Acute Gout
In the main the general principles of treatment conform to those adopted for other inflammatory ailments, with, of course, the important reservation that our mode of procedure be adapted to the individual case; viz., due regard must be had to age, the intensity of the attack, and the presence of complications. For obviously the treatment suitable for a robust plethoric subject might prove the very reverse of salutary for a broken-down victim more or less worn out by previous attacks and haply the subject also of arterial and renal changes.
The medicinal treatment of acute gout necessarily divides itself into constitutional and local measures. In pursuance of the first, we seek to control the inflammation and febrile disturbance while assisting the organism to eliminate those toxic substances in the blood that have determined the incidence of the paroxysm.
The attack usually supervenes while the subject is in bed, and, generally speaking, keeps him there. Indeed, rest is imperative, and as far as possible sources of worry should be excluded. The nature of the diet suitable for the acute stages has already been adverted to, and, practically speaking, the first point that calls for investigation is the state of the bowels. Were they prior to the attack open regularly, loose, or confined? Constipation is the usual forerunner, and if so, a swiftly acting purge must be given. Indeed, even if previously the action of the bowels has been free, they usually, with the onset of the attack, become bound, the intensity of the local pain presumably exerting an inhibitory effect.
As to the advisability of initial purgation in acute gout, Sydenham was definitely opposed thereto. In contrast, others, who held with Scudamore that portal congestion was an etiological factor, highly eulogised free catharsis. The truth, as usual, lay between the opposing views. In other words, we must strike the happy mean between adequate evacuation and excessive purgation, for there is good reason to believe that the latter often so to speak, defeats its own end. It may determine more rapid recurrence of the disorder or its perpetuation in a chronic and asthenic form.
Incidentally one may recall that the objections unfairly launched against colchicum took origin in the misconception that its good offices were referable to its cathartic action. Hence by our forefathers the drug was pushed until the characteristic “colchicum stools” appeared, with their attendant nausea and prostration. This of course led to this valuable drug being looked at askance, whereas the error lay, not in the drug, but in the method of its administration, for, fortunately, its specific effect in gouty arthritis may be secured without the induction of depression, nausea, or purgation. Indeed, as Sir Alfred Garrod long since pointed out, it “frequently proves of most benefit when its operation is unattended with increased alvine evacuation.”
Albeit, from the tenor of our digression it must not be inferred that purgation is inadvisable in gout, but only that this salutary purpose must not be effected by colchicum. At the same time we must not think that mere purgation will of itself allay the articular inflammation, for it has been repeatedly shown that it exercises little or no control in this direction; but, on the other hand, it sweeps out irritating matter, promotes the return to a healthy state of the alimentary canal, and in this way reinforces the beneficial effect of colchicum.
My own opinion is that, if seen just before or just after the acute attack begins, it is wiser to secure a free action of the bowels before placing the subject on colchicum, this the more imperatively if it be a case of acute sthenic type supervening in a robust subject evidently labouring under constipation. If there be no palpable derangement of the liver, we may content ourselves with ordering at bedtime a full dose of Gregory’s powder, or Pil. rhei co. gr. 5-8, or Pil. colocynth co. gr. 5-8, followed in the morning by a saline aperient. French physicians, especially Robin, in such circumstances rely solely on sodium sulphate. The salt has the advantage of not lessening the secretion of urine, and the dose advocated is 1 ounce.
If the conjunctivæ show an icteric tinge or the character of the stools suggests that the liver is at fault, small doses of a mercurial preparation, such as calomel (gr. 4) or blue pill, may be given at night, either Pil. hydrarg. gr. 5 or Pil. hydrarg. gr. 1, in combination with Pil. coloc. cum hyoscy. gr. 4, and the same followed in the morning by 1-2 ounces of Mist. sennæ co. The nauseating flavour of the latter is best disguised by 1-2 drachms of Glyl. vanillæ, or for the “black draught” we may substitute 4-6 drachms of sodium sulphate, a Seidlitz powder, or a full dose of Carlsbad or Condal water.
When mercurials are contra-indicated or from experience known by the subject to disagree, podophyllin may be prescribed in some such form as the following: Podophyllin gr. ¼ c̄, Pil. coloc. hyoscy. gr. 4.
