Sir Alfred Baring Garrod.

A treatise on gout and rheumatic gout (rheumatoid arthritis.) online

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We may conclude from these observations, that urea
is often contained in abnormal quantities in the blood in
gout ; whether it is so in the very early attacks has yet
to be determined, but of this we are certain, that at such
times we always find uric acid in excess.

Presence of Oxalic Acid in gouty blood. — Some years
since * I detected oxalic acid in the blood of a patient
labouring under albuminuria: whether or not he had suf-
fered from gout I am unable to say. The acid was sepa-
rated from the watery solution of the serum, mostly in
the form of octohedral crystals of oxalate of lime, but
mixed with small oval bodies somewhat resembling the
dumb-bell varieties of this salt. I have also examined
the blood for this acid in many cases of gout, and have
frequently detected it ; my impression is that it chiefly
occurs during the inflammatory stage of the disease, and
is probably derived from the oxidation of the uric acid.

♦ Medico-Chirurgical Transactions, vol. xxxii. 1849.



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PRESENCE OF UREA AND OXALIC ACID. 113

The whole subject, however, is beset with difficulties,
and, until many other observations have been made, I
should not wish to venture any positive statement,
except as to the fact of the frequent occurrence of oxalic
acid in the blood of gouty subjects.

Traces of Uric Acid and Urea in healthy blood.^ — In
1848, in the postscript to my communication in the
Medico-Chirurgical Transactions already referred to, I
stated that I had not only discovered uric acid in the blood
of gouty patients, but had found it also in healthy human
blood. Tliis statement having been somewhat misunder-
stood, it may be well to explain my views more fully.

It has been asserted that, as m-ic acid has been found
in the blood in health as well as in gout, the importance
of the latter fact becomes greatly diminished, but, on
due consideration, this deduction will be found erroneous.
In health, mere traces exist; quantities which require
the employment of a large amount of blood, and the
most careful chemical manipulation, to enable us to
detect even its presence, and which cannot be shown by
the thread experiment. The same objection might, with
equal truth, be urged against the value of the presence
of urea in cases of albuminuria, because I have also
detected this principle in healthy blood ; the difiference in
the amount, however, in the two cases, is very great.
Traces of all the principles contained in the urine are
probably present in the blood, although it is only from
defective excretion that they accumulate in sufficient
quantities to become the source of disease. _

Carbonic acid is also a natural constituent of the blood,
but it is only when its proportion is increased beyond a

* The blood employed in this experiment was from a stout man confined in a
jail ; bat 1 know nothing of his history or habits, as to whether he inherited goat,
or had or had not drank freely.



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114 BLOOD IN GOUl.

certain limit, that it proves injurious to the fiinctions of
the animal economy.

Condition of the blood in the intei^als between the
attadcs of gout, — It is a matter of interest to know the
state of the blood in gouty patients durmg the absence
of inflammation, and in the intervals of complete freedom
from all symptoms of the disease. I have been able, though
not without some considerable difficulty, in a few instances
to obtain some facts which are of importance in reference
to this subject, and which may be thus summed up : —

1. In the long intervals between the attacks in early
cases of gout, no appreciable amount of uric acid was
found in the blood.

2. As patients were recovering from an acute attack
of gout, a very marked diminution of uric acid in their
blood was observed.

3. In very chronic gout, the blood, even in the in-
tervals between the exacerbations, was always discovered
to be rich in uric acid.

4. In cases where symptoms of irregular gout were
manifested without any accompanying joint disease, uric
acid was also present in the blood.

Secretion from the shin in gout. — There are many
instances on record in which a whitish powder has been
noticed as developing on the skin of gouty patients,
especially after profuse perspiration, and it has been
frequently supposed to consist of some combination of
uric acid, but in most cases assumed rather than proved to
be urate of soda. Swediaur stated that he had seen a
patient, labouring under a severe gouty paroxysm of
several months' duration, with the entire surface of the
body covered ev6ry morning with a white powder, as
though he had been dusted with flour. Wolff thought
he had detected uric acid in the perspiration from a



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IN INTERVALS BETWEEN ATTACKS. 115

patient suffering from calculus, and Dr. Mayer, of Madi-as,
has stated that he observed it in the case of a gentle-
man who also suffered from stone in the bladder, and
suppression of urine. In the latter instance, I think the
statement is open to doubt, as the acid was obtained
from the shirt worn by the patient, who had recently had
a blister applied to the back, and we have shown that
blister serum is at times rich in this principle.

