Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

The Schnee four-cell bath may be used where ionisation is indicated. It possesses obvious facilities for local or sectional application, as drugs can be added to the water in the cell and carried through the skin by means of the continuous current. Thus, in cases of large gouty deposits, the joint may be placed in a bath containing a 2 per cent. solution of iodide of lithium or of 5 per cent. bicarbonate of potash. The positive electrode is then located in the bath, while the negative pole, moistened with hot water, is applied to the lumbar region. Working with lithium in this manner, Bordier detected the presence of uric acid in the fluid of the bath, thus demonstrating introduction of the cation-lithium and removal of the anion-uric acid at one and the same time. In this way proof is adduced that the lithium penetrates the tissues, and coming directly into contact with uratic deposit, tends partly to dissolve it.

To achieve the dual purpose, viz., absorption of inflammatory and uratic deposits, we may with advantage give the chlorine or iodine ions, for their sclerolytic effect on the tissues, in alternate sittings with the lithium ions. When time is no great object, two or three séances a week will suffice, but where time presses, the sittings, according to Leduc, may be given daily, always provided that the position of the electrode and therewith the direction of the current in its passage through the joint be changed at each application. It is necessary to emphasise the fact that the use of too mild currents is futile, and to secure adequate results a prolonged series of séances is necessary. Also I would suggest that the simultaneous taking of a course of atophan would appear to be indicated.

Surgical Treatment.—In pre-antiseptic days, catastrophes, e.g., erysipelas, gangrene, etc., having occasionally followed the evacuation or removal of tophi, it was deemed inadvisable to interfere with them by any surgical methods. But, the danger of sepsis having been largely removed, it is now regarded as quite permissible to attempt the removal of uratic deposits for aesthetic reasons, or, more cogently, when they give rise to pain or restrict the movement of the related articulations.

Moreover, the old view that incision or evacuation of tophi was followed by obstinate ulceration is not borne out by modern experience. Thus my colleague Lindsay found that healing takes place quite naturally provided the incision is made over the more healthy skin towards the base of the swelling. With this I am in agreement, and furthermore would suggest that tophi when of large size and fluctuating are better opened with aseptic precautions than allowed to evacuate their contents spontaneously, for in this last event suppuration ensues, the sores become troublesome, and remain open for a long time. Sir Alfred Garrod in such circumstances advised touching up of the indolent parts with nitrate of silver.

In my search through the literature I have only come across two instances in which operation has been undertaken for the removal of gouty deposits in relation to tendon sheaths, bursæ, and skin. These were performed by Alexis Thomson. In one the subject was a medical man, aged thirty, the subject of inherited gout. Multiple tumour-like nodules, ranging in size from a pea to a cherry, were located over the knuckles, and the same were attached to the extensor tendons and moved with them. At the patient’s request, they were removed on account of their unsightliness. Their dissection from the tendons was achieved with some difficulty, and healing, though retarded a little by watery discharge from the wounds, was “in the end quite satisfactory.”

The other example occurred in a tailor, aged thirty-seven, in whom massive tophi developed at many sites. The larger deposits were located over the left external malleolus, the left olecranon, and the right malleolus. Because of their exposure to injury and pressure, removal of these various gouty tumours was decided upon. In all save the specially large swelling over the left external malleolus this was easily accomplished by cutting through the surrounding healthy tissues. But that at the site named “was so fixed to the bone that it had to be separated with a chisel; it was then seen that the chalky deposit occupied spaces in the spongy interior of the bone, and in the substance of the internal lateral ligament; the removal of the chalky material in the area of the wound was carried out more satisfactorily by scrubbing the tissues with gauze and hot water than with the sharp spoon. The peronei tendons exhibited a very pretty deposit of urates under the endothelium covering them.”

Healing of the wounds took place very satisfactorily, and nine months later the general health was excellent; no further tophaceous deposits had accumulated, and the scars of the wound had remained quite sound. As Alexis Thomson observed, that though, even as this particular case showed, spontaneous disappearance of tophi may follow a subsequent attack of gout, still such could not be hoped for in the case of a massive deposit in the left internal malleolus, invading as it did the interior of the bone. He sums up his conclusions in the following words: “My own experience is limited. So far as it goes, it establishes not only the safety of the removal of gouty tumours by surgical means, but also the improvement in the general health which follows the removal of large masses of urates from the exposed parts of the body. So far as appearances are concerned, the substitution of linear scars for unsightly tumours is a decided improvement.”

Now, if we take Riedel’s two instances of acute gout and their tolerance of incision and local cleansing of urates and the equally happy tolerance exhibited by Alexis Thomson’s two cases of chronic gout, we see that, in these days of aseptic surgery, even gouty arthritis can no longer be regarded as outside the pale of operative interference. But, as a caveat against rash ventures, I would point out that recently I canvassed the desirability of operation in a case of massive tophaceous deposits in the hands and feet; but fortunately a skiagraph was taken which revealed that several of the phalangeal shafts had at some sites in their length undergone total absorption.

Nevertheless, given sound general health and failure of other modes of treatment, I think that operative measures should be seriously considered, for in the more inveterate types of tophaceous gout the crippledom and painful ulceration renders the victim’s life a misery, and one incapable of appreciable amelioration by medicinal or other methods of therapy.