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.
CHAPTER XXIX
MEDICINAL AND OTHER MODES OF THERAPY (continued)—INTER-PAROXYSMAL PERIOD
Treatment in the Inter-paroxysmal Period
Despite the fact that heredity plays so dominant a rôle in the genesis of gout, how relatively scanty the attention paid to prophylactic measures! It is the second, never the initial, attack of gout that we endeavour to avert. Surely to inhibit the development rather than to prevent the recurrence of the malady is the better part. The idea is not wholly utopian, for such shrewd observers as Scudamore, Austin Flint, and others, were convinced that by timely and judicious intervention a threatened outbreak might be averted or at least its severity mitigated.