One of the most universal consequences of chronic arthritic tox wmia is an impoverished state of the blood. The death and insufficient reproduction of the red corpuscles are constant results of the pres ence of the nitrogenous toxins. Bitter tonics—quinine, strychnine, quassia, gentian, and calumba—are useful, and, if there be no con siderable catarrhal inflammation of the gastro-intestinal mucous membrane, iron may be given. The ferrated mineral waters then fulfil a valuable indication. But if the patient cannot tolerate iron, arsenical preparations form the best substitutes. The waters of Royat, Orezza, and of the Mt. Shasta arsenical springs in California, have a good reputation in such cases. Or the liquor potassii arseni tis may be given in moderate doses for a long period of time. The ordinary stimulants, tea, coffee, and alcohol, which usually are not tolerated in chronic gout, can be sometimes administered for a few clays at a time to these feeble subjects when they experience the need of a cardiac stimulant. In many instances laxatives are required. Among the best for anemic patients is guaiacum, which can be ad ministered in capsules or wafers or effervescing powders in order to obviate its disagreeable taste. Cascara is also a valuable laxative. The combination of sulphur and cream of tartar in tablet form is a very gentle and elegant remedy in cases of hemorrhoidal tendency with torpor of the liver and kidneys. An occasional purgative course of blue pill, colocynth, colchicum, and hyoscyamus is advantageous. When atonic dyspepsia is a conspicuous symptom, the simple bitters, quassia, calumba, mix vomica, gentian, and euonymin are beneficial. Associated with rhubarb they are useful in cases of intestinal atony. Sydenham was in the habit of prescribing for such patients an elec. tuary composed of various mints, horseradish, mustard, and bitter herbs. This was supplanted during the next century by a mixture of bitter and aromatic powders derived from the vegetable kingdom and rendered fashionable by the affix of the aristocratic title of the Duke of Portland. In comparatively recent times Sir Alfred Garrocl has endeavored to popularize the following prescription, which is also indorsed by Sir Dyce Duckworth : All such preparations have for their common object a gentle stim ulation of the circulation and of the excretory functions.
When the renal complications of chronic gout become predomi nant it is necessary to avoid the use of colchicum, and to restrict the patient to a milk diet. This constitutes the surest means of retarding the progress of nephritis, and of obviating the mal-assimilation and semi-starvation that are inevitable when ordinary food is allowed. Tonics and astringents may be administered, but their utility is often open to suspicion. The excretory action of the skin and intestinal tract should be stimulated by hot-air baths, counter-irritation over the loins, and hydragogue cathartics.
Many cases of chronic gout are terminated by failure of the heart to maintain the circulation. So long as compensatory hypertrophy of the ventricle persists, the blood will be efficiently propelled; but when the ventricular tissues begin to yield, so that dilatation of the cavities occurs, stagnation commences, and the protracted agony of death at the heart is initiated. At first, great relief may be ob tained by the use of digitalis, but this drug soon disorders the stomach, rendering it necessary to have recourse to sparteine, strophanthus, and convallaria. These remedies in their turn cease to relieve and then temporary benefit can be procured from caffeine. Milk, either with or without coffee, forms the best nourishment, and is the diuretic that can be for the longest time endured by the kidneys. Taken in the form of an effervescent kumyss it is
usually agreeable and always efficient. Small doses of blue pill or of calomel are often prescribed, and the liver should be suffi ciently drained by the aid of saline laxatives. In advanced cases, the application of sinapisms or flying blisters over the precordial region may relieve pain and aid the circulation for a brief period. Hot whiskey and water and hot coffee also act as palliatives when cyanosis and other evidences of stagnation are apparent. But all these measures fail at last, and when their need is urgent the end is near.
Besides the general management of chronic gout that has been already described, it is a matter of great importance to prescribe ener getic local treatment for the joints that have been the seat of uratic deposits. The articular rigidity and disorganization that result from such incrustations serve to cripple and to disable the patient even more than is effected by the conditions that accompany the acute attack. It is, therefore, desirable to hinder the process of infiltra tion with uratic salts, and to promote their absorption and removal when they have already been deposited. It has been shown that the feeble circulation of blood and lymph in the substance of the articu lar structures is one of the causes that determine the precipitation of urates in the tissues rather than elsewhere. For this reason the principal indication for local treatment is to quicken the circulation of blood in the affected parts. This can be accomplished by hot fo mentations reinforced with turpentine, mustard, oil of sassafras, and other aromatic substances and essential oils. The various liniments that contain ammonia, camphor, menthol, oil of cajeput, and similar ingredients, are all rubefacient, and consequently beneficial. Friction of the surface with coarse towels, hair gloves, and flesh-brushes, operates in a similar manner. Steaming the affected parts, or even the entire body, with terebinthinate vapors from pine needles and cones, or from the berries of the juniper bush, has had its advocates. Copious perspiration induced by the Turkish bath is beneficial, and may be frequently encouraged if the heart and kidneys are intact. Massage of the stiffened joints is very useful to counteract the devel opment of rigidity. The manipulation of the joints should be per formed in a warm bath, for the reason that the process of resolution is aided by the local application of heat in connection with movement of the stiffened. parts. For the same reason the patient may be advised to visit the various hot springs, especially those sources whose water is charged with sulphur. Of comparatively little value in the acute forms of gout, these waters are decidedly beneficial in the local treatment of the articular and cutaneous disorders that occur in the chronic variety of the disease. Chief among the American springs that are adapted to this purpose are the hot sulphur springs among the mountains of Virginia, and at Glenwood in Colorado. The hot springs of Arkansas, and of South Dakota, Idaho, and the Yellowstone Park, are principally useful by reason of their very ef ficient thermal qualities. But when the rigid joints cannot be re laxed by such measures, it becomes necessary to apply strong tincture of iodine or flying blisters of cantharidal plaster, or even to cause superficial vesication of the skin by a few strokes with the actual cautery lightly applied in the vicinity of the stiffened articulations.