MEDICINAL AND OTHER MODES OF THERAPY—ACUTE GOUT
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.
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.
_Colchicum in Acute Gout._
Whatever be its mode of action, colchicum still remains _par excellence
the_ remedy for acute gout. As before noted, Dixon and Maiden hold
that _colchicine_ has no action on the _metabolism_ or _excretion_ of
_purins_, nor on the _kidneys_. On the other hand, it influences markedly
the _leucocytes_, their number in the circulation undergoing a primary
decrease and a secondary increase. Bain, it is true, found that under
colchicum a slight _increase in uric acid excretion_ occurred, but thinks
it extremely doubtful if its influence in this direction is invariable.
That colchicine should exert such a marked effect in gout and yet
apparently be destitute of any influence on _uric acid excretion_ is of
course very striking. It calls, moreover, for more reflection on the part
of those who seem to contend that because a drug _increases uric acid
elimination_ it must necessarily be beneficial both for the gout as well
as for the victim.
_Method of Administration._—In _initial_ attacks the drug must be
exhibited with caution. Some persons are idiosyncratically sensitive
thereto. Attacks of faintness may ensue, or even ordinary doses occasion
purging or nausea and vomiting. Their incidence shows either that the
subject is abnormally sensitive or the dose too large. Such untoward
phenomena indicate its abandonment or drastic reduction. With these
reservations, colchicum may be administered in every primary attack and
most, if not all, of the succeeding paroxysms.
Albeit, the older the subject and the more ancient the gout, the more
warily should we proceed, especially if there is marked irritability of
the digestive system, renal disorder, or cardiac degeneration. Robin
holds that if _visceral_ gout is present, or the urine contains much
_albumen_, no colchicum should be given.
It is notorious that _old_ persons stand colchicum badly. In their
instance we need be the less ready to resort to heroic doses when we
recall that acute gout is a self-delimited disease, and while it would be
improper to do nothing in elderly subjects exhibiting visceral lesions,
etc., it is well that we proceed cautiously, so as to avoid the induction
of circulatory depression or the excitation of nausea or a diarrhœa which
may be, and often is, difficult of control. Moreover, if these untoward
symptoms are allowed to ensue, there is a tendency for the gout to recur
as soon as the effects of the colchicum have worn off.
_Preparations of Colchicum and Dosage._—Those most commonly in use are
the _tincture_ and _wine_ of colchicum, and of these the latter is most
in favour. As to dosage, most authorities agree that a full dose—30-40
minims of the vinum colchici—should be given at the inception of
treatment and followed by smaller amounts, from 10-20 minims two or three
times a day.
By French physicians the tincture of colchicum is preferred, and by Robin
that extracted from the _flowers_ rather than the seeds. The dose of our
own official _Tinct. colchici seminum_ ranges from 5-15 minims, and by
the French Codex the maximum single dose is placed at 25 minims, and the
maximum intake during twenty-four hours at 100 minims approximately. It
may be noted that preparations from the _seeds_ are more purgative than
those derived from the corn. Lastly, we have the official extract of
colchicum and the acetic extract. The dose of the former ranges from ¼-1
grain, and it is frequently given in the form of a pill with ipecacuanha
and mercury. The addition of a small dose of atropine is often advisable,
to obviate the vomiting and diarrhœa often primarily induced by increase
of peristalsis. By many the acetic extract is preferred, J. S. Matthews
holding that the effective dose ranges from 2-6 grains.
Turning now to discuss the most opportune juncture at which to administer
colchicum, certainly in the _initial_ and the earlier paroxysms we may
with advantage postpone the giving of colchicum pending _free clearance
of the bowels_. No harm will follow its being withheld until the _second_
day. Indeed, many physicians, both British and Continental, counsel delay
in its exhibition until the fit is well established.
Again, in _primary_ paroxysms—viz., while ignorant of the personal
equation in respect of _colchicum_—it is well that our maximum dose
should not exceed 20 minims, and when the bowels have not been previously
purged, the drug should be combined with sulphate and carbonate of
magnesia, as in the following prescription:—
℞ Magnesii sulphatis gr. 60
Magnesii carbonatis gr. 10
Potassii citratis gr. 30
Vini colchici ♏︎ 20
Aquæ menthæ viridis ad unciam.
Misce. fiat mistura. Two tablespoonfuls with two of hot water every
three hours until bowels have been freely opened.
This achieved, the sulphate of magnesia may be omitted, and the mixture
taken every six instead of every three hours; but it is a good plan to
keep the original mixture at hand, giving a dose every morning while the
acute stage lasts. Then during the day the colchicum should be persisted
with either in the form of the wine or the tincture.
