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to begin with, has been placed on colchicum, and, symptoms of irritation having supervened, the drug has had to be withdrawn.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.