3. The alkaline sulphated waters. 270 GOUT: TREATMENT. [Part IV. 4. The alkaline muriated waters. 5. The common salt or muriated waters. 6. The sulphur waters. 1. The simple waters, op waters comparatively free from sodium salts. — These are the waters that are especially likely to prove useful for the removal of uratic deposits in the joints and tissues. They contain small pro- portions of calcium carbonate and calcium sulphate, but the quantities of sodium salts present are so small that for all practical purposes they may be neglected. The following table (Table LX.) shows the proportions of sodium salts in the respective waters of this class, represented as grains of sodium per gallon : — TABLE LX. Showing the proportions of sodium salts, represented as grains of sodium per gallon, in the principal simple waters. Mineral water. Grains of sodium per gallon. Teplitz 0.20 Strathpeffer 0.45 Contrexeville 0.79 Buxton 1.47 Pfaefers . 1. 61 Gastein . 5.89 Wildbad . 7-6Z Bath 9.42 Vittel 13-39 Teplitz (Bohemia). The waters are hot (83° to 114° F.). Altitude about 730 feet. Thermal baths and peat baths are provided. Open all the year, but the usual season is from May to September. Strathpeffer (Scotland, Ross-shire). The waters are cold. Altitude about 200 feet. Strathpeffer also pos- sesses sulphur springs and a chalybeate spring. Various kinds of baths are provided. The sulphur waters are useful chap.xvi] mineral waters. 271 in the treatment of the various skin affections connected with gout. Open all the year, but the usual season is from May to October. Contrexc'ville (France). The waters are cold. Altitude 1,150 feet. Baths are provided. The water, in addition to being almost free from sodium salts, contains magnesium sulphate, so that it is useful not only for the removal of uratic deposits, but also in the treatment of gastro-intestinal and hepatic disorders associated with gout, and for the treatment of urinary gravel. The season is from the beginning of June to the end of October. Buxton (England, Derbyshire). The waters are warm (82° F.). Altitude 1,000 feet. Baths, douches, and douche- massage are provided. The water contains a considerable amount of free nitrogen. On account of the very small proportion of sodium salts present it is an extremely benefi- cial water to employ with the object of removing uratic deposits. The climate is bracing. Open all the year, but the season is from April to September. Pfaefers (Switzerland). The waters are warm (89° to 93° F.). Altitude about 1,700 feet. Baths are provided. The season is from May to October. Gastein (Austria). The waters are hot (78° to 121° F.). Altitude 3,310 feet. Baths are provided. The season is from the beginning of May to the end of September. Wildbad (Germany). The waters are hot (91° to 105° F.). Altitude about 1,320 feet. Baths, douches, and electric baths are provided. The season is from the beginning of May to the end of September. Bath (England, Somersetshire). The waters are hot (104° to 120° F.). Altitude 100 feet. Excellent baths, douches, and douche-massage are provided. The water is a very useful one to employ with the object of removing uratic deposits, and chronic affections of the joints can be well treated at Bath by external methods. Open all the year, but the spring and autumn are the favourite seasons. 272 GOUT: TREATMENT. [partiv. The climate of Bath is mild, and it is therefore a good winter resort. Vittel (France). The waters are cold. Altitude i,ioo feet. The season is from May to September. 2. Simple alkaline wateps. — These waters contain sodium bicarbonate. They are useful for gouty patients suffering from hepatic congestion, dyspepsia, and gastro- intestinal catarrh. The principal waters of this class are those of Vichy, Vals, Neuenahr, Salzbrunn, Fachingen, and Bilin. Vichy (France). The waters are hot (89° to 110° F.). Altitude 736 feet. Baths are provided. The waters are especially useful in the treatment of gouty dyspepsia and gastro-intestinal catarrh, in cases of deranged hepatic function, and for plethoric gouty patients suffering from glycosuria or diabetes. The cases best suited to Vichy are gouty dyspeptics, fairly vigorous, with a tendency to pass acid urine, with deposits of urates and uric acid. It is also very efficacious in promoting the evacuation of renal (uric acid) calculi. Open all the year, but the season is from the middle of May to the end of September. In the middle of summer Vichy is very hot. Vals (France). The waters are cold. Altitude 300 feet. The waters may be used for the same class of gouty cases as mentioned in connection with the Vichy waters, but those springs containing iron should be avoided by gouty patients. The season is from the middle of May to the middle of October. Neuenahr (Germany). The waters are hot (75° to 104° F.). Altitude 760 feet. Baths are provided. The waters may be used for the same class of gouty cases as mentioned in connection with the Vichy waters. The season is from May to October, but in the middle of the summer Neuenahr is very hot. Salzbrunn (Prussian Silesia). The waters are cold. Altitude 1,320 feet. The waters may be used for the same chap.xvi] mineral waters. 