In other instances the cholagogue effect of the mercurial is procured by substitution for it of a small dose of the Ext. colchici in combination with the compound colocynth pill. Our forefathers, too, frequently prescribed colchicum and mercury conjoined with aloes or colocynth, and the following is an excellent and well-tried formula:—
| ℞ | Ext. colchici acet. | gr. ½ |
| Ext. aloes barb. | gr. 1 | |
| Ext. hyoscy. vir. | gr. 1 | |
| Pil. hydrarg. | gr. 1½ | |
| Fiat pil., 1. | ||
In short, in the matter of the initial purgation the drug chosen must be suited to the individual and the degree of purgation also graded. The old rule was that if the belly is hard, the subject can stand purging, but not otherwise; and it is, I think, a fairly sound index. Mercurials in aged subjects are best avoided, and likewise in those with defective kidneys. Salivation in their instance is easily provoked, and Sir Alfred Garrod held that mercury “in advanced forms of gout should be altogether avoided.” French physicians think saline aperients preferable to the English method of giving calomel, and unquestionably they are eminently suitable for robust and plethoric subjects.
Colchicum in Acute Gout.
Whatever be its mode of action, colchicum still remains par excellence the remedy for acute gout. As before noted, Dixon and Maiden hold that colchicine has no action on the metabolism or excretion of purins, nor on the kidneys. On the other hand, it influences markedly the leucocytes, their number in the circulation undergoing a primary decrease and a secondary increase. Bain, it is true, found that under colchicum a slight increase in uric acid excretion occurred, but thinks it extremely doubtful if its influence in this direction is invariable.
That colchicine should exert such a marked effect in gout and yet apparently be destitute of any influence on uric acid excretion is of course very striking. It calls, moreover, for more reflection on the part of those who seem to contend that because a drug increases uric acid elimination it must necessarily be beneficial both for the gout as well as for the victim.
Method of Administration.—In initial attacks the drug must be exhibited with caution. Some persons are idiosyncratically sensitive thereto. Attacks of faintness may ensue, or even ordinary doses occasion purging or nausea and vomiting. Their incidence shows either that the subject is abnormally sensitive or the dose too large. Such untoward phenomena indicate its abandonment or drastic reduction. With these reservations, colchicum may be administered in every primary attack and most, if not all, of the succeeding paroxysms.
Albeit, the older the subject and the more ancient the gout, the more warily should we proceed, especially if there is marked irritability of the digestive system, renal disorder, or cardiac degeneration. Robin holds that if visceral gout is present, or the urine contains much albumen, no colchicum should be given.
It is notorious that old persons stand colchicum badly. In their instance we need be the less ready to resort to heroic doses when we recall that acute gout is a self-delimited disease, and while it would be improper to do nothing in elderly subjects exhibiting visceral lesions, etc., it is well that we proceed cautiously, so as to avoid the induction of circulatory depression or the excitation of nausea or a diarrhœa which may be, and often is, difficult of control. Moreover, if these untoward symptoms are allowed to ensue, there is a tendency for the gout to recur as soon as the effects of the colchicum have worn off.
Preparations of Colchicum and Dosage.—Those most commonly in use are the tincture and wine of colchicum, and of these the latter is most in favour. As to dosage, most authorities agree that a full dose—30-40 minims of the vinum colchici—should be given at the inception of treatment and followed by smaller amounts, from 10-20 minims two or three times a day.
By French physicians the tincture of colchicum is preferred, and by Robin that extracted from the flowers rather than the seeds. The dose of our own official Tinct. colchici seminum ranges from 5-15 minims, and by the French Codex the maximum single dose is placed at 25 minims, and the maximum intake during twenty-four hours at 100 minims approximately. It may be noted that preparations from the seeds are more purgative than those derived from the corn. Lastly, we have the official extract of colchicum and the acetic extract. The dose of the former ranges from ¼-1 grain, and it is frequently given in the form of a pill with ipecacuanha and mercury. The addition of a small dose of atropine is often advisable, to obviate the vomiting and diarrhœa often primarily induced by increase of peristalsis. By many the acetic extract is preferred, J. S. Matthews holding that the effective dose ranges from 2-6 grains.
Turning now to discuss the most opportune juncture at which to administer colchicum, certainly in the initial and the earlier paroxysms we may with advantage postpone the giving of colchicum pending free clearance of the bowels. No harm will follow its being withheld until the second day. Indeed, many physicians, both British and Continental, counsel delay in its exhibition until the fit is well established.
