THE PATHOGENESIS OF GOUT 131 



is evident that the presence of so-called predisposing, favoring factors is not 

 alone sufficient for the development of gout. 



In this connection, Thomas Oliver alludes in his valuable book, " Lead 

 Poisoning," to an investigation regarding the workmen in the large lead works 

 at Newcastle-on-Tyne, and this is very characteristic. As is well known, lead 

 is a predisposing factor in the development of gout. Yet such of the worlcers 

 in lead at Newcastle-on-Tyne as come from the north of England are only 

 rarely attacked by gout, even when their kidneys' are diseased, for in that por- 

 tion of the population the predisposition to gout is absent; while those who 

 come from the south of England, where the gouty predisposition is widely 

 distributed, are frequently attacked with gout when employed in the pre- 

 viously mentioned lead works in the north of England. One problem referred 

 to by me in the above named theses on the pathogenesis of gout requires 

 further discussion : in what does the predisposition to gout consist, and how 

 is the so-called gouty predisposition, the uric acid diathesis, to be conceived ? 

 The principal role is played by a faulty composition, not of the "humors," 

 the juices of the human body, but of the protoplasm including the nuclei of 

 the cells, in consequence of which uric acid, and perhaps still other bodies 

 of the group of the alloxur and nuclein bases, are either formed in increased 

 amounts or in an unusual region. I believe it to be very likely that the simul- 

 taneous occurrence of both these anomalies is the rule. The organs richest in 

 nuclein play the most important part in this process, and I believe we may 

 assume from the clinical history of gout that bone marrow and the great mus- 

 cular masses of the human body, especially those of the extremities, are in- 

 volved in this anomaly of uric acid formation. It is quite possible that in 

 these tissues, already rich in nuclein substance, an increased formation of 

 alloxur or nuclein bases, that is, of uric acid, takes place. My investigations 

 have shown that uric acid is a chemical poison, and hence, until the same has 

 been proven of the other previously named substances, and until the question 

 has been answered whether there is a specific " gout poison," as is believed 

 -by some authors, uric acid may be looked upon as. the materia peccans in gout. 

 The uric acid, loosely combined with an alkali formed in the muscles and bone 

 marrow, is dissolved, iiows through the lymph and blood channels, and is for 

 the most part excreted by the kidneys, unless other processes of decomposition 

 take place during its course. If this process of excretion occurs smoothly and 

 without hindrance, and if the gouty predisposition is not too decided, the con- 

 sequences of the existing anomaly of metabolism will show themselves only 

 after a certain time by a number of pathological phenomena, mild or severe, 

 subjective and objective. But as soon as any intercurrent cause produces 

 stasis of the juices rich in uric acid in the affected area — naturally at first in 

 the peripheral parts, particularly in the lower extremities, in which stasis is 

 especially prone to happen — engorgement will occur which, in consequence of 

 this local stasis, also primo loco, in the affected parts of the body, will become 

 more or less noticeable as a typical attach of gout. I call these cases primary 

 arthritic gout. In Observation I, we have a case of primary arthritic gout 

 which should more correctly be designated primary extremity gout, since not 

 only the joints were implicated, but also the muscles, and especially the skin. 



