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.