Again, in primary paroxysms—viz., while ignorant of the personal equation in respect of colchicum—it is well that our maximum dose should not exceed 20 minims, and when the bowels have not been previously purged, the drug should be combined with sulphate and carbonate of magnesia, as in the following prescription:—
| ℞ | Magnesii sulphatis | gr. 60 |
| Magnesii carbonatis | gr. 10 | |
| Potassii citratis | gr. 30 | |
| Vini colchici | ♏︎ 20 | |
| Aquæ menthæ viridis | ad unciam. | |
| Misce. fiat mistura. Two tablespoonfuls with two of hot water every three hours until bowels have been freely opened. | ||
This achieved, the sulphate of magnesia may be omitted, and the mixture taken every six instead of every three hours; but it is a good plan to keep the original mixture at hand, giving a dose every morning while the acute stage lasts. Then during the day the colchicum should be persisted with either in the form of the wine or the tincture.
Moreover, there are often special indications to be met. Thus the skin in acute gout is often hot and dry, and the urine unusually scanty and high-coloured. In this event the colchicum may with advantage be given with the citrate, bicarbonate or nitrate of potash, so as to produce a diaphoretic and diuretic effect. In other instances acidity is a prominent symptom, and here the combination of colchicum with the citrate of potash and magnesia will be found useful.
As the intensity of the inflammation wanes and the local pain and tension subside the dose of the colchicum should be gradually diminished; but even after convalescence is established it may advantageously be continued for a few days in small doses, say, 5 minims of the vinum colchici three times a day. The condition of the tongue will usually furnish a safe index, as rarely will it clean up prior to abatement of the gouty fit.
In subsequent paroxysms and alike in the acute exacerbations that chequer the course of chronic gout we may, in the absence of idiosyncrasy or other contra-indication, proceed more boldly. Thus, if the bowels have not previously been briskly purged, we may at once prescribe the following formula:—
| ℞ | Vini colchici | ♏︎ 15-20 |
| Magnesii carbonatis | gr. 15 | |
| Magnesii sulphatis | gr. 60 | |
| Aquæ cinnamomi ad ℥j. | ||
| Fiat mistura, ℥ij. statim sumenda et ℥j. quartis horis p.p.a. | ||
The primary dose, as will be noted, will contain either 30 or 40 minims of the wine, and, though Sir Alfred Garrod prescribed up to a drachm, it will scarcely, if ever, be necessary to exceed 30-40 minims. The subsequent dose of from 15-20 minims may after a day or two be reduced, and instead the mixture given in ½-ounce doses three or four times a day. Or, if preferred, the mixture in its reduced dosage may be renounced in favour of a pill containing either the extract of colchicum or, what many consider even better, the acetic extract thereof. Thus the following pill may be taken every night for a few days, and then on alternate nights:—
| ℞ | Ext. colchici | gr. ¼ |
| Aloin | gr. ⅛ | |
| Ext. bellad. alcoh. | gr. ⅛ | |
| Capsicin | gr. ⅟₂₀ | |
| Ext. rhei | gr. 1 | |
| Fiat pil., 1. | ||
The acetic extract may be given in larger doses, and was in great favour as the chief constituent of many so-called “gout pills” in combination with ipecacuanha and mercury:—
| ℞ | Ext. colchici acet. | gr. 1½ |
| Pulv. ipecac. co. | gr. 1½ | |
| Ext. colocynth co. | gr. 1½ | |
| Fiat pil., 1 nocte sumenda. | ||
An excellent formula, in which the colchicum is combined with mercury, has already been furnished on a preceding page. Needless to say, it should, like the above pill, be followed in the morning, if necessary, by a mild saline purgative.
Colchicine.—This, the active principle of colchicum, has of recent years been widely and successfully employed in acute gout, as well as in exacerbations of the chronic type. By some subjects, especially the old, it is often better borne than colchicum preparations. The dose ranges from ⅟₁₀₀-⅟₃₂ grain in a pill. By the French Codex the maximum single dose is fixed at ⅟₃₂ grain, and the maximum administered during twenty-four hours should not exceed ⅟₁₆ grain approximately.
