Treatment

It is generally believed that food rich in nuclein and purin bodies should not be given to the gouty or should be given only in small quantities that it may not increase the production of uric acid. It is also believed that its conversion into urea should not be hindered and that if possible its elimination should be helped.

There is little that can be done to shorten the painful attacks of acute gout, though the discomfort attending them may be lessened by suitable treatment. A great deal more can be accomplished toward preventing a recurrence of acute attacks by instituting a proper regimen.

It is impossible to remove the inherited fault of nutrition, but it may be possible to retard the development of the symptoms. Temperance must be taught as the cardinal rule for the conduct of life. Those who inherit a tendency to gout should, even in early childhood, learn the necessity of abstemiousness. Gluttony, even in its most moderate form, must be avoided. A fairly varied diet may be permitted provided it include foods which are simply prepared and easily digested, but they should be taken only in moderate quantities.

When the gouty state is fairly established, not only must temperance be insisted upon, but certain articles of diet must be forbidden. These are sweets, confections of all kinds, fats, articles cooked with much fat, game, and the richer meats, especially when dressed with rich sauces. Those vegetables which are rich in oxalates ought also to be avoided by the gouty.

Gouty people should use as little sugar as possible. Such vegetables as rhubarb, tomatoes, radishes, spinach, cabbage, and, if they cause flatulence, baked beans, should be avoided.

The foods which these patients eat should be fairly varied, and the diet well balanced, containing the necessary proportion of albumin, carbohydrates, and fats; and the individual articles of food should be prepared so as to be most easily digested. Meat may be eaten moderately, but green vegetables and some fats, as well as cereal foods, may be taken generously. In prescribing a diet for those who are gouty, care should be taken not to restrict it so as to lessen the vitality of the individual. It has been urged that a milk diet is the best for the prevention of outbreaks of gout in those disposed to them; but milk, unless used in excessively large quantities, is not sufficiently nutritious; and while it may well be used as an important element of food, it should not be the exclusive diet of the gouty.

Soups, which may usually be taken in small amounts by those inclined to this ailment, should be forbidden when the symptoms of goutiness are clearly manifested. Whenever they are used, they should be entirely free from fats, and preferably should not be made with a meat stock. Eggs, oysters, and clams may also be eaten, but lobsters, crabs, and shrimps are not to be recommended. Most fish can be eaten without harm; for example, bluefish, whitefish, perch, shad, bass, and trout; but the fish richer in fats and those that are smoked and salted, such as salmon, mackerel, halibut, and cod, should not be used. Rich sauces should also be avoided. Meat should be eaten not oftener than once daily, and generally roasted or broiled. The meats most to be avoided are pork, veal, game, and meat which is salted and smoked. Fat should be used in very moderate amounts. Butter can be used with a reasonable degree of freedom, and cream moderately. It will be noticed that the amount of protein in the flesh foods which are permitted does not differ much from that in those forbidden. In choosing between different kinds of meat one must be guided mainly by their digestibility. Boiled meats contain less extractives than fried, broiled or meats cooked in other ways and are the best especially for those whose kidneys are defective. Such carbohydrate foods as bread, rice, sago, tapioca, oatmeal, and cracked wheat may be eaten generously, but pastries, hot breads, pancakes, and other articles of a similar kind, which are liable to form doughy masses in the stomach during the period of gastric digestion, should be avoided. The following green vegetables may be used freely: peas, string-beans, corn, potatoes, turnips, carrots, parsnips, celery and celery plant, cauliflower, artichokes, broccoli, salads, cucumbers and egg-plant. Of the fruits, the following are best adapted to the use of gouty patients: pears, apples, raspberries, blueberries, blackberries, and oranges; but grapes, bananas, prunes, strawberries, and melons are not so wholesome. Pickles and condiments are to be avoided at all times. Eating between meals should not be permitted. Gouty patients should be taught to eat slowly and to masticate their food carefully.

