Preventive Treatment

The prophylactic treatment of gout in those who inherit a constitutional predisposition to the disease is very important. From birth onward the children of gouty parents should be abstemious, have the diet carefully balanced so that neither animal nor vegetable food predominates in great excess. As the child grows older, confectionery and sweets in general should be avoided, especially with other food or at the conclusion of meals, as well as alcohol in every form. In youth all varieties of beer, ale, cider, etc., are particularly injurious. Tea and coffee, if allowed at all, should be taken in moderation, and some persons can often precipitate a violent attack of gout by a single glass of champagne or sweet wine.

If they are accustomed to the use of alcoholic beverages and it is impossible for them to go without them, those which are least injurious are a dry white wine or old Bordeaux, but all wines containing sugar must be absolutely prohibited.

Cyr says: "If a glass of beer, spirits, or wine is habitually followed by pain in a joint or nerve it is gouty".

Theory Of Dietetic Treatment

An important question in regard to the theory of gout is still under discussion - namely, whether the increased quantity of uric acid is to be attributed to overproduction or merely to faulty elimination. It is conceivable that the fluids of the body, by becoming less alkaline than normal, may fail to retain the salts of uric acid in solution, and are consequently precipitated in the joints and elsewhere. The matter is of vital importance in the selection of the proper diet for gouty patients. If the disease is caused merely by imperfect oxidation of nitrogenous food, the indication is clearly to diminish the quantity of such food ingested and to promote oxidation by exercise and fresh air. If, on the other hand, oxidation processes are fairly normal, but the blood is in a morbid state in which it becomes less alkaline than normal and loses its solvent power upon the nitrogenous waste matters, it is possible that other causes may be responsible for the condition produced. Albumins contain both sulphur and phosphorus which are destined to leave the body in the form of salts of sulphuric and phosphoric acids respectively.

If these acids fail to be wholly neutralised while yet in the blood they will lessen its alkalinity, and in this way overindulgence in albuminous food by furnishing an excess of sulphur and phosphorus may diminish the alkalinity of the blood and produce uricaemia. This explains why the use of alkaline waters is so generally beneficial in gout and lithaemia. Such fluids assist in regulating the normal alkaline reaction of the blood. This is the line of argument which has been advanced by many physiological chemists, and it applies in equal force to the method of formation of renal calculi and gravel. The acidity of the urine is increased by a meat diet and reduced by a vegetable diet. With the latter it may even become strongly alkaline. Whether we adopt the theory of deficient oxidation or of diminished alkalinity of the blood, the indications for dietetic treatment of gout are the same - namely, reduction of proteid food and increase of vegetable food. It does not follow that albuminates must be entirely given up in all cases of gout, but they should be so restricted that the normal balance of the metabolism of the blood shall be restored.

It will be found necessary for those who live luxurious and idle or sedentary lives to give up nitrogenous food absolutely while those who are accustomed to take active muscular exercise may be allowed animal food in very moderate quantities once a day.

Dietetic Treatment

Although no one food is invariably injurious at all times, it is almost universally agreed that for the gouty, fat and nitrogenous food should be greatly restricted and saccharine food should be entirely prohibited.

It may be established as a general rule that the diet of the gouty should consist principally of easily digested fresh green vegetables and sometimes certain fruits, in addition to which a moderate quantity of lean meat (beef, lamb, and mutton) may be eaten to prevent the necessity of taking an excessively bulky diet, which in order to furnish sufficient nitrogen for the needs of the body would unduly tax the digestive system. Fruit is less apt to disagree if taken by itself, not with sugar or other food. Luff, of London, believes that the mineral salts of such vegetables as spinach, turnip-tops, Brussels sprouts, string beans, cabbage, and celery act chemically in preventing formation of gouty deposit in the tissues by increasing the solubility of sodium biurate and retarding the conversion of quadriurates into biurates.