The following is a suitable combination in an elderly subject, and it may be noted that the drug has been found of use, too, in cerebral congestion and uræmia:—
| ℞ | Colchicine | gr. ⅟₁₀₀ |
| Ext. belladon. alcoh. | gr. ⅛ | |
| Ext. nucis vomicæ | gr. ¼ | |
| Fiat capsule or cachet, 1 every three or four hours. | ||
In robust subjects the colchicine may be given in larger doses. Luff states that few patients will tolerate ⅟₅₀ grain, because of the diarrhœa and griping pains produced. He found that colchicine (⅟₇₀ grain), in combination with henbane and nux vomica in the form of a pill, rapidly relieved gout when taken every three or four hours.
Or as a substitute we may use the salicylate of colchicine, the dose of which is ⅟₆₀ grain. Colchicine is readily soluble in methyl salicylate, and is conveniently administered in the form of capsules, each containing ⅟₂₅₀ gram (Martindale). In acute gout one capsule may be given every two hours, or two capsules three or four times a day. These doses are well within the limits of safety, and, if necessary, may be combined with nux vomica and belladonna; but with the alkaloids, as with the colchicum itself, it is essential that the bowels should be kept freely opened. Also with the waning of the pain and inflammation the colchicine or its salicylate should be given less frequently, so as to obviate any depression.
Atophan.—This is a yellowish cream-coloured amorphous powder of the composition 2-phenylchinolin 4-carbonic acid. Its use has been much extolled both in acute and subacute gout. The dose ranges from 30-45 grains daily for three to four days, according to some authorities, but others consider that it may be taken for prolonged periods with advantage. It is most conveniently exhibited in the form of tablets containing 4 or 8 grains. Agotan, a drug identical with that formerly sold under the German registered name “atophan,” is supplied in the form of crystalline powder and in 7½-grain tablets, and appears to be equally efficient.
Atophan is incompatible with sodium bicarbonate and other alkalies in vitro, but Martindale and Westcott “did not find it incompatible with potassium iodide.” It has been repeatedly noted that, following the intake of atophan, the uric acid content of the blood falls and the urinary uric-acid output increases. Weintraud in gouty patients on a purin-free diet noted that after atophan the quantity of uric acid excreted in the urine was more than doubled, but subsequently the excretion fell below normal.
Even in healthy individuals when taking atophan the urine becomes turbid from the presence of urates. This excess of uric acid in the urine may in gouty individuals be precipitated in the urinary tract, and so induce an attack of gravel. Consequently Weintraud advises that the drug be taken with alkalies, either sodium bicarbonate or alkaline waters. Drs. Jansen and Plum, of Copenhagen, during their recent visit to the Royal Mineral Water Hospital, Bath, informed me that they had met no instances of gravel, but in several of their cases atophan had induced urticaria.
As to the simultaneous intake of alkalies, while the precaution is probably desirable, I have known gouty patients take atophan without alkalies for several weeks in full doses without any apparent ill effects. Brugsch, indeed, states that in polyarthritis urica the subjects are able to take 15-30 grains of atophan per diem for a year without any affection of the kidneys. Moreover, uric acid excretion was increased throughout the whole period, and when the drug was discontinued, the pains recurred.
As to the usurpation of colchicum by atophan, I do not think it is at all likely, for it does not, I consider, exert the specific effect of the former on the gouty inflammatory process, taking the humbler rôle of obviating the formation or promoting the absorption and elimination of uratic deposits. In other words, colchicum influences the causa causans of gouty inflammation, atophan only the consequences or sequels thereof.
The most favourable juncture at which to prescribe atophan is at the close of a paroxysm. I have myself been much impressed with the manner in which it produces softening and palpable diminution in the size of tophaceous deposits, so much so, indeed, that I feel sure we have in this drug a valuable agent wherewith to prevent the formation of uratic deposits.