273 class of gouty cases as mentioned in connection with the Vichy waters. The season is from the beginning of May to the end of September. 3. Alkaline sulphated waters. — These waters con- tain sodium bicarbonate, sodium sulpliate, and generally a moderate proportion of sodium chloride. They are useful in the treatment of gout connected with congestion of the liver and portal system, and of gout connected with gastro-intestinal catarrh and with some forms of dyspepsia. They may also be employed in the treatment of gouty glycosuria. The principal waters of this class are those of Carlsbad, Marienbad, Tarasp-Schuls, Brides- les-Bains, Cheltenham, Leamington, and Bertrich. Carlsbad (Bohemia). The Carlsbad waters are rich in sodium sulphate and sodium bicarbonate, and also contain a moderate proportion of sodium chloride. The waters are hot (95° to 162° F.). Altitude 1,160 feet. Baths are provided. The waters are best suited for gouty patients suffering from torpor of the hepatic and gastro-intestinal functions, and especially for cases of congestive enlarge- ment of the liver with a tendency to haemorrhoids. The Carlsbad waters have a remarkable action on the liver, and they have been especially utilised in the treatment of gout associated with hepatic congestion, haemorrhoids, and " abdominal plethora." They are also of use in the treatment of gouty glycosuria. The waters are best suited for those of fairly robust constitutions. They are contra- indicated if heart disease is present, or if arterio-sclerotic changes are advanced, or if the kidneys are seriously impli- cated. The season is from the middle of April to the end of September. A course at Carlsbad may advanta- geously be succeeded by a stay in Switzerland at a station situated at a high altitude. Marienbad (Bohemia). The waters are cold. Alti- tude about 1,980 feet. Baths are provided. The waters are very similar in composition to those of Carlsbad, and s 274 GOUT: TREATMENT. [Partiv. are useful for the same class of cases. The season is from May to September. A course at Marienbad is also advan- tageously succeeded by a stay at a high altitude. Tarasp-Schuls (Switzerland). The waters are cold. Altitude 3,870 feet. Baths are provided. The waters are useful for the same class of cases as mentioned in con- nection with the Carlsbad waters. The season is from the middle of June to the middle of September. Brides-les-Bains (France.) The waters are hot (95° F.). Altitude about 1,860 feet. Baths are provided. The waters are useful for the treatment of gouty dyspepsia associated with constipation. The season is from the beginning of June to the end of September. Cheltenham (Gloucestershire). The waters are cold. They are rich in sodium chloride and sodium sulphate ; one of them contains in addition a large amount of mag- nesium sulphate ; the Pittville or alkaline water contains, besides sodium chloride and sodium sulphate, a fair pro- portion of sodium bicarbonate. Baths are provided. The Cheltenham waters differ to a considerable extent from any other mineral waters found in England. They are fairly closely comparable to the waters of Marienbad, Homburg, and Tarasp-Schuls. The waters are useful for the same class of cases as are dealt with at Carlsbad, Marienbad, and Homburg. Cheltenham possesses a com- paratively dry atmosphere, and the winters are mild. It is especially suitable for those who have lived long in hot climates. Leamington (Warwickshire). The waters are cold. Baths are provided. The waters are useful in the treat- ment of torpid conditions of the liver and of the gastro- intestinal tract associated with gout, and also in the treat- ment of gouty glycosuria. 4. Alkaline muriated waters. — These waters contain sodium bicarbonate and sodium chloride. They are use- ful in the treatment of gouty dyspepsia and of gouty Chap. XVI.] MINERAL WATERS. 