442 JOSEPH H. PRATT 



tion of urates, but it is certain that not every excess of uric acid in the 

 blood leads to a deposition of urates. It is also certain that in gout 

 local changes in the places where tophi are formed play an important part. 



The Ferment Theory. Brugsch and Schittenhelm held that gout was 

 an anomaly of the entire system of ferments concerned in the formation 

 and destruction of uric acid. In gout, according to them, there were re- 

 tarded uric acid formation, retarded uric acid destruction, and finally re- 

 tarded uric acid elimination. The correctness of the elaborate theory 

 they built up was made improbable by Wiechowski, who found that uric 

 acid was not destroyed by any human organ, and by Jones and his co- 

 workers who demonstrated that the distribution of ferments in gout was not 

 different from that in normal persons. 



The Combined Uric Acid Theory. Minkowski in 1900 pointed out 

 that proof was lacking that uric acid circulating in the blood and tissue 

 juice was in the form of a simple alkali salt. He suggested that in gout 

 uric acid might be in a form not readily excreted. This view he based on 

 some experiments in which uric acid was combined with nucleic acid and 

 thereby changed so that it could not be precipitated from the solution by 

 the addition of acetic acid or by silver and magnesia in ammoniacal solu- 

 tion. Dohrn made this hypothesis more definite by advancing the view 

 that in the blood of gouty subjects a nucleotid circulates whose purin por- 

 tion was already oxidized to uric acid. This idea of a combined uric acid 

 in gout finds some support from the discovery by S. Benedict of a uric 

 acid nucleosid in ox blood. 



Tissue Retention Theory. According to Umber (#) the tissues in gout 

 have a special affinity for uric acid. There must be an abnormal chemical 

 property of the tissues which leads to this retention. He holds there are 

 present an increase of receptors for uric acid which the normal tissues 

 possess in less number and that the same mechanism exists for the re- 

 tention of the arthrotropic poisons of metabolism in other joint diseases; 

 for example, homogentisic acid which injures the joints in ochronosis. 



Recent studies made with atophan and the result of intravenous in- 

 jections of uric acid show that in gout uric acid is retained in the tissue 

 juices in considerable amount and thus give support for the hypothesis that 

 there is a special affinity of the tissues for uric acid in this disease. 



Treatment 



It would seem that the clinical experience of the best observers since 

 the time of Sydenham would have settled long ago the question as to the 

 proper diet in chronic gout, but it did not do so. All authoritative writers 

 were agreed that the diet formed the most important part of treatment, 

 but their ideas as to what constituted the proper diet differed widely. 

 Sydenham himself emphasized the importance of moderation in meat and 