A two or three weeks’ course of atophan after an acute attack is, I have found, very advantageous, in doses of 30-45 grains per diem, after meals. It may, for the special reasons given, be well combined with an alkaline stomachic mixture taken half an hour or more before food.
| ℞ | Potassii bicarbonatis | gr. 15 |
| Sodii bicarbonatis | gr. 20 | |
| Spts. ammoniæ aromat. | ♏︎ 20 | |
| Tinct. zingiberis fort. | ♏︎ 5 | |
| Inf. aurantii co. ad unciam. | ||
| Fiat haustus, thrice daily well diluted with water. | ||
To sum up, our medicinal treatment of acute gout consists in initial purgation, followed by maintenance of an adequate daily evacuation; secondly, the exhibition of colchicum or its active principle and continuance of the same in diminishing doses until pain and inflammatory phenomena have departed. With the passing of the paroxysm atophan should be resorted to in combination with an alkaline stomachic mixture. Supervision of the subject should not cease until the digestive and assimilative functions have, as far as possible, attained functional efficiency, for it is certain that this is the most important point in the management of the gouty constitution. Conjoined therewith, the bowels should never be allowed to become constipated, the urine maintained free from acid lithates, and the skin active by regular exercise.
Alternative Remedies in Acute Gout.—Of the various drugs advocated as substitutes for colchicum the salicylate group alone seems to have evoked something like enthusiasm. Thus Germain Sée affirmed that sodium salicylate was the best remedy for gout, whether of acute or chronic type. In this country Haig strongly upheld its claim. On the other hand, Ebstein, when he used this salt in acute gout, found that the inflammation, though it quickly subsided in one joint, immediately reappeared in another, even though the administration of the drug was continued.
Lecorche, again, though he found it useful in acute gout, was equally certain that it was altogether inferior to colchicum. It did lessen the pain and the violence of the paroxysm, but in no way shortened its duration. But, on the other hand, he attached a prophylactic value to it in chronic gout marked by recurring subacute attacks. His method was to give it in the intervals of paroxysms in doses of from 60-80 grains a day, whereby he claimed to abort attacks, prevent ankyloses, and facilitate absorption of uratic deposits.
As to its mode of action, salicylate of soda, both in gouty and healthy subjects, determines an immediate increase in the uric acid excretion, 30-60 per cent. The increase, however, is but ephemeral, the excretion of uric acid sinking gradually to normal in about forty hours, and this whether the drug be persisted with or not. The increase in total nitrogen excretion does not reach 10 per cent.
Discussing this mode of response, MacLeod (who noted the same after citrates) is of opinion that salicylate of soda and citrate act, not by influencing the metabolic processes that originate uric acid, but by promoting the excretion thereof. Walker Hall and Magnus Levy, albeit, suggest that the increase is due to diminution in the normal destruction of purins in the organism, with resulting transmission of the same in larger quantities to the kidneys for excretion. It is possible therefore that in the presence of sodium salicylate there is diminished oxidation of uric acid.
Bain, however, studying the elimination of nitrogen in a gouty subject, found, contrary to expectation, that after sodium salicylate there ensued only a small increase in the uric acid, with a slight augmentation of the alloxur bases relative to the acid. We see therefore that all the above observers agree that an increased uric acid output in the urine follows the administration of salicylate of sodium, though they differ in opinion as to the manner of its production.
As to the employment of salicylate of soda in acute gout, it must, I think, be seldom called for, save in the presence of idiosyncratic sensitiveness to colchicum. Now, though of this latter much has been written, yet I venture to affirm it is exceptional, and the adverse symptoms are attributable rather to injudicious dosage of the individual than to inherent peculiarities on his side in respect to this valuable drug.
If we should encounter such an instance, there is no objection to our giving the salicylates of sodium or potassium a trial, especially in an acute febrile attack occurring in a healthy subject. In isolated cases the relief to pain may be swift and striking; but, generally speaking, the results are neither so decisive nor so prompt as those obtained in suitable cases by colchicum. The potassium and lithium salicylates are usually given the preference, and they may be combined with citrate or bicarbonate of potash. If the latter salt be used, the draught will prove more grateful if given in effervescent form, viz., by the addition of citric acid or lemon juice.
Frequently it happens that the patient, to begin with, has been placed on colchicum, and, symptoms of irritation having supervened, the drug has had to be withdrawn. The tardy resort then to salicylates is fortunately rather beneficial than otherwise, for, apart from its analgesic effect, it reinforces the increased uric acid output in the urine that follows the attack, and so tends to counteract the tendency to uric acid deposition.