Dr. Golding Bird, in his work on urinary deposits,
also mentions having noticed the appearance of frosting,
from microscopic crystals of urate of soda, on parts in
which the exudation of an eczematous eruption had dried,
the patient being bed-ridden with rheumatic gout, but it
is not stated that these crystals were chemically examined.
The most positive observations on this subject were
made by Dr. Charles Petit, who affirmed that he had
taken the cuticular secretion from the skin of gouty
patients, at the termination of an attack of the disease,
and had it chemically examined by M. Henry. The first
portion was from the hand of a patient fifty-six years of
age, who had suffered from the disease from the age of
twenty-four ; it contained about four-fifths of its weight
of albumen, some lactic and phosphoric acids, chloride of
sodium, and phosphate of lime, together with sensible
traces of urate of soda. In another instance the matter
was taken from the surface of the chest ; in a third, from
the back of the foot ; in these specimens, also, M. Henry
demonstrated the existence of urate of soda. Some
objection, perhaps, might be urged against these results,
especially when the matter was derived from the hands
or feet ; for if the patients were the subjects of deposits
of urate of soda, a portion might possibly have been
detached with the cuticle, as they frequently approach
the surface, and even become exposed.

I 2



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ai6 BLOOD IN GOUT.

Some years since I adopted the following method to
ascertain if uric acid is thrown out in the perspiration of
gouty patients: A man was selected suffering from a
severe attack of gout ; he had been subject to the disease
for a long time, and had many tophi, or concretions of
urate of soda ; his blood also gave evidence of containing'
a large amount of this principle. Several folds of white
bibulous paper were steeped in a weak solution of potash,
and applied for about thirty hours to the abdomen, pro-
tected by oil-silk. The papers were rendered acid, and
found to be strongly impregnated with the perspiration, and
to contain much organic matter ; they were treated with
rectified spirits, and afterwards with hot water, and the
watery solution, when evaporated, carefully examined for
uric acid. No trace of this body could be discerned by
the murexide test, nor any crystals separated by the
addition of acetic acid.

More recently I have made two other observations
with reference to this subject: A man was selected,
suffering severely from gout, with extensive deposits of
urate of soda in different parts, the great toe being greatly
affected, as shown in Plate L, fig. 3. The cuticle from
this part being very thick, was detached, and after
digestion in alcohol, treated with warm water; the
watery solution was then evaporated, and acetic acid
added. After remaining for some hours, a very few
microscopic crystals of uric acid were discovered. In
this experiment eome error may have arisen from the
very close proximity of the deposits of chalky matter to
the surface, a fact well indicated in the drawing.

In the second case the hand, fore-arm, and arm of a
gouly patient were placed in a very long and wide glass
jar, the vapour being prevented from escaping by means
of caoutchouc sheeting attached to the arm ; a consider-



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PERSPIRATION IN GOUT. 117

able quantity of the perspiration, amounting to several
drachms, was thus collected and subjected to analysis.
No uric acid could be discovered either in the form of
crystals or by the murexide test ; but in lieu of this body
a considerable quantity of oxalate of lime was found, a
portion of which had crystallised on a fibre in the evapo-
rated liquid, and exhibited the appearance seen in Plate V. j
fig. 6, the drawing being made at the time. It will be
observed that the crystals are of the octahedral variety,
and some are aggregated in the form of rudimentary
calculi. The patient from whom the perspiration was
taken was sufiering from an acute attack of the disease,
although the arm itself was not implicated; a large
amount of uric acid was present in his blood.

1863. Since the last edition of this work, I had an
opportunity of examining the perspiration obtained from
a patient during an acute attack of gout, at the time he
was in the Turkish bath : the patient, a gentleman forty-
six years of age, had suffered from gout for twenty
years, at first in the feet only, but once lately in the
right elbow ; several ounces were obtained. Rectified
spirit was at once added to prevent decomposition: it
was then evaporated to dryness in a water bath, and
the residue first exhausted with absolute alcohol, and
subsequently with hot distilled water. From the alcoholic
solution urea was obtained as the crystallised nitrate:
but the watery solution failed to yield any trace of uric
acid, although oxalate of lime could be detected and
crystallised. The patient kindly ftimished me at the
same time with about three ounces of his blood, drawn
before going into the bath ; the serum was examined and
found to be rich in uric acid.

