THE METABOLISM IN GOUT 453 



Atophan in my experience frequently produces symptoms of hyper- 

 acidity. To prevent digestive disturbances the employment of the small 

 dose of 0.5 gram frequently repeated should be tried, rather than the 

 common^ habit of giving large doses once or twice a day. The drug should 

 be taken with plenty of water. Sodium bicarbonate should be given with 

 each dose of atophan if there is a history of gravel, as renal colic has 

 occurred after the administration of atophan in cases of nephrolithiasis. 

 Give 10 to 15 gm. of sodium bicarbonate on first day and 5 to 10 gm. on 

 subsequent days. On the other hand as alkalies seem injurious in gout so- 

 dium bicarbonate should not be added to atophan as a routine procedure. 



Some patients have a strong idiosyncrasy against atophan. Diarrhea, 

 vomiting, severe headache, and tinnitus have been produced by the drug 

 according to Brugsch and on their development its use should be abandoned, 

 and the milder preparation, novatophan (tolysin), employed. 



Colchicum. This drug may be fairly accounted a specific in the acute 

 paroxysm of gout and has enjoyed a deservedly high reputation for gen- 

 erations. It has "the property of easing, in an almost magical manner," 

 the pain of gout. The wine of colchicum is a favorite preparation. The 

 dose is 1 to 2 c.c. three times a day for two or three clays. It may be of ad- 

 vantage to give a large dose at first, 2 to 4 c.c. and follow this up by much 

 smaller doses as the elder Garrod suggested. Allbutt(&) gives it in a mix- 

 ture of laxative drugs half an hour before meals. In my hands it has been 

 less effective than the alkaloid colchicin which can be obtained in granules, 

 each containing 1 mg. Three or four may be given the first day of an acute 

 attack in doses two to four hours apart. Relief from the pain is usually 

 experienced after a few hours. On the second day the drug is given in 

 the same dosage, but instructions should be left with the patient to stop 

 the medicine if diarrhea or vomiting occurs. It is well to follow the col- 

 chicum with a course of atophan. 



How colchicum produces its favorable action is unknown; possibly 

 through increasing the circulation through the inflamed joints as recent 

 experimental work would indicate. It does not cause an increased output 

 of uric acid as Chace and others have shown. 



Other Methods. If the pain is very severe morphin should be used 

 so that relief may be obtained in the interval of hours that always elapses 

 before the benefit from colchicum is apparent. English writers urge the 

 importance of a brisk purge. For this purpose Allbutt(&) prefers a blue 

 pill to which 0.1 to 0.2 of a gram of extract of colchicum is added. He 

 would give this for the first two or three nights of an attack. Personally 

 I have not used purgation. As colchicum pushed to the physiological limit 

 produces diarrhea I do not wish to lose this valuable warning that the 

 limit of safe administration has been reached. A mild laxative may be 

 given at the onset of the attack. If a saline is given magnesium sulphate 

 is preferable to salts containing sodium (Roberts). 