There is yet another contingency in which resort to salicylates may be indicated, viz., in those long-standing cases of chronic gout with recurring exacerbations in which the colchicum, formerly beneficial, has now through acquired tolerance become impotent. Here, either during or immediately after the acute phases, the salicylates may be exhibited, if the stomach be tolerant and there be an absence of cardiac or renal degeneration. As to the employment of salicylates in massive doses in the inter-paroxysmal periods as a prophylactic measure, I think this is better attained by occasional courses of atophan.
Lastly, there are instances in which both colchicum and salicylates appear to be contra-indicated. In this event we may either rely simply on alkalies—and we have Duckworth’s authority that in many cases of acute gout they have proved satisfactory—or we may adopt Sir Alfred Garrod’s plan of giving quinine (2½-5½ grains) suspended by tragacanth in combination with the bicarbonate or citrate of potash. By this means the pyrexia is controlled, and, according to the above authority, any tendency on the part of the disorder to wander from joint to joint; and he holds it especially valuable in those subacute attacks that so commonly chequer the course of chronic gout.
Thyminic or nucleotin-phosphoric acid in doses of 5-10 grains has also been highly eulogised, being held to have an affinity for and a solvent action on uric acid. But Walker Hall, while he agrees that the results obtained in gout are encouraging, yet from his own experiments does not find that “the improvement is at all associated with any change in uric acid excretion—a result which also applies to citerin.”
As to quinic acid and its synthetic combinations, their popularity seems to have been evanescent. It is claimed that “urosin” or lithium quinate speedily controls the acute manifestations of gout, this apparently without any evidences of cinchonism, even though given in 7½-grain tablets ten times daily in acute paroxysms. Others give quinic acid in combination with piperazine, i.e. “sidonal” in doses of 1-1½ grains per diem. But of these, as well as of many other vaunted specifics, I feel inclined to say, with Bianca, “Old fashions please me best; I am not so nice to change true rules for new inventions.”
Anodynes in Acute Gout.—On this point it may be recalled that such was the prejudice at one time against colchicum that Ebstein thought it preferable to relieve the pain of acute gout by hypodermic injections of morphia, which, he thought, acted “quicker, more easily, and with less danger.” Fortunately, however, it is only very exceptionally that colchicum fails to mitigate the pain in acute gout.
In rebellious instances salicylate of soda in full doses for a few hours sometimes succeeds. Hypodermic injections of morphia must rarely, if ever, be called for, and I have never had occasion to invoke them. In fact, opium in any form is best avoided, and if unavoidable is best given in the form of Dover’s powder in combination with aspirin and phenacetin, viz., 2½ grains of each in a cachet at bedtime. Luff in some cases found a full dose of extract of hyoscyamus a very useful anodyne, and if sleeplessness through pain prevails, advises 7 grains of veronal or 10 grains of trional. Sir William Whitla’s “routine hypnotic in gout” is paraldehyde.
All these are preferable to opium in any form, for we deal with a disease in which defective elimination is a prominent feature, and that we should exhibit unnecessarily a drug which inhibits all excretory processes save that subserved by the skin seems wholly irrational. Of this we have an object lesson in the clay stools that in some gouty subjects, as Burney Yeo remarked, persist for some days after even a very small dose of morphia. My own rule is to rely on colchicum as far as possible, and for any extra anodyne effect on local applications, to the consideration of which I now proceed.
Local Measures in Acute Gout.
The affected limb must be kept at rest on a firm pillow and slightly raised above the body level. The inflamed part should be protected from pressure by a cradle. In the majority of instances, as the elder Garrod long since pointed out, the only local application needed is cotton wool covered with oiled silk, evenly and lightly bandaged. By this means the joint surface is kept both warm and moist, and moisture is important, as dry heat is not grateful and seems to aggravate the pain. The dressing soon becomes wet, requires changing two or three times in the twenty-four hours, when dry warm wool should again be applied, and in this way a local vapour bath of sorts is provided for the inflamed part.
If pain be marked, hot fomentations or stupes or even a foot-bath may be substituted. At one time warm spirituous lotions on lint covered with oiled silk were popular, whisky and water being much in vogue. Others (Pye-Smith) spoke well of a lotion containing 1 drachm of sulphuric ether to 6 ounces of water. Some pack the joint with warm alkaline lotions to which opium or belladonna, or both, are added; but, whether dealing with spirituous or alkaline lotions, all are agreed that cold applications should be carefully shunned.
