Illustrations Of Treatment

From the foregoing outline of treatment it will be evident that the dietetic measures vary enormously with the different stages and very diverse manifestations of the disease. Every case of gout is a new problem in treatment. I have thought it well to give further point to this by recording in detail a series of illustrative cases, and have selected a few which have been under my observation for a lengthened interval, so that I am in the position to speak with accuracy of the effects of the different regime recommended in each case.

1. Mr A., Aet. 16, Schoolboy

Marked hereditary history of gout.

1. Erythematous eruptions, ii. Pharyngitis and tonsillitis. iii. Nail disorders.

This case is selected to illustrate some clinical features of gout in the young subject, and also to emphasise the rational prophylactic treatment of the disease. The patient is a tall, big-boned, muscular subject whose weight is distinctly above the average for his height and years. He excels in athletics, being an adept football player, golfer, and swimmer. His home surroundings have been of the kind most favourable to the full indulgence of a keen appetite and sound digestion. His diet is plentiful and rich, and all his life he has been in the habit of drinking large quantities of milk independently of much nitrogenous food at ordinary meal-times. Scotch oatcakes, butter and jam are a special weakness. He is a total abstainer.

The case admirably illustrates the treatment appropriate to the disease. His symptoms develop after a slight or marked excess in diet, more especially if jams or other sweets have been largely consumed, on which occasions there has been no abatement in the amount of red meats and other nourishing foods. The occasions of these various congestive attacks in a young subject are probably, as with the paroxysms in adults, to be explained as the result of longstanding over-nutrition, with deficient elimination, and the excess immediately preceding the attack has merely strained the capacity of the tissues - intestinal viscera and general cell life - to breaking point. The general plan of treatment appropriate to such a case may be briefly summarised -

(i.) Moderation in diet - a slight all-round diminution of the total quantity of food consumed at each meal; the acquirement of self-control.

(ii.) Restriction and gradual cessation of the milk-drinking between foods, and also a diminution in the amount of fluid drunk at meal-times. His habit is to drink very large quantities of fluid at the different meals, which fluid would be more wisely taken in the intervals.

(iii.) Limitation of the jams, sweets, and fruits, of which he partakes inordinately, also care in the consumption of the various sweet summer beverages. (These patients are as a rule addicted to sweets of different kinds).

(iv.) Daily satisfactory evacuation of the bowels, by artificial means if necessary. In any case, to be supplemented by an occasional saline (once in eight or ten days).

2. Mr B., Aet. 26, Mason

1. Chronic articular gout. ii. Lithaemia. iii. Acute exacerbations.

This case is selected to illustrate some points in the dietetic treatment of the disease in its more acute phases. The patient was a hospital one, and I have not the same knowledge of the later history in this case as of the others; but the points that I wish to emphasise are sufficiently brought out by the notes available. Unlike the others recorded, this patient was in the habit of passing large quantities of free uric acid, and he was thin, weak, and slightly cachectic in appearance.

Alter recovery from the acute attack patient was gradually put on a light hospital diet, as follows: -

Breakfast

Porridge and milk, toast, tea, and frequently an egg. Dinner - Soup, bread, and fowl, fish, or red meat, with potatoes; or fish, fowl, or meat and potatoes, with a pudding; occasionally green vegetables. Tea - Tea, bread and butter.

And in addition a cupful of milk was taken either alone or with soda-water twice daily. During this time patient was making a very slow recovery, being continuously very subject to sharp recurring pains in different regions, excessive weakness in the feet, hands, etc., and he was in this state when he left the hospital to go to the Convalescent Home for four weeks.

His diet then was as follows: -

1. Porridge, tea, bread and butter.

2. Fish or fowl, bread, potatoes, rice or other milk pudding.

3. Tea, bread and butter. ' 4. Porridge and milk.

The most important differences between this and his former diet were the absence of all soups, red meats, and green vegetables. Under this regime he improved very materially, and, for him, very rapidly. The pains diminished and soon disappeared; he gained 6 1/2 lbs. in weight in four weeks. He now felt well.

On his return to hospital for further observation his diet was inadvertently changed back to his former hospital diet with immediate unfortunate results. The pains reappeared, the stiffness and weakness became accentuated, and at least one of the former weak spots became swollen, red, and tender within thirty-six hours after his return to hospital. His appetite and digestion remained apparently unaffected, the tongue was slightly furred, and the total amount of food consumed was actually less in amount than it had been at the Convalescent Home. No actual acute attack developed, but his whole metabolism was deranged, and he lost 3 1/4 lbs. within six flays. Even allowing for the change of air incurred on his return to the hospital, the case was a perfect picture of the profound influence of diet on the disease. If we analyse the altered circumstances which led to the derangement of metabolism, there is no doubt that the soup was prejudicial, and mainly because it interfered with the normal local metabolism of the proteins in the diet. There is also every reason to believe that the milk taken in the course of the hospital diet was not calculated to give the various glandular secretions the rest requisite for their due functional activity. Other points there may be, but these will suffice. In gout, as in health, the tissues can cope with a range of diet within which no untoward effects result. The "convalescent" diet was the more physiological one, and a reference to its nature and amount clearly shows what nature is willing and able to do. Further, that diet could certainly be modified in different directions, e.g. to include vegetables without detriment so long as the necessary rearrangement of the diet was made.

There are not a few cases like this one in respect of the noxious influence of soup, but in this connection regard should be paid to the points in the composition of soup already referred to. With regard to the meat, this patient is an illustration of a type in which all red meats are better avoided. Whatever the exact cause may be, there are cases of gout when the reaction of the tissues to intestinal influences is more marked and more unfavourable if red meats are a component of the diet, and these should be dieted accordingly. But such cases are exceptional.