275 catarrhal affections of the respiratory organs. The principal waters of this class are those of Ems, Royat, Assmanns- hausen, and La Bourboule. Ems (Germany). The waters are hot (80° to 120° F.). Altitude 300 feet. Baths are provided. The waters are especially useful for patients suffering from gouty bron- chitis and asthma, for the treatment of which affections they can be inhaled in a finely divided condition. They may also be employed in the treatment of gouty dyspepsia. The climate is a relaxing one, and is best suited to elderly gouty patients. ** Royat (France). The waters are warm (68° to 95° F.). Altitude 1,480 feet. Baths are provided. The waters are useful for the same class of cases as mentioned in con- nection with the Ems waters. The season is from the middle of May to the middle of September. Assmannshausen (Prussia). The water is tepid (82° F.), and contains a small proportion of lithium bicarbonate. La Bourboule (France). The water is hot (130° F.). Altitude 2,780 feet. Baths are provided. The waters are arsenical as well as alkaline muriated, and may be useful in certain cases of chronic gouty skin disorders. The season is from the beginning of June to the end of September. 5. Common salt or muriated waters. — These waters contain sodium chloride as their principal constituent, and some of them also contain a large amount of free carbonic acid gas. Sodium chloride has a stimulating effect upon the mucous membrane of the gastro-intestinal tract. In the stomach it dissolves the mucus, increases the secretion of gastric juice, and so helps to promote the digestion of albuminous substances. In the intestines it stimulates the flow of pancreatic juice and bile, and owing to its influence on the process of osmosis, promotes the absorp- tion of food. Intestinal peristalsis is also increased. The 276 GOUT: TREATMENT. [partiv. waters are of use in the treatment of gastro-intestinal and hepatic gout, especially when accompanied by constipation, and in cases of gouty dyspepsia associated with general atony. They are not indicated in cases of articular gout, when the removal of the uratic deposits is the main object of treatment. The principal waters of this class are those of Homburg, Wiesbaden, Kissingen, Baden-Baden, Nau- heim, Llandrindod Wells, Woodhall Spa, Llangammarch Wells, Oeynhausen. Homburg (Germany). The waters are cold. Altitude about 600 feet. Baths, massage, and electrical treatment are provided. The waters produce slight purgation and diuresis, and are useful for the treatment of gouty dyspepsia with a tendency to constipation, and of gouty gastro- intestinal catarrh and hepatic congestion associated with general atony. Wiesbaden (Germany). The waters are hot (100° to 156° F.). Altitude 380 feet. Baths are provided. The waters are useful for the same class of cases as men- tioned in connection with the Homburg waters, but should be avoided in cases of articular gout. Open throughout the year, but in midsummer Wiesbaden is very hot. Kissingen (Bavaria). The waters are cold. Altitude about 600 feet. Baths are provided. The waters are useful for the same class of cases as mentioned in con- nection with the Homburg waters. The season is from May to the end of September. Baden-Baden (Grand Duchy of Baden). The waters are hot (120° to 150° F.). Altitude about 650 feet. Baths, douches, and electric baths are provided. The waters are useful in the treatment of gastro-intestinal catarrh and sluggish conditions of the liver. Open all the year, but the season is from the beginning of May to the end of October. During July and the first half of August Baden-Baden is very hot. Nauheim (Germany). The waters are warm (82° to Chap. XVI.] MINERAL WATERS. 277 95° F.). Altitude about 400 feet. This spa is specially known for its baths in connection with the treatment of various affections of the heart. Two of the waters are somewhat similar in composition to the Homburg water, and may be employed in the treatment of gouty dyspepsia. The season is from May to the end of September. Woodhall Spa (Lincolnshire). This water, in addi- tion to being a highly muriated water, contains bromides and iodides. Llangammarch Wells (Wales, Brecknockshire). Alti- tude about 600 feet. This water, in addition to being a muriated water, contains a small quantity of barium chloride. Brine baths. — The brine baths of Droitwich (England, Worcestershire), Kreuznach (Germany), Ischl (Austria), Rheinfelden (Switzerland), Aussee (Styria), Reichenhall (Bavaria), and Bourbonne-les-Bains (France) are useful in the treatment of stiffness and thickening of the joints in cases of chronic articular gout, but should be avoided if gouty skin affections are present. 