In confirmation of this statement, Dr. Charcot remarks
that in cases of uraemia, as in the collapse of cholera, ureAZ



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118 BLOOD IN OOUT.

has been found in the white powders obtained from the
skin in parts covered with hair, but no trace of uric acid.

Considering the nature of the perspiration, it would
hardly seem probable that a body possessing the pro-
perties of uric acid should be thrown out with it, either
in its free state, or in the form of a salt ; but, on the
other hand, I could easily imagine, that the cutaneous
secretion in eczema, or other moist skin eruptions, when
occurring in patients whose blood is rich in uric acid,
would contain this principle, because such secretions are
alkaline, and bear a close resemblance to the serum
effused by the application of a blister.

The above observations warrant the conclusion, that
the healthy skin does not possess the power of eliminating
uric acid, even when the blood is freely charged with it :
this fact is of some practical importance, and will be
again referred to when speaking of the value of Turkish
baths, and other diaphoretics in the treatment of gout.



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CHAPTER V.

UBINE in GOXJT: — CHABACTEBS op healthy UBINE— table EXHIBITINa
THE COMPOSITION OP ITBINE AND THE DAILY ELIMINATION OP ITS
DIFFEBENT constituents— UBIC acid — THE MANNEB IN WHICH IT
EXISTS IN THE UBINE— BBLATION BETWEEN THE ACIDITY OP L'BINB
AND THE UBIC ACID CONTAINED IN IT— CONDITION OP THE UBINE IN
ACUTE €K)UT—NO EXCESSIVE EXCBETION OP UBIC ACID IN MANY CASES
—ELIMINATION OP THE UBEA BUT LITTLE INFLUENCED— UBINE IN
CHBONIO GOUT— DEFICIENT EXCBETION OF UBIC ACID — NO MABKED
DEFICIENCY IN THE EXCBETED UBEA— FBEQUENT PBESENCE OP SMALL
AMOUNTS OP ALBUMEN— UBINE OP GOUTY INDIVIDUALS IN THE IN-
TEBVALS OF THE PITS— PBOBABLE EXPLANATION OP THE FBEQUENT
BETUBNS OP CK)UT— MICB08C0PIC CHABACTEBS OP THE UBINE IN DIF-
FEBENT FOBMS OP CK)UT— MODE OF DETECTING ALBUMEN IN UBINE OP
GOUTY SUBJECTS.

The urine of the healthy human subject when first
passed is of a bright amber colour, transpai-ent, with a
peculiar characteristic odour and distinct acid reaction,
but when allowed to stand for a short time, a fine
flocculent cloud is deposited, consisting of mucus with a
few epithelium scales.

The urine is subject to numerous changes, both in
appearance and composition, and hence the ancients,
who only studied its physical appearances, gave different
names to that secreted at different periods of the day, as
urinapotAs^ to that passed shortly after drinking ; urina
cthiy to the urine voided during the digestion of a solid
meal ; and urina sanguinis^ to the urine secreted firom
the blood, and uninfluenced by food ; urina potiis has a
pale colour, and low specific gravity ; urina cibi is both
heavier and darker ; whereas the urina sanguinis is inter-
mediate in its characters.



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120 URINE IN GOUT.

It is often a matter of importance to ascertain the total
amount of some one or more solid constituent eliminated
in the twenty-four hours, and to effect this a sample from
the whole daily secretion should be examined.

The quantity of urine passed in the twenty-four hours
is subject to variations, depending on many circum-
stances, as individual peculiarities, the amount of fluid
ingested, and the condition of the atmosphere ; it may be
regarded as a rule, that between the skin and kidneys a
vicarious action exists. Notwithstanding these varia-
tions, a pretty close approximation to the average may
be arrived at, and it is generally considered that the daily
quantity in summer is about 30 fluid ounces, in winter
40 fluid ounces, giving as a mean 35 ounces ; the
specific gravity in health varies from 1015 to 1025, the
average being 1020.

Dr. Parkes, in his valuable work on the composition
of the urine, gives as the mean quantity in twenty-four
hours, 52^ fluid ounces. This number was deduced
from numerous observations made by diflerent indivi-
duals in this countiy and abroad ; the variations from
the mean in any one day may be considerable, although
where the health is perfect they seldom extend over a
lengthened period.