Moreover, there are often special indications to be met. Thus the skin
in acute gout is often hot and dry, and the urine unusually scanty and
high-coloured. In this event the colchicum may with advantage be given
with the citrate, bicarbonate or nitrate of potash, so as to produce
a diaphoretic and diuretic effect. In other instances acidity is a
prominent symptom, and here the combination of colchicum with the citrate
of potash and magnesia will be found useful.
As the intensity of the inflammation wanes and the local pain and tension
subside the dose of the colchicum should be gradually diminished;
but even after convalescence is established it may advantageously be
continued for a few days in small doses, say, 5 minims of the vinum
colchici three times a day. The condition of the tongue will usually
furnish a safe index, as rarely will it clean up prior to abatement of
the gouty fit.
In _subsequent_ paroxysms and alike in the _acute exacerbations_
that chequer the course of _chronic_ gout we may, in the absence of
_idiosyncrasy_ or other contra-indication, proceed more boldly. Thus,
if the bowels have not previously been briskly purged, we may at once
prescribe the following formula:—
℞ Vini colchici ♏︎ 15-20
Magnesii carbonatis gr. 15
Magnesii sulphatis gr. 60
Aquæ cinnamomi ad ℥j.
Fiat mistura, ℥ij. statim sumenda et ℥j. quartis horis p.p.a.
The primary dose, as will be noted, will contain either 30 or 40 minims
of the wine, and, though Sir Alfred Garrod prescribed up to a drachm,
it will scarcely, if ever, be necessary to exceed 30-40 minims. The
subsequent dose of from 15-20 minims may after a day or two be reduced,
and instead the mixture given in ½-ounce doses three or four times a day.
Or, if preferred, the mixture in its reduced dosage may be renounced in
favour of a pill containing either the extract of colchicum or, what many
consider even better, the acetic extract thereof. Thus the following pill
may be taken every night for a few days, and then on alternate nights:—
℞ Ext. colchici gr. ¼
Aloin gr. ⅛
Ext. bellad. alcoh. gr. ⅛
Capsicin gr. ⅟₂₀
Ext. rhei gr. 1
Fiat pil., 1.
The acetic extract may be given in larger doses, and was in great favour
as the chief constituent of many so-called “gout pills” in combination
with ipecacuanha and mercury:—
℞ Ext. colchici acet. gr. 1½
Pulv. ipecac. co. gr. 1½
Ext. colocynth co. gr. 1½
Fiat pil., 1 nocte sumenda.
An excellent formula, in which the colchicum is combined with mercury,
has already been furnished on a preceding page. Needless to say, it
should, like the above pill, be followed in the morning, if necessary, by
a mild saline purgative.
_Colchicine._—This, the active principle of colchicum, has of recent
years been widely and successfully employed in acute gout, as well as
in exacerbations of the chronic type. By some subjects, especially the
old, it is often better borne than colchicum preparations. The dose
ranges from ⅟₁₀₀-⅟₃₂ grain in a pill. By the French Codex the maximum
single dose is fixed at ⅟₃₂ grain, and the maximum administered during
twenty-four hours should not exceed ⅟₁₆ grain approximately.
The following is a suitable combination in an elderly subject, and it may
be noted that the drug has been found of use, too, in cerebral congestion
and uræmia:—
℞ Colchicine gr. ⅟₁₀₀
Ext. belladon. alcoh. gr. ⅛
Ext. nucis vomicæ gr. ¼
Fiat capsule or cachet, 1 every three or four hours.
In robust subjects the colchicine may be given in larger doses. Luff
states that few patients will tolerate ⅟₅₀ grain, because of the diarrhœa
and griping pains produced. He found that colchicine (⅟₇₀ grain), in
combination with henbane and nux vomica in the form of a pill, rapidly
relieved gout when taken every three or four hours.
Or as a substitute we may use the _salicylate of colchicine_, the dose of
which is ⅟₆₀ grain. Colchicine is readily soluble in methyl salicylate,
and is conveniently administered in the form of capsules, each containing
⅟₂₅₀ gram (Martindale). In acute gout one capsule may be given every
two hours, or two capsules three or four times a day. These doses are
well within the limits of safety, and, if necessary, may be combined
with nux vomica and belladonna; but with the alkaloids, as with the
colchicum itself, it is essential that the bowels should be kept freely
opened. Also with the waning of the pain and inflammation the colchicine
or its salicylate should be given less frequently, so as to obviate any
depression.