Tea and coffee, if in small amounts and with no, or very little, sugar, may be used by many who are predisposed to gout so long as they have no active symptoms of the disease or of indigestion; but if digestion is slow, or there are other symptoms of gout or goutiness, these beverages should not be taken. It is universally admitted that alcoholic beverages of all kinds are harmful. Their use not infrequently, even in very small amounts, will provoke attacks of gout. The degree of tolerance of alcoholic beverages by those who are gouty is, of course, very variable. It is generally believed, however, that the fermented beverages are more harmful than the distilled.

It is not necessary, in order to provoke gout, that these beverages should be taken to the point of intoxication. Indeed, it is rare that the drunkard develops symptoms of the disease. Most frequently it manifests itself in those who are habitual users of alcoholic beverages in moderate amounts. Ale, beer, and the sweet and the heavy wines are the beverages which are most apt to provoke the trouble. Of wines, the dry white wines and old Bordeaux have been found the least harmful.

Patients who are gouty should be instructed to drink water freely, as by its use the kidneys can be made to act freely and thus wash out much of the waste matter that might otherwise accumulate in the system. They should drink from five to eight glasses of good pure water daily. Often, however, these patients are taught to drink too much fluid for when their hearts grow weak or arteriosclerosis is extensive large quantities unduly tax the cardio-vascular system.

There have been many spring-waters recommended as preventives of gout. It is probable that large quantities of water do more good by the physical presence of fluid in the blood-vessels and tissues than the various mineral ingredients which spring-water may from time to time contain. There are three varieties of spring-waters especially recommended for gout: First, those which are particularly pure and contain a minimum amount of mineral matter. Without doubt, their effect is purely a physical one. The second group includes the alkaline waters of which Vichy is a type. The alkalies, introduced into the blood well diluted, do seem to stimulate normal nutritive changes in the tissues of the body. The alkaline waters also have a beneficial effect upon the contents of the stomach, which are usually acid because of abnormal fermentation. The third group of waters often used by those who are suffering from gout are the alkaline purgative waters of which Carlsbad is a type. This kind is particularly good for those who are fleshy and inclined to constipation.

At all times those modifications of the diet must be remembered which the common gastric, hepatic, renal and cardiovascular complications necessitates. Indeed one or more of these complications may govern the diet completely. In almost every case indigestion in one of its forms will necessitate changes and frequent variations in the diet of individual patients. These changes have been discussed already in the chapters devoted gastric, renal and cardio-vascular diseases.

While it is absolutely essential, in order to prevent the symptoms of goutiness and the recurring attacks of gout, that the food and drink of patients should be carefully regulated, it is equally necessary that exercise be taken regularly in at least moderate amounts in order to maintain normal nutritive changes in the tissues of the body and to correct the metabolic vice that is characteristic of goutiness. Although, occasionally, excessive exercise will cause very rapid wasting of the muscular tissues and consequent accumulation in the blood of a large amount of effete matter, which is provocative of attacks of gout, it is much more frequently the case that lack of sufficient exercise to maintain a perfect distribution of the fluids of the body, and to stimulate the necessary metabolic processes of the tissues, is the cause of the disease. Therefore it becomes necessary early to educate those who are disposed to gout to take daily a sufficient amount of active exercise to promote healthful nutritive changes in the tissues. These changes will take place only when sufficient exercise is taken to maintain a fairly firm condition of the muscles and to prevent the accumulation of any considerable amount of fat about the viscera. It is not only necessary to promote free elimination of waste matter by the kidneys, but it is essential that both by exercise and bathing, the skin be kept active, and deep breathing, and thorough oxygenation of the blood be maintained. It is also important that the intestinal tract be thoroughly and regularly emptied. Frequently the daily bowel movement is not sufficient, and it must be made more copious.

During the acute attacks of gout we may palliate by medicinal treatment, or by hot baths, or by heat applied locally to the inflamed joints; but, after all, Cullen's aphorism that "the treatment of gout must consist chiefly in patience and flannels" is as true to-day as when it was first spoken.