Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

Medicinal Therapy

The illustrious Sydenham, for more than thirty years a sufferer from gout, was clearly in doubt as to whether a cure of the malady was to be attempted or even desired. It was Nature’s prerogative, he contended, to dispose of the peccant matter after her own fashion by depositing it in the joints, whence it might be dissipated by insensible transpiration. Evacuant measures were, he thought, frankly prejudicial in that they occasioned reabsorption into the blood of morbid substances already cast forth from the system into the joints, with haply deflection of the same upon the viscera, with all its added perils.

In view of these conceptions, Sydenham naturally discountenanced any attempt to arrest or control the course of acute gout. “Nay, more,” said he, “I can confidently affirm that the greater part of those who are supposed to have died of the gout have died of the medicine rather than the disease.” Not only were purging, blood-letting, and alike the use of diaphoretics by him condemned, but, more, a policy of “inert expectancy” enjoined. The true rôle of the physician was that of the bystander viewing the workings of the vis medicatrix Naturæ, while for the tortured victim remained the pithy consolation that his gout was to be regarded as a minister of health, whose presence and stay ought by all means to be courted. Long years after Sydenham’s death his laisser faire attitude survived in Meade’s epigram, “the gout is the only cure of the gout,” and in Cullen’s depressing axiom that “in patience and flannel alone” lay salvation. Can we wonder that this policy of masterly inactivity made gout the happy hunting ground of the charlatan?

It may be admitted that an initial attack of gout often leaves the subject better than before, but the deep remedial forces of Nature, at first apparently all-sufficing, later prove unequal to their task. Secondary evils follow the attacks, and “the racking pains, unfitness of motion and other disorders which afflicted him during the greatest part of his life” are at once a proof of Nature’s limitations and the fallaciousness of Sydenham’s doctrines.

So much by way of prelude, but perhaps, as Heberden surmised, the chief reason why Sydenham and his disciples found it advisable to do nothing to curb the violence of gout was that they knew nothing wherewith to achieve such control. Thus, though colchicum had been used from time immemorial by the ancient physicians, it had in Sydenham’s time almost been abandoned as a remedy in gout, when, long after, according to Scudamore, a Mr. Want (“Essays in the Medical and Physical Journals,” No. 185, etc.) drew attention to its specific value in gout, and restored the drug to its pristine status.

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.