THE METABOLISM IN" GOUT 441 



considers this relation in the excretion of uric acid and glycocoll to be 

 pathognomonic of gout. 



Burger and Schweriner claim that the intravenous injection of uric 

 acid in gouty subjects about doubled the output of glycocoll while the uric 

 acid was largely retained. This same procedure in health led to no ex- 

 cretion of glycocoll. The value of all this work is impaired from the fact 

 that there is no direct method for determining glycocoll and the indirect 

 methods are not reliable (Samuely(c), Abderhalden and Guggenheim (&)). 



Kionka's(a) theory that in gout glycocoll is not 'completely burned and 

 Frey's claim that uric acid could be destroyed and glycocoll formed in 

 the blood have been rejected (Abderhalden and Schittenhelm(c), Brugsch 

 and Schittenhelm(c)). Kionka's(&) experiment of adding uric acid to 

 blood and finding glycocoll proved nothing because the uric acid was re- 

 covered unchanged. 



Theories of Gout 



The Renal Theory. This was advanced by Garrod the elder in 1848, 

 and has many adherents to-day. According to this theory gout is primarily 

 a disease of the kidney and not a metabolic disorder, "at least in so far 

 as the uric acid phenomena of the disease are concerned" (A. E. Garrod 

 (e)). In early interstitial nephritis there is evidence of uric acid reten- 

 tion, as the concentration in the blood often exceeds that in gout (Fine and 

 Chace) . McClure found "definite depression" of renal function in all five 

 cases of gout he tested by modern methods. The disturbance in renal 

 function was slight in most of these cases. There is certainly no definite 

 relation between the degree of nephritis present and the retention of uric 

 acid. This was shown in the cases studied by McClure and Pratt. The 

 patient with most severe nephritis, and whose phthalein output was only 

 5 per cent in two hours, excreted the largest percentage of exogenous uric 

 a.cid of any in our series. On the other hand in a case in which all the 

 uric acid injected was retained, there was no albumin or casts in the urine, 

 and the phthalein excretion was 52 per cent. 



The low endogenous level of uric acid output in gout in the intervals 

 between attacks with the high uric acid concentration in the blood suggests 

 that the kidneys excrete uric acid with difficulty in this disease. This 

 idea of functional impairment of the kidney is weakened by the fact 

 that during the height of an acute attack they frequently put out an ab- 

 normally large amount of uric acid. 



If the high blood uric acid in chronic interstitial nephritis indicates 

 its relation to gout, a "potential gout" as it were, it is remarkable that 

 the retention of uric acid in chronic interstitial nephritis is so rarely fol- 

 lowed by symptoms of gout. 



The accumulation of uric acid in the blood probably favors the deposi- 