6. Sulphur waters. — These waters contain sulphur, some in the form of sulphuretted hydrogen only, while others, in addition to free sulphuretted hydrogen, contain combined sulphur in the form ol the sulphides of calcium, magnesium, and sodium. They are frequently very useful in the treatment of gouty skin affections, especially eczema and psoriasis. Sulphur baths are also of benefit for the same purpose. In my opinion, patients actually suffering from acute or subacute articular gout, or who are apparently on the verge of such an attack, are better without sulphur waters, as in such cases the waters tend to accentuate or precipitate an attack in the joints. At the present time, however, it is far commoner to meet with gout in some of its irregular forms than in the articular form, and in most of the cases- of irregular gout the beneficial effects of sulphur waters are beyond question, and especially does this apply to 278 GOUT: TREATMENT. [partiv. the forms of gastro-intestinal catarrh, hepatic inadequacy, and eczema due to the gouty condition. The sulphur springs may be classified into the cold and hot springs. Cold sulphur springs. — The principal waters of this class are those of Harrogate (England, Yorkshire), Strath- peffer (Scotland), Llandrindod Wells (Wales, Radnorshire), Gurnigel (Switzerland), Heustrich (Switzerland), Nenndorf (Prussia), and Weilbach (Germany). Hot sulphur springs. — The principal waters of this class are those of Aix-les-Bains (France), Aix-la-Chapelle (Germany), Baden (Switzerland), Baden (near Vienna), Uriage (France), Bagneres-de-Luchon (France), Allevajd (France), Saint-Honore (France), and Schinznach (Switzer- land). Harrogate (Yorkshire), The waters are cold. Alti- tude 400 to 600 feet. The principal waters contain sul- phuretted hydrogen and sodium sulphide. The " Kissingen well " water is a muriated chalybeate water. Harrogate is well provided with recent and elaborate appliances for baths, douches, etc. The waters are especially useful in the treatment of the various forms of gastro-intestinal catarrh, hepatic inadequacy, and eczema due to the gouty condition. The various baths are extremely beneficial in the removal of the stiffness and swelling of the joints left after an attack of gout. The spa is open all the year, but the season lasts from May to September. Llandrindod Wells (Wales). The waters are cold. Altitude 700 feet. The waters are somewhat similar to those of Harrogate, and are used for the same class of cases. The season is from May to October. Strathpe-ffer (Scotland). The waters are cold. Alti- tude 200 feet. The principal waters contain sulphuretted hydrogen and sodium sulphide, and are used for the same class of cases as the Harrogate waters. Various kinds of baths, including peat baths, are provided. The spa is open all the year, but the season lasts from May to October. Chap. XVI.] MINERAL WATERS. 279 Aix-les-Bains (France). The waters are hot (112'' F.). Altitude 870 feet. The waters contain free sulphuretted hydrogen. This spa is especially known for its baths, douches, and douche-massage, all of which methods of treatment are most beneficial in the removal of the stiff- ness and swelling of the joints left after an attack of gout. The waters are also employed in the treatment of cutaneous affections connected with gout. The spa is open all the year, but the season lasts from April to November. Hot and cold mineral waters. — The following table shows a classification of the various mineral waters used in the treatment of gout into hot and cold waters :— . TABLE LXI. Classification of the various mineral waters used in the treatment of gout into hot and cold waters. Hot. Cold. Aix-les-Bains Cheltenham Aix-la-Chapelle Contrexeville Baden Harrogate Baden-Baden Homburg Bath Kissingen Brides-les-Bains Leamington Buxton Llandrindod Wells Carlsbad Marienbad Ems Salzbrunn Gastein Strathpeffer La Bourboule Tarasp-Schuls Nauheim Vals ITeuenahr Vichy (some springs) Ragatz-Pfaefers Vittel Royat Teplitz Vichy (some springs) . Wiesbaden Wildbad Choice of a spa. — In the selection of a spa, so many factors have to be considered that it is impossible, in a work of this nature, to deal fully with the subject. I wish, 28o GOUT: TREATMENT. Part IV. however, to state clearly that the high state of efficiency to which our home spas have been raised renders it no longer essential to banish our patients to foreign health resorts, and that, unless a complete change of environ- ment is desired by the patient or is essential to recovery, treatment can, in the great majority of cases, be carried out as effectually in our own country. The following table may be of some value as an attempt to classify the therapeutic indications of mineral waters in the treatment of gouty conditions. TABLE LXII. Classification of the various mineral waters according to their therapeutic value in the treatment of the variotis forms of gout. Object of taking the waters. Absorption of gouty deposits from the joints and tissues. The waters best suited to the purpose. Bath, Buxton, Contrexeville, Gas- tein, Harrogate, Pfaefers, Strathpeffer, Teplitz, Vittel, Wildbad, Aix-les-Bains (for baths). Treatment of gouty