_Atophan._—This is a yellowish cream-coloured amorphous powder of the
composition 2-phenylchinolin 4-carbonic acid. Its use has been much
extolled both in _acute_ and _subacute_ gout. The dose ranges from 30-45
grains daily for three to four days, according to some authorities,
but others consider that it may be taken for prolonged periods with
advantage. It is most conveniently exhibited in the form of tablets
containing 4 or 8 grains. _Agotan_, a drug identical with that formerly
sold under the German registered name “atophan,” is supplied in the form
of crystalline powder and in 7½-grain tablets, and appears to be equally
efficient.
Atophan is incompatible with sodium bicarbonate and other alkalies
_in vitro_, but Martindale and Westcott “did not find it incompatible
with potassium iodide.” It has been repeatedly noted that, following
the intake of atophan, the uric acid content of the _blood_ falls and
the _urinary uric-acid output_ increases. Weintraud in gouty patients
on a _purin-free_ diet noted that after atophan the quantity of uric
acid excreted in the urine was more than doubled, but subsequently the
excretion fell below normal.
Even in healthy individuals when taking atophan the urine becomes turbid
from the presence of _urates_. This excess of uric acid in the urine may
in gouty individuals be precipitated in the urinary tract, and so induce
an attack of _gravel_. Consequently Weintraud advises that the drug be
taken with _alkalies_, either sodium bicarbonate or alkaline waters.
Drs. Jansen and Plum, of Copenhagen, during their recent visit to the
Royal Mineral Water Hospital, Bath, informed me that they had met no
instances of _gravel_, but in several of their cases atophan had induced
_urticaria_.
As to the simultaneous intake of _alkalies_, while the precaution is
probably desirable, I have known gouty patients take atophan _without_
alkalies for several weeks in full doses without any apparent ill
effects. Brugsch, indeed, states that in _polyarthritis urica_ the
subjects are able to take 15-30 grains of atophan per diem for a year
without any affection of the kidneys. Moreover, uric acid excretion
was increased throughout the whole period, and when the drug was
discontinued, the pains recurred.
As to the usurpation of colchicum by atophan, I do not think it is at
all likely, for it does not, I consider, exert the specific effect of
the former on the gouty inflammatory process, taking the humbler _rôle_
of obviating the formation or promoting the absorption and elimination
of _uratic deposits_. In other words, colchicum influences the _causa
causans_ of gouty inflammation, atophan only the _consequences_ or
_sequels_ thereof.
The most favourable juncture at which to prescribe atophan is _at the
close of a paroxysm_. I have myself been much impressed with the manner
in which it produces softening and palpable diminution in the size of
tophaceous deposits, so much so, indeed, that I feel sure we have in
this drug a valuable agent wherewith to _prevent the formation of uratic
deposits_.
A two or three weeks’ course of atophan after an acute attack is, I have
found, very advantageous, in doses of 30-45 grains per diem, after meals.
It may, for the special reasons given, be well combined with an alkaline
stomachic mixture taken half an hour or more before food.
℞ Potassii bicarbonatis gr. 15
Sodii bicarbonatis gr. 20
Spts. ammoniæ aromat. ♏︎ 20
Tinct. zingiberis fort. ♏︎ 5
Inf. aurantii co. ad unciam.
Fiat haustus, thrice daily well diluted with water.
To sum up, our medicinal treatment of acute gout consists in _initial
purgation_, followed by maintenance of an adequate daily evacuation;
secondly, the exhibition of _colchicum_ or its active principle and
continuance of the same in diminishing doses until pain and inflammatory
phenomena have departed. With the passing of the paroxysm _atophan_
should be resorted to in combination with an alkaline stomachic mixture.
Supervision of the subject should not cease until the digestive and
assimilative functions have, as far as possible, attained functional
efficiency, for it is certain that this is the most important point in
the management of the gouty constitution. Conjoined therewith, the bowels
should never be allowed to become constipated, the urine maintained free
from acid lithates, and the skin active by regular exercise.
_Alternative Remedies in Acute Gout._—Of the various drugs advocated
as substitutes for colchicum the salicylate group alone seems to have
evoked something like enthusiasm. Thus Germain Sée affirmed that sodium
salicylate was the best remedy for gout, whether of acute or chronic
type. In this country Haig strongly upheld its claim. On the other
hand, Ebstein, when he used this salt in acute gout, found that the
inflammation, though it quickly subsided in one joint, immediately
reappeared in another, even though the administration of the drug was
continued.
