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Treatment of Acute Gout

water, patient, active, anodyne, morphine, pain and application

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Having thus passed in review the most important of the elements in the treatment of gout—important because they relate to the daily life and habits of the arthritic subject—it remains to consider the measures that are necessary in the management of the acute crises which constitute the most conspicuous feature of the arthritic diath esis. Opinions regarding the treatment of the attacks have greatly varied during the course of time. Celsus and Galen advised copious blood-letting, while Sydenham and Cullen advocated an expectant method. Some have regarded acute gout as a disease to be com bated and suppressed by abortive treatment: others regard it as a beneficial crisis that should be permitted to run its own course. Modern practice inclines toward the adoption of a medium course that shall aid and support the body during the critical evacuations that constitute the attack, and that shall serve to mitigate the suffer ings of the patient so far as that can be accomplished without inter fering with the natural course of events.

In a majority of eases the symptoms are not marked by a degree of intensity sufficient to require active intervention on the part of the physician. The patient should be kept in bed during the attack and the diet should be restricted so long as a febrile movement exists. Copious draughts of pure water should be encouraged in order to quench thirst and to promote the action of the skin and kidneys. Our forefathers under such circumstances were great admirers of herb-tea. In modern times such inert beverages as Poland water, Buffalo lithia water, and the simple aerated waters have acquired for themselves the reputation that was formerly connected with barley water and other harmless infusions. The various granular efferves cent salts of lithium, potassium, and sodium may be also given with good result in the way of increasing the flow of urine and thus aiding the natural eliminative processes. Active purgation is unnecessary in these cases. In the course of a week the tongue cleans, the appe tite returns, pain subsides, and convalescence begins without the em ployment of active measures.

But. when the crisis is violent and painful, it becomes needful to moderate its severity. If heart and kidneys are yet intact, con siderable latitude is permissible in the exhibition of remedies. If,

however, these important organs are materially injured by disease— if the pulse be weak and irregular, and if there be albumin in the urine great caution is necessary, and the treatment should be prin cipally devoted to the application of local remedies to the affected joints. When the patient is young and vigorous, he should be kept in the recumbent position, with the inflamed joint upon a well-ad justed cushion by which the limb can be supported a little above the level of the body. The application of leeches is no longer practised, since it has been shown to be either without effect or positively in jurious. But much relief from pain can often be procured by the Use of hot fomentations—hot whiskey and water applied on flan nels covered with thin rubber cloth or oiled silk. In the same way may be applied the time-honored lotion of lead water and tincture of opium. Sir Dyce Duckworth praises the following com binations : Three parts of menthol and two of camphor may be rubbed up together to form an anodyne application, or ss. of menthol may be dissolved in f vi. of spirit of chloroform for a lotion.

Four grains of cocaine may be dissolved at a gentle heat in r" ss. of oil of sweet almonds, or of oleic acid, to form an anodyne liniment. Internal medication in this class of patients should begin with the administration of a mercurial cathartic—either a few grains of calomel followed by a glass of effervescent citrate of magnesia, or For the relief of pain, the local use of anodynes, as above de scribed, is usually sufficient. Hypodermic injections of morphine have been made occasionally in the vicinity of a painful joint, but the practice is attended with some danger of metastasis, followed by the development of the symptoms of retrocedeut gout. There can be, however, no objection to the moderate use of small doses of morphine —the thirtieth of a grain every hour for example. These minute and frequently repeated doses relieve nausea, allay irritation, promote perspiration, and exert an appreciably anodyne effect. When con siderable fever is manifested, a drop of the tincture of aconite may be also given with each portion of the morphine. But such medica tion is only adapted to cases of moderate severity ; it would avail but little in the stormy crises that sometimes occur.

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