dyspepsia. Brides-les-Bains, Carlsbad, Ems, Harrogate, Homburg, Kissingen, Neuenahr, Royat, Vals, Vichy, Wies- baden. Treatment of gouty congestion and torpor of the liver, and of gastro- intestinal catarrh and tor- por. Baden-Baden, Bourbonne, Carlsbad, Cheltenham, Contrexeville, Harrogate, Homburg, Kissingen, Leamington, Llandrindod Wells, Marienbad, Neuen- ahr, Tarasp-Schuls, Vals, Vichy, Vittel, Wiesbaden. Treatment of gouty affections of the respira- tory organs. Ems, Royat. Treatment of gouty gly- cosuria and diabetes. Carlsbad, Contrexeville, Harrogate, Kissingen, Leamington, Llandrindod Wells, Marienbad, Neuenahr, Strath- peffer, Vals, Vichy, Vittel. Treatment of gouty skin affections. Aix-les-Bains, Baden, Bagneres-de- Luchon, Harrogate, Llandrindod Wells, Schinznach, Strathpeffer. Chap. XVI.] BALNEOLOGY. 281 Balneolog'y. — Useful as may be the drinking of a water at a spa, yet equally, and even in some cases more, useful is the encouragement for therapeutic purposes of the functions of the skin by balneological methods. The skin is the largest organ of the body, and, as would be expected of such an organ, it possesses various and com- plex functions. Amongst its functions are (i) the ex- cretion of toxic bodies, the retention of which proves harmful and ultimately fatal to the organism ; (2) the power that it possesses through its nerve-endings of stimu- lating distant organs and tissues ; and (3) its heat-regu- lating power. The success of balneology, whether in the treatment of chronic joint conditions, of affections of the fibrous tissues, of certain heart and kidney affections, or of certain skin diseases, depends upon the recognition of the powerful aid which can be given by the skin in restoring the normal balance. Heat, whether applied in the form of water baths or in that of air baths, lowers the arterial pressure and raises the venous pressure, as a consequence of the relaxation of the muscular coats of the arteries and of the arterioles that is induced. The flushing effect of a course of warm baths on the clogged periphery of the circulation is useful in chronic gout and in chronic renal disease, and this bene- ficial influence extends to the heart, since the opening up of the peripheral circulation eases the work of the left ventricle, which consequently is able to deliver its load more and more completely, and retain less and less residual blood as the peripheral resistance diminishes. The cabinet electric light bath in which the whole body is enclosed up to the neck is a powerful means for the reduction of the arterial blood pressure, and is service- able in the treatment of high arterial pressure, such as that observed in granular kidney. In addition to its 282 GOUT: TREATMENT. [Partiv. pronounced action on the circulation, it is a powerful stimulant of the cutaneous excretion of waste products. Warm baths are of great therapeutic value as vaso- motor relaxants, but there is another group of baths possess- ing quite different properties — namely, those of cardiac and vaso-motor stimulation. These are percussive baths, massage baths, and baths of alternating temperature. Percussive baths are represented by the various forms of douche and needle baths. The general effect on the blood pressure is to raise the arterial and to lower the venous pressure. George Oliver states that the needle bath, doubly alternating in temperature {i.e. falling from warm to cool, then rising to warm, and again falling to cool), with a hot descending spinal douche, has the most powerful effect in raising the arterial pressure. There is no doubt that the effect of the percussion of water on the peripheral vessels is greatly intensified - by varying the temperature, and especially by allowing it to dip to the lowest ranges. Apart from percussion, the mere alteration of temperature, when considerable, has a remarkable effect on the blood pressure, and especially is this the case when the cold plunge is taken either after a very hot water bath, or after a hot-air or Turkish bath. It is on this account that the subjects of advanced chronic gout, associated with high arterial tension, should avoid the cold plunge, and the cold needle bath or douche after a hot bath. Climatic treatment. — A fairly bracing air with a low relative humidity is, in my experience, the most suitable for the gouty. High mountain situations, and valleys where there is an excessive relative humidity of the air, are alike unsuited to the gouty. Especially is it desirable to avoid exposure to the cold east and north-east winds which prevail in this country in the early months of spring, and which are so apt to be provocative of what has been called a " chill on the liver," a condition which no doubt is brought about by the chilling effects of these winds Chap. XVI.] CLIMATIC TREATMENT. 