As to anodyne preparations, we suffer from what may be truly described as un embarras de richesse; but the inexplicable variability of response is such that it is always well to have another shot in one’s therapeutic locker. Practically all the analgesic remedies in use have been recommended by some one or other as useful for the relief of pain in acute gout. The mere enumeration of these might be indefinitely extended, for in truth every one has a favourite remedy wherewith to meet certain indications, and the good results obtained are exactly proportional to the skill displayed in exhibiting their use. We should not, however, resort forthwith to the more potent analgesics. It is wiser to give the simpler remedies a prior trial, such as poppy-head fomentations. If these fail, the liniment or unguentum methyl salicylatis co. may be tried, applied on lint covered with oiled silk and a flannel bandage. Equal parts of chloroform and belladonna or of opium and menthol liniment are also very soothing when sprinkled on lint and covered with cotton wool.
In the more intense cases with great local sensitiveness the following preparations may be lightly applied to the affected area with a brush. Anodyne colloid is one of the most reliable, or we may use glycerine of belladonna or atropine, subsequently covering the part with warm, moist dressings or spongiopiline enveloped in oiled silk, cotton wool, and a flannel bandage. In using atropine preparations, however, care must be exercised, as absorption through the unbroken skin may readily cause toxic symptoms.
In less acute types or as local sensitiveness declines various ointments may be gently rubbed into the affected joint, and in this way the beneficial effects of massage superadded. The most suitable unguents are those containing methyl salicylate in hydrous wool fat with or without menthol, or the methyl salicylate may be mixed with equal parts of olive oil and applied with friction. Used in this way, it is rapidly absorbed, and is much to be preferred to the natural oil of winter-green, which not infrequently proves very irritating to the skin.
Under the influence of one or other of the foregoing methods, the pain in these forms of acute gout is usually quickly subdued. Occasionally, however, owing to incomplete absorption of inflammatory exudate, the case proves more obstinate, and a variable degree of pain and stiffness lingers on in the affected articulation.
If means permit, the ideal course to pursue is for the patient to be sent to some spa where, conjointly with the general treatment, he may enlist the advantage of hydrotherapy, massage, and so forth. In default of such facilities, we must of course fall back upon friction with liniments, being careful not to induce tenderness of the joint. Of these there are endless varieties, those containing ammonia, turpentine, camphor, or capsicum being most in vogue. Inasmuch as their efficacy is largely referable to the rubbing which accompanies their use, we should favour preparations containing oleic acid, either alone or diluted with a fatty oil. As an oily liniment perhaps one of the most useful is the linimentum succini co., containing equal parts of the oils of amber and clove combined with twice the quantity of olive oil, or one of the following excellent combinations may be selected:—
| ℞ | Olei origani vel olei terebinthini | Partes æquales. |
| Linimenti ammoniæ. | ||
| To be applied with friction to the affected part. | ||
| ℞ | Ætheris | 1 drachm. |
| Linimenti belladonnæ | ½ ounce. | |
| Tinct. capsici | To 2 ounces. | |
| To be well rubbed into painful parts night and morning. | ||
When a joint is the seat of fixed pain with definite thickening, it may be necessary to resort to blisters; but frequently they are so utilised as to merit the aspersion of “adding additional distress to unrelieved pain.” They are of course unsuitable for cases with acute serous effusion of recent origin; but are often beneficial when applied over joints, bursæ, or tendon sheaths, when the seat of long-standing passive distension.
Garrod held them of most advantage in gout of asthenic character with lingering effusion; but he thought them inadvisable in the later stages of gout with defective kidneys and where the joints were the seat of massive uratic deposits, as in the last event sores difficult of healing may follow.
In the vast majority of instances such drastic counter-irritation is unnecessary, as the pain usually relents to less strenuous measures. For the dissipation of exudates and thickening nothing is superior to iodine and mercurial preparations. Painting with strong iodine may occasion soreness, but not if the glycerinum iodi be used. Better still is it if we use iodine preparations that admit of gentle inunction. The iodide of potassium and soap liniment is of course most reliable, or we may use one of the proprietary preparations, e.g., leukion. The oleate of mercury (10 per cent.) is often useful, and if pain linger on in the joint, may be combined with morphia (½ grain to 1 drachm). Ichthyol lanoline also deserves mention, and is best rubbed in after a fomentation followed by a dry pack. It is extremely probable that the stimulant and absorbent action of these agents is markedly reinforced by the friction which accompanies their usage.