In composition, urine may be represented as water
holding in solution certain organic substances and salts.
Some of the best analyses of the urine in health are those
made by M. Becquerel on several individuals of both sexes,
which are especially valuable inasmuch as they include, not
only the composition of this fluid in the 1000 parts, but
also the total elimination during the twenty-four hours.

The following table shows the results arrived at,
reduced to English grains and fluid ounces : ^

♦ S6m6\'otique des Urines, par M. Becquerel,



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CHARACTER OF HEALTHY URINE.



121





Male.


Female.


Meak.


Urine of
24 hours.


In 1000
parts.


Urine of
24 hours.


In 1000
parts.


Urine of
24 hours.


In 1000
parts.


Quantity of urine .
Density ....


44fl.oz.
1019


1000


48fl.0Z.
1016


1000


46 fl. OK.
1017


1000


Water ....
Solids ....


18949-6
609-9


968-8
.Sl-2


20642-8
628-0


975-1
24-9


19796-2
568-9


971-9

28-1


Urea . .
Uric acid . ...
Fixed salts .
Organic and Volatile 1
Haline Matters . j


270-7

7-6

150-5

181-1


13-8
0-4

7-7

9-3


240-4

8-6

130-0

149-0


10-4
0-4
6-1

8-0


265-5

8-1

140-3

166-0


12-1
0-4
6-9

8-6



Under the head of Jixed salts^ chlorides, phosphates
and sulphates of potash, soda, lime, and magnesia are
included ; and under organic and volatile saline matters^
creatine and creatinine, hippuric acid, colouring, and
many at present undefined extractive matters are
grouped, with traces of ammonia salts.

As we shall dwell particularly upon the alterations of
some of these components, and especially of the uric
acid and urea, when considering the urine of gouty sub-
jects, it will be desirable to notice them a little more in
detail, and also to allude to some of the more important
characters of the renal secretion.

The density of urine is duel* to the solids contained in
it, but we cannot determine their quantity by the specific
gravity alone, as the same weight of different substances
gives very different degrees of density. When the whole
of the urine of the day is collected, the diet of the patient
remaining the same, the density gives a somewhat close
approximation to the quantity of solids, and a tolerably
accurate deduction may be drawn.

It must be remembered that in health the urine is
acid, although at different periods of the day its acidity



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122 URINE IN GOVT.

is subject to considerable variations, depending on the
state of the digestive process. It has been clearly shown
by the late Dr. Bence Jones that immediately before a
meal the urine exhibits the highest degree of acidity:
that which is passed from two to five hours after food is
always less acid ; the decrease being greatest three hours
after breakfast, and about five hours after dinner, when
the lowest point is reached ; the acidity then increases
until immediately before the next meal, when it attains
its highest limit ; animal food is found to cause a greater
and more permanent decrease of acidity than vegetable.
There is one fact that must be carefully borne in mind,
namely, that the presence of uric acid has no influence
upon the acidity, which probably depends in health not
on the existence of any free acid in the fluid, but upon
the presence of an acid phosphate of soda.

The colour of the urme in health bears an inverse
ratio to the quantity passed ; but in disease, the colour-
ing matter is subject to considerable variation, both in
quantity and composition.

The daily average of urea, according to the above
table, is 258 grams, or 270*7 grains, in the male, and
240*4 in the female. Lehmann, whose case seems
somewhat exceptional, from experiments on his own
person found that when living on a mixed diet he passed
500 grains ; on an animal diet, as much as 819 grains ;
on a vegetable diet, 346 grains; and lastly, on non-
nitrogenised food, 237 grains. In this country, for men
in health and on good diet the average may be taken at
about 500 grains, but in many of the analyses given
below, the quantities are much smaller, as the patients
were kept on a moderately spare diet, and were not able
to take exercise. Dr. Parkes gives 512-4 grains as the
average daily elimination of urea by adult males, deduced



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CHARACTER OF HEALTHY URINE. 123

from a very large number of analyses by English and
foreign physiologists, the extremes being 286 and 688
grains.

Most of the analyses upon which we shall have oc-
casion to comment having especial reference to uric acidj
the consideration of this principle becomes invested with
considerable interest and importance. We have seen
from BecquereFs table, that eight gi-ains is the average
quantity passed by the healthy human subject, and many
other investigators have arrived at a similar result. Dr.
William Roberts, in his excellent practical work on
Urinary and Renal diseases, states that he found in three
healthy young students, living on a similar diet, and
under similar circumstances, the following means : — 8*051
grains, 3*462 grains, and 6*071 grains ; and that Dr.
Hammond found in his own case the daily average as
high as 14*14 grains.