283 on the skin, and a consequent reflex affection of the meta- boHsm of the liver cells. A typically bracing climate is provided by a place which is exposed and elevated, which has a low relative humidity, and is therefore liable to rapid variations of temperature. A typically relaxing or sedative climate is one in which the opposite conditions prevail. It is shel- tered and low-lying, with a high degree of relative humidity, and is therefore remarkably equable, both seasonally and diurnally. The physiological effect of a bracing climate is to increase metabolism, of a relaxing climate to diminish metabolism. There are some types of gout which benefit conspicu- ously from bracing climates, but these are the less pro- nounced types, in which stimulating conditions may be tried without danger. On the other hand, those types of gout which are associated with chronic renal disease, and older patients suffering from arterio-sclerosis and high arterial tension, are best treated by sedative climates. In cases of chronic renal disease, care must be taken to avoid any sudden or extreme change of temperature, which would impose an undue strain on the damaged kidneys. It is in such cases that relaxing climates are frequently of immense benefit. In cases of gout associated with fatty degeneration of the heart or with valvular disease, a seda- tive climate is most desirable. All gouty individuals should avoid localities in which there are hard chalky waters, or, if they have to reside in such localities, should avoid drinking the water of the district. In such cases they should drink distilled water, plain or aerated, or some of the simple natural mineral waters. As a winter resort for the gouty I know of no better climate than that of Egypt, where, at Helwan (Helouan), thermal, sulphurous, and saline waters exist, and excellent baths are obtainable. The air of Helwan is that of the desert, and almost germ free. The winter 284 GOUT: TREATMENT. [partiv. sunshine averages eight hours a day ; the average winter temperature is 60° F. at 9 a.m. and 9 p.m., 70° F. at 3 p.m., and 50° F. at the coldest time of the night, and the relative humidity from November to April only 30 to 60 per cent. There is not much wind, and the amount of dust is less than in most parts of Egypt, while the average rainfall for four consecutive winters was only three-quarters of an inch. For the spring, summer, and autumn months we fortunately have for our selection a large number of health resorts in this country and on the Continent, the climates of which are well suited to the gouty. My ex- perience is that residence by the sea is not suited to most cases of gout, and this especially applies to cases of gouty eczema. INDEX. Abarticular gout, 130-146 Acidity and gout, 208-211 , Treatment of gouty, 232 Acute gout. Clinical features of, 106-108 Diet in, 220, 221 Treatment of, 217-221 Adenin, 10 /Etiology of gout, 101-106 Age and gout, loi Aix-les-Bains waters, 279 Albuminuria and gout, 108-111 Alcohol, 260-263 Alkaline muriated waters, 274, 275 sulphated waters, 273, 274 waters, Simple, 272, 273 Alkalinity of the blood, 70, 71 AUantoin, 16 Allevard waters, 278 AUoxur bases and gout, 47, 48 Amorphous urate deposit, 117-119 Angina pectoris and gout, 137 , Treatment of gouty, 234 Animal diet and uric acid, 38-40 food, 247-249 Arthritic disease, Classification of, 147. 148 diseases. Differential diagnosis of, 147-170 Arthritis, Gonorrhoeal, 161, 162 , Malarial, 163 , Pneumococcic, 163 , Rheumatoid, 149-155 , Scarlatinal, 163 Arthropathies, Infective, 162, 163 - — — , Senile, 160, 161 Assmannshausen waters, 275 Asthma, Gouty, 134 B Bacillus coli communis and gout, 61, 63 Bacterial origin of gout, 59-64 Baden-Baden waters, 276 Baden waters, 278 Bagneres-de-Luchon waters, 278 Balneology, 281, 282 Bath, Electric light, 228-230 , Superheated-air, 228-230 Bath waters, 271 Baths, 281, 282 , Percussive, 282 Beverages, 252, 253 Biurates, 2, 3 Bladder, Gouty irritability of, 141 Blood, Detection of uric acid in, 67 diseases and uric acid, 69, 70 , Uric acid a normal constituent of, 66-70 Brachial neuritis. Gouty, 139, 140 Brides-les-Bains waters, 274 Brine baths, 277 Bronchitis, Gouty, 134 Buxton waters, 271 Caffein, 10 Calculi, Uric acid, 141 Carbohydrate foods, 249-251 Cardiac gout, 135-137 Carlsbad waters, 273 Cartilage, Seat of deposit in, 98, 99 Cataphoresis, 230 Cheltenham waters, 274 Chittenden's views, 245, 246 Choice of a spa, 279, 280 Chronic gout. Clinical features of, 108-111 , Treatment of, 221-231 Cider, 263 Climatic treatment, 282-284 Colchicum, Action of, 219, 220 in gout, 219, 220 Common salt waters, 275-277 Conjunctivitis, Gouty, 144 Contrexeville waters, 271 D