In conclusion, it must be recalled that the swelling, stiffness, and pain are of dual origin, viz., in part due to inflammatory products and in part to uratic deposits, and it is the former that will be the most influenced by the foregoing measures. As to the means available for the reduction or dissipation of tophaceous matter, we shall best postpone their consideration until we come to discuss the treatment of tophi.
Ionisation in Acute Gout.—The introduction of medicinal substances into the interior of the joints by means of an electrical current is now in extensive vogue, both as a means of relieving pain and promoting absorption in periarticular and synovial affections. It is of course in the more accessible or superficial articulations that its beneficial effects are most easily attainable.
The sensitiveness of the parts in acute gout is such that I have never felt justified in invoking ionisation therein. Nevertheless Finzi tried it in two cases of acute gout. Instant relief of pain and diminution of swelling followed the first séance, while in sequence to a second all local tenderness disappeared. Finzi used a combination of lithium and iodine, the former at the positive and the latter at the negative pole. I would only add that in non-gouty forms of arthritis, if relief of pain be desired, salicylic ions, by general consent, would appear to be the most reliable. As far as I know, most authorities confine ionisation to chronic articular gout, and to this I shall refer later.
Massage.—The success that follows the application of stimulant or absorbent preparations in the after-treatment of acute gout largely depends on the skill and persistence with which the rubbing or kneading is performed. Hence it is that treatment by external medication has been largely superseded, and rightly so, by skilled massage, the outstanding advantages of which find increasing appreciation.
It need hardly be said that massage is contra-indicated in the acute, and its use should be confined to the subacute, stage. Moreover, I would suggest that its aid be sought more frequently during the decline of acute attacks, instead of its being reserved, as it very largely is, for the more chronic varieties of articular gout. In the latter instance organisation of the inflammatory products has already ensued, and their dispersal is correspondingly more difficult, whereas in the former the soft nature of the effused material renders dissipation more easy and, what is more important, minimises the chances of recurrence. Gentle massage also will promote the absorption and resolution of tophi, for the uratic deposits, even when pre-existing, are often found after an attack to be softened and more mobile, and now is the time to profit by these changes, so as to compass their elimination.
In these subacute stages, of course, vigorous excitation must be avoided, effleurage or light stroking being the only permissible measure at this stage; and of course it should be exercised centripetally. In presence of any marked sensitiveness, too, it is advisable that derivative massage of the limb above the joint should always precede any direct friction of the latter.
The measure of success will depend on the technique of the masseur. If he be unskilful or rough, aggravation of the inflammatory process will almost certainly ensue, with prolongation of stiffness and pain. He should proceed tentatively, the energy displayed being gradually increased as the parts grow more tolerant of manipulation.
Again, it is at the close of a massage séance that passive movements are most advantageously employed, and where irritation and pain follow their performance, gentle centrifugal stroking of the actual joint surface will exercise a grateful, soothing effect.
Surgical Methods.—The intensity of the inflammation and swelling in acute gout has, as before said, sometimes led to its confusion with purulent arthritis. It was just such a mishap that led Riedel to discuss seriously the operative treatment of gout when of monarticular type, e.g., in the great toe joint. He cites the case of a man, aged forty-five, suffering with acute gout of classic site which was operated on under the impression that the joint contained pus. None issued, but the synovial membrane was found covered with urates. The latter were removed, the wound healed in five weeks, and no recurrence of articular gout followed till fourteen years after. The second example occurred in a lady seventy years of age, who likewise suffered an acute attack of gout in the right great toe joint. An incision was made and the revealed urates removed, and the wound healed in a few weeks, and no subsequent attacks followed!
Despite the apparent good results obtained, one can scarcely believe that incision and removal of urates during acute gout will ever be seriously considered. Nevertheless the apparent impunity, if not actual benefit, that followed the above operative interference does, I think, indicate that in these aseptic days we need be less timorous; in other words, that, while the operative treatment of acute gout is unnecessary, yet in chronic cases surgery has its sphere. But to this I shall return later, when discussing the treatment of tophaceous deposits in chronic gout.