Luxurious living and to a certain degree an abuse of alcohol have been recognized as playing a part in the origin of gout. Accordingly up to within the last twenty years an abstemious diet consisting principally of vegetables and the exclusion of alcoholic beverages formed the principal part of the dietetic treatment of this disease.

In gouty conditions uric acid deposits can be discovered in various parts of the body (principally the joints, connective tissue, and bones). Garrod1 showed the presence of uric acid in the blood of the gouty, thus revealing the relationship of uric acid to this disease. The origin of the uric acid had been believed to be a metabolic product of the albuminates, similar to urea.

This appeared to confirm the necessity of restricting the protein foods generally in the diet of gout.

1 A. B. Garrod: Nature and Treatment of Gout, Würzburg, 1861.

A change of this view has been accomplished by the important investigations and the great discoveries in the metabolic process of the nucleo-proteins, by Miescher1 and Kossel,2 Horbac-zewski,3 Schittenhelm,4 E. Fischer,6 Brugsch,6

Wiener,7 Bessau and Schmid8 and C. von Noorden.9

It has been shown by these investigators that uric acid as well as all nucleoproteins (both animal and vegetable) contain in their chemical construction a common atom group, the so-called "purin ring" of five C (carbon) and four N (nitrogen) atoms. The same experiments have proven that uric acid (C5H4N4O3) or trioxypurin is derived in the metabolic process of the nucleoprotein digestion by ferment action. Normally the uric acid derived in the body of the nucleinic acid is partly still further changed to products not yet known, while some of it between 40-50 per cent, sometimes much less, appears in the urine as such.

1 F. Miescher: Physiologisch-chemische Untersuchungen über die Lachstmilch Arch. f. exper. Pathol, und Pharmak., 1895, vol. 37, p. 100.

2 A. Kossel: Untersuchungen liber die Nucleine und deren Spalt-produkte, Strassburg, 1881.

1 J. Horbaczewski: Untersuchunden liber die Entstehung der Harnsäure. Monatshefte f. Chemie, x, 1889, p. 624.

4 A. Schittenhelm: Der Nukleinstoffwechsel. Handbuch der Bio-chemie (C. Oppenheimer) 1910, iv, p. 489.

5 E. Fischer: Untersuchungen über die Puringruppe, Berlin, 1907.

6 T. L. Brugsch: See Brugsch und Schittenhelm. Der Nukleinstoffwechsel und seine Stoerungen, June, 1910.

7 H. Wiener: Die Harnsaure in ihrer Bedeutung für die Pathologic Ergebnisse der Physiol., 1903, 11 i Abt., p. 377.

8 G. Bressau und J. Schmid: Die Diätetik bei harnsaurer Diathese und Gicht. Therap. Monatsheft, 1910, v. 24, p. 116.

9 C. von Noorden, Die Gicht: Lehrbuch der Pathol. des Stoffwechsels. ii, Aufl., Bd. ii, p. 138, Berlin, 1907.

The uric acid originating from the nuclei of the body cells proper is designated as "endogenous" while that derived from the outside material (animal or vegetable foods containing purin bodies) as "exogenous".

In health, when living on a purin-free diet, the blood does not reveal the presence of uric acid. After a purin-rich diet there appears in the blood uric acid for a short period, but very soon it is totally eliminated with the urine, and becomes free again.

In gouty individuals this is quite different. The blood always shows the presence of uric acid even when no purin foods have been indulged in for a long time. Again, after a purin-rich diet the healthy reacts differently from the gouty.

After such an event the normal individual shows quickly for a short while uric acid in the blood "uricemia" which is followed by an increased elimination of this exogenous uric acid with the urine. The gouty on the other hand develops an increase of his usual uricemia but slowly and the exogenous uric acid is not eliminated by the kidneys quickly but at a much slower rate and imperfectly.

Following the teachings of Brugsch, Schitten-helm and Schmid in gout the entire cycle of the purin metabolism is disturbed. The organism is not able to manufacture or destroy the uric acid products as efficiently as in health.

The above explanations make it clear that in addition to the former dietetic management of gout a new principle will have to be added namely a purin-free diet.

Just the same as in diabetes mellitus, abstinence of starchy foods, totally or to a certain degree, according to the existing tolerance, is the mainstay of the treatment, so in gout the restriction of purin foods forms the essential part of the regime.

The dietetic management of the gouty will culminate in two principles:

1. Increased metabolism and elimination of the purin bodies.

2. Strict avoidance or diminution of the ingestion of purin-containing foods.

The first point is best accomplished by flushing the system with fluids (water), and gradually increased muscular exercises (walking, massage, vibratory massage, electro- and hydrotherapy);

The second point consists in a strict observance of a purin-free diet for a more or less prolonged period of time.

In order to facilitate a dietary plan in gout we give in the following Schmid and Bessau's table of the purin content of the more important common foods:

1 Cited after Schittenhelm & Schmid: Die Gicht und ihre diätetische Therapie. Albu's Verdsunngs-und Stoff wechselkrankh, ii, Heft 7, 1910.

1 In one liter.

In looking over the above table it is evident that all the glandular organs of the animal body are rich in purin bodies: thus thymus (or sweet bread) contains 0.3%, liver 0.09%, kidney 0.08%. There is not much difference in the purin content of dark and white meats or between meat of animals or fish.

Eggs (all kinds including caviar), milk and its products (kumyss, cheese) all kinds of fruits (also nuts), and cereals and their products (bread and rolls), are purin free.

Leguminous vegetables are rich in purin, especially lentils, containing 0.05%. Of the beverages clarets and rum are purin free, while beer contains 0.0004% purin bodies. Coffee, tea, and cocoa are rich in purin.

The above items with regard to the purin content of the different foods and drinks make it easy to arrange a diet for the gouty.

In doing this it is best to separate the dietary regime for the acute attack of gout and that for the chronic state.