It is a serious mistake to prescribe any treatment for the gouty which tends to lower the general vitality of the system too much. The diet, therefore, must be so adjusted as to secure the right proportion of the different classes of foods. Atonic cases require a generous diet with more proteids.

Gout is often combined with excessive corpulency, and when this is the case no chronic disease, with the exception, perhaps, of diabetes, requires more strict regulation of the diet and hygiene of the patient. While it is undesirable to allow animal food in large quantities in gout, it is also true that vegetables are fattening, and if the diet is too restricted in both these classes of foods the obese patient suffers from lack of nutrition, and digestion becomes still further impaired in consequence.

The theory has been held that but little fat should be eaten by the gouty, for it fixes oxygen which would otherwise complete the oxidation of albuminates, and hence it favours accumulation of pro-teid waste products. On the other hand, it has been shown that the accumulation of uric acid is not due to lessened oxidation, but that it is increased by proteid metabolism, and its elimination by the kidneys is actually promoted by fats. Clinically, however, it is found best to control the use both of albumins and fats.

Sugars and gelatinous material, like fats, all tend to retard the complete combustion of proteid food, and the latter therefore remains in an imperfectly oxidised condition which may give rise to uricae-mia. The combination of the latter classes of foods, therefore, is particularly injurious in gout. On the other hand, Ebstein favours the use of fat in moderation, on the ground that it appeases the appetite and makes the consumption of a large quantity of carbohydrates unnecessary. If fat is allowed at all in the diet, it is best to give it in very small amount; otherwise it interferes with the local digestion in the stomach and tends to aggravate the dyspepsia which is so common in gouty subjects. It will be better borne in those cases which are not complicated by a tendency to obesity.

In the dietetic management of gout in robust subjects it is of quite as much importance to reduce the quantity of food consumed as to restrict the variety.

Robust gouty patients must be made to restrain a too vigorous appetite, and especially the eating of all sorts of foods between meals, for, as Balfour says (The Senile Heart), "there is nothing so destructive of gastric comfort as the continual pecking induced by gouty bulimia".

They should never be allowed to eat to complete satiety at meals, and all rich sauces, pastry, and strong condiments and fried food should be avoided. The majority of gouty patients have been in the habit for a long time of eating too much meat, and some of them of partaking too freely of carbohydrates. Overeating is almost as bad for patients as drinking too much. "Gout is evidence of an overfed, overworked, and consequently clogged machine "(Osier). As Bence Jones says: " It is best to allow a minimum of albuminous food to produce the least amount of uric acid and a minimum of carbohydrates, in order to give the uric acid formed opportunity to be oxidised as much as possible".

When an acute exacerbation of gout occurs it is necessary to curtail all variety in diet, and put the patient upon light farinaceous food with abundant diluents, alkaline waters, weak tea. Gruels of sago, arrowroot, or barley may be given, with bread or toast. When the fever subsides and the acute symptoms abate, bouillon, clam juice, simple broths made of lean mutton or chicken with rice, may be allowed. Later, a little whitefish or breast of chicken. Meat should be given only when absolutely necessary for nourishment, for, as Garrod says of it, "everything beyond what is absolutely required for the nourishment of the body only feeds the disease".

Sir Dyce Duckworth's treatment of the acute disease is briefly as follows: He recommends such substances as rice, bread, arrowroot, sago, tapioca pudding, and semolina. He allows milk, weak tea, and infusion of cocoa nibs. Later, chicken broth may be given, followed by fish and a mealy roasted potato. No meat should be given until all acute symptoms are over, and then it should be allowed but once a day. Elderly persons may have a little dilute whisky or brandy, not to exceed two ounces per diem. He also favours the use of hot water, as in the treatment of dyspepsia, but discountenances the eating of fruits, especially with sugars.

When the acute attack subsides and chronic gout supervenes Garrod replaces the farinaceous diet gradually by fruit, fish, fowl, and finally by meat, but any dishes containing free acids or sweets are liable to cause a relapse.