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The Urine in Gout

acid, uric, urea, quantity, chronic and acute

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Much confusion exists in the writings of the earlier authors re garding the condition of the urine in gout, owing to faulty methods of analysis, and to the variable quantity and quality of the urine itself in the different stages of the disease. In order to arrive at accurate knowledge the daily quantity of urine should be ascertained for a period of several days or weeks; and the amount of uric acid should not be estimated from the daily sum total, but from each specimen that is voided at stated intervals during the twenty-four hours. This precaution is rendered necessary by the fact that the discharge of uric acid is not uniform, but is subject to great and rapid variations. During an acute attack of gout the urine exhibits the ordinary char acteristics of febrile urine—it is scanty, high-colored, acid, often in creased in specific gravity, yet containing little uric acid. After the attack, and during convalescence, the urine becomes abundant, of a lighter color, and richer in uric acid. The recent investigations of E. Pfeiffer (Berliner klinische Wochenschrift, 16, 17, 19, 20, and 22, 1892) agree in this particular with the earlier observations of Garrod. According to Pfeiffer, the secretion of uric acid is diminished in acute gout, while it is increased in the chronic forms of the disease accom panied by incrustation of the joints. He is also of the opinion that while the production of uric acid is not increased in acute gout, in the chronic stage it does show an increase. In both forms of the disease metabolism is diminished and the excretion of urea is also reduced accordingly. The analysis of Garrod showed that in acute gout, and in chronic gout with or without u•atic deposits, there was a reduction of uric acid in the urine to a point below the normal physiological amount. These observations have been repeated and confirmed by a number of chemists.

On the contrary, however, Bouchard, Lkorch4, and the later analysts have reported an array of causes in which the quantity of uric acid, though somewhat diminished before an attack of acute gout, rises to the normal figure, or even exceeds it, during and after the attack, unless the kidneys had been injured by chronic inflamma tion. Haig has recently shown that these apparently contradictory

statements can be reconciled by taking into account the fact that for every individual the average ratio between uric acid and urea in the urine remains about the same when a long period of time is taken into consideration. So that it becomes necessary to measure the quantity of urea as well as of uric acid that is voided, and to ascer tain the quantitative relation between these two substances, in order to decide whether uric acid is really being voided in excess at any given time in the course of the disease. The normal proportion between uric acid and urea is about 1 : 35. Now, if this proportion be dis turbed so that the urine contains the two substances in the ratio of, say, 1: 28, it can be asserted that uric acid is voided in excess, even though the sum total of orate be less than in healthy urine. Since the formation of uric acid is assumed to take place at a rate that is uniform with that of urea, the quantity that is actually formed in the body may be indicated by the amount of urea that is excreted in the urine; consequently, the oscillation in the discharge of urates is clue to retention and to subsequent reactionary excretion rather than to any considerable variation in production. Therefore, gouty patients (whose kidneys have not been ruined by chronic nephritis) if they consume large quantities of animal food, will excrete large amounts of urea and orates; but, if they become feeble and cachectic, the formation of nitrogenous excreta will sink below the normal level. And when from any cause a temporary retention of urates occurs, it will be followed by a sufficiently excessive discharge to even up the ratio.

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