THE METABOLISM IN GOUT 439 



of the drug. In gout the increased output may continue for many days. 

 The uric acid in the blood drops markedly within a few hours (Folin and 

 Lyman, McLester, Fine and Chace(d), Smith and Hawk). 



Griesbach and Samson claim that this fall is preceded in some cases 

 at least by a transitory increase of the blood uric acid. It is probable that 

 atophan exerts an elective stimulation on the kidneys which increases 

 the secretion of uric acid (Weintraud(c) ). In addition to its stimulating 

 action on uric acid excretion it appears to have an inhibitory action on the 

 whole purin metabolism (Starkenstein(c) ). llaskkis(r) has noted periods 

 of depressed output when the administration of atophan had been discon- 

 tinued. There is no evidence that it causes an increased nucleic acid 

 metabolism as Nicolaier and Dohrn held. Atophan, either acting di- 

 rectly or as a result of its renal action in removing uric acid from the body, 

 mobilizes the uric acid in the tissues and organs. In this way a new supply 

 continues to enter the blood. The increased output of uric acid in gout 

 induced by atophan comes from reserves in the body (Frank and Przedor- 

 ski, Starkenstcin(c), Rosenberg, Graham). This action of the drug is 

 strong evidence that the uric acid in gout is retained in the tissue fluids in 

 considerable amount. 



When uric acid is injected into the veins or when sodium nucleate 

 is fed in most cases of gout the uric acid is largely or entirely retained in 

 the body, but under the influence of atophan in these cases the exogenous 

 uric acid is quantitatively excreted (Frank and Bauch). 



Deposition of Sodium Monourate in Gout. The most characteristic 

 feature of gout is the deposition of sodium monourate in the tissues. It 

 is this alone which sets it apart as a clinical and pathological entity from 

 other forms of arthritis. In acute attacks of gout it has been held since 

 the time of Garrod that uric acid is always deposited in the acutely in- 

 flamed tissues. In chronic gout collections of sodium monourate are found 

 in sites of predilection cartilages, especially of the metatarso-phalangeal 

 joint of the great toe, the finger joints, and of the ear ; fibrous capsules of 

 the smaller joints of the hands and feet; bones of the fingers; prepatellar 

 and olecranon bursas ; and subcutaneous connective tissue. In subacute 

 localized inflammations of the subcutaneous tissues (gouty abscesses) and 

 of the bursas the contents in the early stages consist of a milky fluid con- 

 taining prisms of sodium monourate. Later the fluid disappears and 

 chalky concretions remain. These consist chiefly of sodium monourate, but 

 may contain a small amount of lime. 



The local conditions that cause the deposition of urates is unknown 

 as well as the relation of the urates to the acute inflammation. The blood 

 in gout is not supersaturated. It will dissolve uric acid in considerable 

 amount (Klemperer(a) ). But even if the blood were supersaturated that 

 fact would not explain the deposit of uric acid in the tissues. It is quite 

 possible that the amount of uric acid in the tissue-fluids may exceed the 



