447 



uric acid from this source possibly has no clinical significance. It takes 

 a very large amount of these proteins to produce only a slight increase 

 in the uric acid excretion. 



The effect of the purin poor diet in reducing the uric acid content of 

 the blood in gout should be studied whenever possible. In this disease 

 blood analyses are much more important than -urine analyses. In spite 

 of the exclusion of exogenous purins the blood uric acid usually drops 

 slowly. This shows that the high value in gout is due chiefly to increased 

 endogenous formation. Steinitz(c) found in a case of gout placed on a 

 purin poor diet that the amount of uric acid was 4.9 mg. per 100 grams 

 of blood after four days, 5.5 mg. after three months, and 3.5 mg. after 

 six months. In one of my patients whose blood I followed for six years 

 there was slow diminution of the uric acid in the blood, but it did not 

 reach normal until he had been on the purin poor diet for nearly two years. 



In those cases in which no benefit is said to result from a purin poor 

 diet it would be instructive to follow closely the uric acid content of the 

 blood. It is possible that some of these patients were continuing to eat 

 purin foods without their physician's knowledge. It may be that the diet 

 was not continued sufficiently long to diminish notably the uric acid 

 content of the blood and tissues. 



It is possible that attacks may continue in spite of the reduction of 

 uric acid in the blood to the normal. I had two cases in which the blood 

 uric acid was not increased, but there may have been an excess of uric acid 

 in the tissue fluids. The atophan. test should be tried in such cases to 

 determine whether or not the uric acid in the tissues is increased. 



Fruits of all kinds are of value in gout and should be given freely. 

 They are free from purins. There is a prevalent idea in England that 

 strawberries are injurious, and Sir Archibald Garrod prohibits their use. 

 I see no reason for this and clinical evidence if it exists has never been pre- 

 sented. Linnanis thought strawberries had a curative power in gout. 



Alcohol disturbs uric acid metabolism as Pollak showed and its use 

 should be prohibited. Wines and beer seem more injurious than distilled 

 spirits. In beer the purin content derived from the yeast is considerable. 

 In a liter of Munich beer there is as much purin as in 100 grams of beef. 



All writers agree that water should be taken in large amount. The 

 reputed efficacy of mineral waters is probably due to this valuable thera- 

 peutic agent they have in common rather than to their other chemical consti- 

 tuents. The cause of the beneficial action of water is unknown. The uric 

 acid output is not increased by diuresis as is sometimes maintained. 



Sodium chlorid diminishes the solubility of urates in blood plasma. 

 This was first shown by Sir William Roberts who held that the use of table 

 salt should be restricted. He advised potassium chlorid as a substitute. 



Calcium has a marked action in checking the output of uric acid as 

 shown by the recent work of Lubieniecki, Abl, Bain and Starkenstein. 