Lecorche, again, though he found it useful in _acute_ gout, was equally
certain that it was altogether inferior to colchicum. It did lessen
the pain and the violence of the paroxysm, but in no way shortened its
duration. But, on the other hand, he attached a _prophylactic_ value to
it in chronic gout marked by recurring subacute attacks. His method was
to give it in the intervals of paroxysms in doses of from 60-80 grains
a day, whereby he claimed to abort attacks, prevent ankyloses, and
facilitate absorption of uratic deposits.
As to its mode of action, salicylate of soda, both in gouty and healthy
subjects, determines an immediate increase in the uric acid excretion,
30-60 per cent. The increase, however, is but ephemeral, the excretion
of uric acid sinking gradually to normal in about forty hours, and this
whether the drug be persisted with or not. The increase in total nitrogen
excretion does not reach 10 per cent.
Discussing this mode of response, MacLeod (who noted the same after
citrates) is of opinion that salicylate of soda and citrate act, not by
influencing the metabolic processes that originate uric acid, but by
promoting the excretion thereof. Walker Hall and Magnus Levy, albeit,
suggest that the increase is due to diminution in the normal destruction
of purins in the organism, with resulting transmission of the same in
larger quantities to the kidneys for excretion. It is possible therefore
that in the presence of sodium salicylate there is diminished oxidation
of uric acid.
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.
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:—
℞ Olei origani vel olei terebinthini Partes æquales.
Linimenti ammoniæ.
To be applied with friction to the affected part.
℞ Ætheris 1 drachm.
Linimenti belladonnæ ½ ounce.
Tinct. capsici To 2 ounces.
To be well rubbed into painful parts night and morning.
When a joint is the seat of fixed pain with definite thickening, it may
be necessary to resort to _blisters_; but frequently they are so utilised
as to merit the aspersion of “adding additional distress to unrelieved
pain.” They are of course unsuitable for cases with _acute serous
effusion_ of recent origin; but are often beneficial when applied over
joints, bursæ, or tendon sheaths, when the seat of _long-standing passive
distension_.
Garrod held them of most advantage in _gout_ of _asthenic_ character with
lingering effusion; but he thought them inadvisable in the later stages
of gout with _defective kidneys_ and where the joints were the seat of
massive uratic deposits, as in the last event sores difficult of healing
may follow.
In the vast majority of instances such drastic counter-irritation is
unnecessary, as the pain usually relents to less strenuous measures. For
the dissipation of exudates and thickening nothing is superior to iodine
and mercurial preparations. Painting with strong iodine may occasion
soreness, but not if the glycerinum iodi be used. Better still is it if
we use iodine preparations that admit of gentle inunction. The iodide of
potassium and soap liniment is of course most reliable, or we may use one
of the proprietary preparations, _e.g._, leukion. The oleate of mercury
(10 per cent.) is often useful, and if pain linger on in the joint, may
be combined with morphia (½ grain to 1 drachm). Ichthyol lanoline also
deserves mention, and is best rubbed in after a fomentation followed by
a dry pack. It is extremely probable that the stimulant and absorbent
action of these agents is markedly reinforced by the _friction_ which
accompanies their usage.
In conclusion, it must be recalled that the swelling, stiffness, and pain
are of dual origin, viz., in part due to _inflammatory products_ and in
part to _uratic deposits_, and it is the former that will be the most
influenced by the foregoing measures. As to the means available for the
reduction or dissipation of _tophaceous_ matter, we shall best postpone
their consideration until we come to discuss the treatment of tophi.
_Ionisation in Acute Gout._—The introduction of medicinal substances
into the interior of the joints by means of an electrical current is
now in extensive vogue, both as a means of relieving pain and promoting
absorption in periarticular and synovial affections. It is of course in
the more accessible or superficial articulations that its beneficial
effects are most easily attainable.
The sensitiveness of the parts in acute gout is such that I have never
felt justified in invoking ionisation therein. Nevertheless Finzi tried
it in two cases of acute gout. Instant relief of pain and diminution of
swelling followed the first _séance_, while in sequence to a second all
local tenderness disappeared. Finzi used a combination of lithium and
iodine, the former at the positive and the latter at the negative pole.
I would only add that in non-gouty forms of arthritis, if relief of pain
be desired, _salicylic_ ions, by general consent, would appear to be the
most reliable. As far as I know, most authorities confine ionisation to
_chronic_ articular gout, and to this I shall refer later.
_Massage._—The success that follows the application of stimulant or
absorbent preparations in the after-treatment of acute gout largely
depends on the skill and persistence with which the rubbing or kneading
is performed. Hence it is that treatment by external medication has been
largely superseded, and rightly so, by skilled _massage_, the outstanding
advantages of which find increasing appreciation.
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.