Diabetes, Gouty, 144 , Treatment of gouty, 238, 239 285 286 INDEX. Diagnosis of gout from rheumatoid arthritis, 157-159 Diet, Animal, 247-249 for the gouty, 256-258 in acute gout, 220, 221 in gout, 241-258 Dieting, General principles of, 241- 244 Digestibility of food, 242-244 Dimmock-Branson's method, 121-125 Douche, Scotch, 227 Droitwich brine baths, 277 Dupuytren's contraction, 170 Dyspepsia, Gouty, 132 , Treatment of gouty, 232 E Ear and gouty deposits, 91 diseases and gout, 144 Ebstein-'s views and experiments, 48- , Criticism of, 50-53 Eczema, Gouty, 142 , , Treatment of, 236-238 Egypt, 283 Electric light bath, 228-230 Electrolysis, 231 Ems waters, 275 Endogenous purins, 12, 13 Epididymitis, Gouty, 141, 142 Epilepsy and gout, 140 Estimation of uric acid, 1 19-125 Exogenous purins, 13-17 Eye affections and gout, 144 Fibrositis, Distinction of gout from, 165-170 , Forms of, 165-170 Food, Animal, 247-249 , Digestibility of, 242-244 — , Saccharine, 251 -, Starchy, 249-251 , Vegetable, 249 Fruits, 251, 252 Galvanism of gouty joints, 227 Gastein waters, 271 Gastralgia, Gouty, 132 Gastric gout, 134 Gastro-intestinal gout, 133, 134 Garrod's thread test, 67 Geographical distribution of gout, lOI Glycocine and uric acid formation, 27 Glycosuria, Gouty, 144 , Treatment of gouty, 238, 239 Gonorrhoeal arthritis, 161, 162 Gout, Abarticular, 130-146 , Acute, 106-108 , Etiology of, 101-106 , Alkalinity of blood in, 70, 71 and habits of life, 104, 105 lead, 125-129 — ■ — ■ plumbism, 125-129 rheumatism. Distinction of, 165-170 rheumatoid arthritis, Differential diagnosis of, 157-159 Bacterial origin of, 59-64 Causation of, 4-64 Chronic, 108-111 , deforming, 109 Definition of, i Development of, i, 2 Diet in acute, 220, 221 Exciting cause of, 106 Gastric, 134 Gastro-intestinal, 133, 134 Irregular, 130-146 Metastatic, 145, 146 Preventive treatment of, 225, 226 Primary causation of, 41-65 Principles of treatment of, 215 216 Prognosis in, 171 Retrocedent, 145, 146 Tophaceous, 109 Treatment of acute, 217-221 chronic, 221-231 subacute, 221-231 Urine in, 109-119 Gouty angina. Treatment of, 234 asthma, 134 attack, Duration of, 107, 108 bronchitis, 134 deposit, Formation of, 85-91 deposits. Seats of, 91, 92 diabetes, 144 dyspepsia, 132 eczema, 142 Treatment of, 236-238 epididymitis, 141, 142 gastralgia, 132 glycosuria^ 144 heart, 135-137 , Treatment of, 233, 234 herpes, 143 hyperchlorhydria, 132, 133 INDEX. 287 Gouty joints, Treatment of, 226-231 kidney, 140, 141 laryngitis, 134 neuralgia, 139 neuritis, 139, 140 , Treatment of, 235 ■ orchitis, 141, 142 parotitis, 132 paroxysms. Treatment of, 217- 219 pharyngitis, 131, 132 phlebitis, 138, 139 , Treatment of, 235 pruritus, 143 sciatica, 139 , Treatment of, 235 tonsillitis, 131 tracheitis, 134 Govvland-Hopkins method, 120, 121 Gravel, Uric acid, 141 Guaiacum resin and gout, 221 Guanin, 10 Gurnigel waters, 278 H Harrogate waters, 27S Hay-fever and gout, 145 Heart, Gouty, 135-137 , Treatment of gouty, 233, 234 Heberden's nodes, 151, 152 Helwan waters, 283 Hepatic congestion and gout, 145 torpor, Treatment of, 233 Hereditary predisposition, 102-104 Herpes, Gouty, 143 Heustrich waters, 278 Homburg waters, 276 Hyperchlorhydria, Gouty, 132, 133 , Treatment of, 232 Hyperpyraemia, 57-59 Hypoxanthin, 6 I Imperial drink, 253 Inflammatory changes and gout, 53- 55 Insomnia and gout, 140 , Treatment of, 236 Intestinal bacteria and gout, 61-64 Ionic theory, 266, 267 Iritis, Gouty, 144 Irregular gout, 130-146 , Forms of, 130-146 Irritable temper in gout, Treatment of, 236 J Joint diseases and gout, 147-170 , Classification of, 147, 148 — ■ — • , Differential diagnosis of, 147-170 Joints, Treatment of gouty, 226-231 K Kidney affections and gout, 29-35 disease and uratic deposits, 30- 33 , Gouty, 140, 141 Ividneys and uric acid formation, 24-34 in chronic gout, 109-111 Kissingen waters, 276 La Bourboule waters, 275 Laryngitis, Gouty, 134 Lead and gout, 125-129 poisoning and gout, 34, 35 Leamington waters, 274 Leucocytosis and uric acid, 7-9 Leukaemia and uric acid, 69, 70 Lithium salts and gout, 207, 208, 222 Liver and destruction of toxins, 64, 65 and uric acid formation, 35-37 , Congestion of, 145 diseases and uric acid forma- tion, 28 Llandrindod Wells waters, 278 Llangammarch Wells waters, 277 Lumoago, 169, 170 Lymph circulation, 92-97 Lysidine and sodium biurate, 206 M Malarial arthritis, 163 Marienbad waters, 273 Massage of gouty joints, 226-228 Meals, Simplicity of, 253-255 Meat diet, 247-249 , Mineral constituents of, 173 Mental depression and gout, 140 Metastatic gout, 145, 146 — — ■, Treatment of, 239, 240 Migraine and gout, 139 288 INDEX. Mineral waters, 268-280 ■ — — -' , Classification of, 269, 270 , Cold, 279 Hot, 279 Radio-activity of, 267, Simple, 270-272 ■ — — •, Therapeutic uses of, 280 Murexide test, 4 Muriiited waters, 275-277 , Alkaline, 274, 275 N Nauheim waters, 276 Necrotic changes and gout, 48-53 Nenndorf waters, 278 Nervous disturbance and gout, 55-57 Neuenahr waters, 272 Neuralgia, Gouty, 139 Neuritis, Gouty, 139, 140 , , Treatment of, 235 Neuro-humoral view of gout, 55-57 Nucleic acid, 9 Nuclein formation of uric acid, 5-10 O Orchitis, Gouty, 141, 142 Osteo-arthropathy, Pulmonary, 165 Otto Folin method, 121 Parotitis, Gouty, 132 Percussive baths, 282 Perry, 264 Pfaefers waters, 271 Pharyngitis, Gouty, 131, 132 Phlebitis, Gouty, 138, 139 , , Treatment of, 235 Piperazine and sodium biurate, 205 Plumbism and gout, 125-129 Pneumococcic arthritis, 163 Potassium salts and gout, 221, 222 Potato, 250 Preventive treatment of gout, 221;, 226 Prognosis in gout, 171 Prophylactic treatment of gout, 225, 226 Pruritus, Gouty, 143 Psoriasis and gout, 143 Pulmonary osteo-arthropathy, 165 Purin bodies, 10-23 and absorption, 18, 19 ■ — ■ — ' blood pressure, 17, 18 • food, 14-16 uric acid, 19 , Origin of, n Purin-free diet, 14, 15, 248, 249 Purins, Endogenous, 12, 13 , Estimation of, 22, 23 , Exogenous, 13-17 Q Quadriurates, 2-4 R Radio-activity of mineral waters, 267, 268 Raynaud's disease, 165 Renal calculi, Treatment of, 236 Renal disease and gout, 29-35 uratic deposits, 30-33 Retrocedent gout, 145, 146 , Treatment of, 239, 240 Rheumatic diseases of joints, 155-157 Rheumatism, 155-157 , Chronic, 165-170 , Distinction of gout from, 165- 170 — ■ — -, Muscular, 169 Rheumatoid arthritis, 149-155 and gout. Differential diagnosis of, 157-159 Royat waters.. 275 Saccharine food, 251 Saint Honore waters, 278 Salicylates and gout, 21 1-2 14 Salisbury diet, 255, 256 Salt pack, 227, 228 Salzbrunn waters, 272 Saturnine gout, 125-129 Scarlatinal arthritis, 163 Schinznach waters, 278 Sciatica, Gouty, 139 , Treatment of gouty, 235 Scotch douche, 227 INDEX. 289 Sex and gout, loi Simplicity of meals, 253-255 Simple alkaline waters, 272, 273 mineral waters, 270-272 Skin eruptions and gout, 142-144 Sodium biurate and alkalies, 201-204 alkalinity of the blood, 71-84 as an irritant, 41-45 , Deposition of, 87-91 quadriurate, 86 and alkalies, 199, 200 Solvents of uric acid, 224 Spa, Choice of, 279, 280 treatment, 265-269 Spirits, 259, 260 Spleen and uric acid formation, 36 Starchy food, 249-251 Still's disease of the joints, 159, 160 Strathpeffer waters, 270, 278 Streptococci and gout, 63 Subacute gout. Treatment of, 221- 231 Sugar as food, 251 Sulphated waters. Alkaline, 273, 274 Sulphur springs, Cold, 278 , Hot, 278 waters, 277-279 Superheated-air bath, 228-230 Syphilitic joint disease, 164, 165 Tarasp-Schuls waters, 274 Teplitz waters, 270 Theobromin, 10 Thymic acid, 9 Toe and gouty deposits, 91 Tonsillitis, Gouty, 131 Tophaceous gout, 109 Tophi, 98, 109 Toxicity of uric acid, 45-47 Tracheitis, Gouty, 134 Treatment at spa, 265-269 by mineral waters, 268-280 , Climatic, 282-284 of acute gout, 217-221 chronic gout, 221-231 gout, Principles of, 215, 216 gouty angina, 234 diabetes, 238, 239 dyspepsia, 232 eczema, 236-238 glycosuria, 238, 239 heart, 233, 234 joints, 226-231 neuritis, 235 Treatment of gouty phlebitis, 235 sciatica, 235 hepatic torpor, 233 hyperchlorhydria, 232 insomnia, 236 metastatic gout, 239, 240 retrocedent gout, 239, 240 subacute gout, 221-231 Tuberculous joint disease, 164 Turkish bath, 230 U Urates, 2, 3 Uratic deposits, Seats of, 91 Uriage waters, 278 Uric acid and animal diet, 38-40 blood diseases, 69, 70 blood, 5 its compounds, 2-4 nuclein, 5-10 purins, 19 calculi, 141 Cause of presence of, in 67 112-117 34 Destruction of, 13 Detection of, in blood. Estimation of, 119-125 Excretion of, in gout, gravel, 141 in blood, 66-70 not toxic, 45-47 Renal formation of, 24- Solvents of, 224 Urinary purins. Estimation of, 22, 23 Urine, Amorphous urate deposit of, 117-119 , Estimation of, 119-125 , Estimation of purins in, 22, 23 ', Estima'tion of uric acid in, 119-125 , Examination of, 216, 217 in gout, 109-119 of chronic gout, 109-111 Urticaria, Gouty, 143 Vals water, 272 Vegetable ashes, Alkalinity of, 182 food, 249 Vegetables and gout, 172-197 , CalciMm salts in, 187 290 INDEX. Vegetables, Chlorides in, 190 for the gouty, 197 , Mineral constituents of, 175 , Phosphates in, 188 , Potassium salts in, 184, 185 , Sodium salts in, 185, 186 , Sulphates in, 189 Vertigo and gout, 140 Vichy waters, 272 Vittel waters, 272 W VVeilbach waters, 278 Wiesbaden waters, 276 Wildbad waters, 271 Wines, 260-263 Woodhall Spa waters, 277 X Xanthin, 6 Printed by Cassjjll & Company, Limited, La Belle Sauvage, London, E.C, Date Doe '^^^^.,y ^'^-^^ ■ '^\ \v^\ \ i\ o,\ '4 r \ ^ J RC291 Luff Gout L96 1907 '^r^ Jy i-i^ 2-25-49 InterlibrarjA Loan Photostat I>ept. UOi' rl