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:—