THE SPECIFIC CHEMICAL AND MICROSCOPICAL PHENOMENA OF GOUTY INFLAMMATION

A.B. Garrod
1859 The Lancet  
French and Italian hospitals for the purpose of cleansing foul and sloughing ulcers. He had himself employed it, and thought that its virtues and advantages were much overrated ; that it sometimes produced more irritation in the part than was desirable, and that it was less convenient in application than other equally effective cleansing remedies, whilst it was far inferior in value in sloughing ulcers to that combination of the manganate and permanganate of potash called " manganese cum
more » ... anganese cum potassa." A distinction should be drawn between ulcers secreting unhealthy pus which rapidly decomposed, and ulcers that were foul because of sloughing tissue which would not readily come away. In the former class the chlorate of potash lotion was the neatest and most effective agent in cleansing the ulcers, and rapidly neutralizing the smell by the amount of oxygen which was contained in the salt. The carrot poultice, the charcoal poultice, and chloride of lime were also very useful in this form of foul ulcers, but none of these was thoroughly effective in foul sloughing ulcers. In these the root of the slough must be destroyed by some caustic application, and this was best effected by the application of manganese cum potassa upon a small piece of lint the size of the slough. It is very quick in its action ; in the course of twenty-four hours the slough generally came away, and with it all the foul odour which had previously been so offensive and injurious, not only to the patient, but to all whose duty it was to be in attendance. In the discussion which ensued, various applications were mentioned by different speakers, such as charcoal, nitric acid, the tincture of perchloride of iron, lemon-juice, &c. The tincture of the perchloride of iron produced so much pain that the French surgeons in the Crimea had reported against its use. Lemon-juice and nitric acid, diluted according to the circumstances appertaining to the condition and the nature of the sore, were found to be the most efficacious; and Dr. JAMES BmD remarked, that the experience of the French surgeons coincided with his own. When in India, he had found the application of nitric acid, properly diluted, to be the most effective of all remedies, both in hospital gangrene and offensive ulcers. Mr. DE MÉRIC referred to some experiments lately instituted in France for the treatment of tetanus by the use of the wourali poison, administered internally, and applied externally to the wound. The result was not satisfactory. He mentioned some experiments performed by Sir Benjamin Brodie, nearly fifty years ago, on the action of the poison in question. Sir B. Brodie had arrived at the conclusion, that in the French case the remedy employed had had no real influence. Mr. de Meric entered into an argument to show that it was necessary, in order to arrive at a just conclusion respecting the effect of remedies in tetanus, to determine the nature of the particular case in which the treatment had been employed. He mentioned a case which had occurred in his practice at the German Hospital, and others, to show that in some instances of the chronic form of the disease patients seem to recover altogether independently of the remedies which may have been administered. THE author remarked that many and discordant views were held concerning the nature of gouty inflammation, and such I A A /' diversity of opinion arose from the fact, that up to the present time no characteristic structural change had ever been demonstrated to accompany it. The object of his communication was to supply that deficiency, and prove that special chemical and microscopical phenomena invariably attend true gouty inflammation. After alluding very briefly to the views held by the ancients, and within the last century by Murray, Forbes, and Wollaston, and by Cullen and his followers, and of the difficulties which each had to contend with in applying their hypo. theses to the explanation of the various symptoms of the diseases, he proceeded to speak of his discovery of the constant presence of uric acid in the blood in gout, and his subsequent researches in the nature of that disease. From these he first drew the three following conclusions :-1. In health, the blood contains minute traces of urate of soda and urea, and probably of all the principles destined for excretion; but the quantities are so small, that the most careful and refined analysis is required to demonstrate their presence. 2. In gout, the blood is invariably rich in urate of soda, and uric acid can be readily crystallized from it. 3. In by far the greater number of diseases the blood is free from an abnormal quantity of uric acid, but in certain cases of albuminuria, lead-poisoning, and other affections, its presence can be demonstrated, and still no gouty inflammation ensue. Lastly, in many gouty subjects the same condition exists in the intervals of the paroxysms. From these conclusions, Dr. Garrod considered it evident that something more than the mere presence of urate of soda in the blood was required to produce gouty inflammation, and his next object was to ascertain its nature. For this purpose a careful examination of the joints which had suffered was required, and within the last few years many opportunities had fallen to his lot. The subjects of these examinations are divided into four classes. 1. Subjects of chronic gout with extensive chalk stones. 2. Subjects of gout with no appreciable deformity, and no visible deposits of chalk stones, except one or more specks on the external ear. 3. Subjects of gout in whom no trace of chalky matter was externally visible, and in one case only eight attacks of the disease had occurred. 4. Subjects in whom only a single joint (the ball of a great toe) had been affected with gouty inflammation, or in whom some joint had only been once slightly inflamed. These examinations proved beyond the possibility of doubt, that in the very slightest forms of the disease, as well as the most severe, a structural change invariably occurs, and that this change, when once produced, remained, if not permanently, at least for a very lengthened time. After detailing the microscopical and chemical characters of the deposit producing this change, Dr. Garrod finished his communication by stating that be considered the facts which had been brought forward warranted him to conclude that-" Specific, chemical, and microscopical phenomena invariably accompany gouty inflammation, and these consist in the deposition of urate of soda in a crystalline form within the cartilages and ligamentous structures of the joints, and that such deposition is altogether pathognomonic, never being found in any disease other than true gout;" and again, that "Such deposition is probably the cause, rather than the effect, of the inflammatory action." Lastly, the author pointed out the great importance of ascertaining the true nature of the disease as a means of conducing to its rational and successful treatment.
doi:10.1016/s0140-6736(02)21448-8 fatcat:nesxv6xnjbd7xf5hjwcm23aipa