Uric acid in its free state is scarcely soluble in cold
water, requiring from twelve to fifteen thousand parts; it is
also sparingly soluble in boiling water. How, then, does
it exist in the urine, seeing that the quantity of water
passed daily cannot hold these eight grains in solution ?
It appears from more recent observations, that uric acid
is present in human urine chiefly in the form of urate of
soda, which is capable of existing without decomposition
in a solution of the acid phosphate of soda ; hence it is
evident that there is no necessary relation between the
amount of acidity and the quantity of uric acid present.
The experiments of Dr. Bence Jones appear to indicate
that at the time the urine is very acid, there is but little
uric acid present ; and when uric acid exists in large quan-
tities, the urine is sometimes even neutral in reaction. It
is important to bear in mind, that the presence of
a lu-ate deposit is no necessary proof of an excess of



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124



VRINE IN OOUT.



uric acid in the urine, for urate of soda is held in solution
in smaller or larger quantities in proportion to the acidity
of the urine ; this is readily shown by adding a drop or
two of acetic acid, to a dense and almost neutral urine ;
if much uric acid be present, a copious cloudy deposit
of urate of soda will immediately take place, which is
slowly converted into crystalHsed uric acid. The same
result often ensues, when a few drops of cold nitric acid
are added to such urine, and the precipitate, which at
first appears white and flaky, has often been mistaken
for albumen.

Not unfirequently, if the urine be very acid, either
from containing free acid at the time of its emission, or
from its subsequent formation, uric acid becomes de-
posited in the form of rhombs, more or less coloured.
Urine which has given rise to such crystalline deposits,
contains scarcely a trace of uric acid in solution ; it is,
in fact, in the same condition as after the addition of a
foreign acid.

The digestion of the food has a marked influence on
the excretion of uric acid. Dr. W. Roberts gives in his
work the following table, which represents the amount of
uric acid passed at different hours.



Time of Day.
(Dinner at 2 p.m.)


Uric acid

per 1000 grains of

liquid urine.


Uric acid per
hour.


Uric acid

per 100 grains of

solid urine.


4— 7 P.M. Alkaline tide .
9—11 P.M. Acidity restored
1— 7 A.M. Urine of deep .


0-40 gi-ain,
0-18 „
0-39 „


0-36 grain.
013 „
0-10 „


0-83 grain.
0-34 „
0-GO „



Has clinical observation thrown any light upon the
changes which occur in the urine in gout ?

Some authors pass over the subject altogether, others
content themselves with giving a very meagre account of



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CONDITION OB URIC ACID IN THE URINE. 125

the condition of this important fluid, and errors and dis-
crepancies are constantly met with. Perhaps the most
prevalent idea is, that uric acid is thrown out in excess,
and in support of this view it is stated that copious
deposits of uric acid and urates are so frequently seen in
the urine of gouty patients, that the appearance of .brick-
dust sediments has been regarded as almost characteristic
of this disorder; added to which, there is a prevalent
impression that gouty patients are liable to attacks of
nephritic gravel, a fact which, at first sight, appears to
strengthen such an opinion.

This subject is treated more ably and fully by Scuda-
more than any previous writer, and the substance of
his remarks may be seen in the following quotations :
** The urine is of a deeper colour than natural, is secreted
scantily with relation to the quantity of the patient's
drink, and on cooling, deposits a pink or brick-dust sedi-
ment, with much mucus. The specific gravity is increased
beyond the healthy standard. During the most urgent
symptoms of the paroxysm it is usually passed with con-
siderable irritatron, both as to frequency and sense of
heat. The pink or lateritious sediment appears more or
less in every portion of the urine during the inflammatory
symptoms.*'

Again, the same author observes, " A deposition of
pink or brick-dust sediment on the cooling of the urine,
is of such ordinary occurrence when any active symptoms
of gout are present, that its connexion becomes forcibly
impressed on the mind of the patient, and he gives it the
name of gouty urine."

This description is intended to apply to genuine acute
gout, for it is remarked in other parts of the same work,
that " it now and then occurs, that for a day or two before
the fit, the urine is passed copiously and of a pale colour,



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126 URINE IN OOUT.

but this seldom happens except in persons of a nervous



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