This patient is a big, well-built woman of active bodily and mental habits, with keen appetite and excellent digestion, which she is in a position to gratify, although she does not eat immoderately. Her weight well exceeds the average for her height and years. She occasionally has a glass of claret to dinner, and takes very exceptionally a glass of beer to lunch. The hitter is a beverage of which she is particularly fond, but she indulges very occasionally, as she has long recognised that it was prejudicial to her. This case illustrates well the ill-declared type of gout that is more frequently seen in Scotland than the truly typical form.
The special treatment may, then, be summarised as follows: -
(i.) A slight all-round restriction in the quantity of food consumed. The lunch to be mainly if not always a vegetable one, and red meats to be replaced by chicken or fish for dinner, once or twice in the week. Sweets of all kinds only to be partaken of sparingly. The principal meal to be taken dry; one small glass of claret to be taken occasionally at dinner if desired. Beer is better avoided in this case. Water to be drunk freely between meals, and a tumbler of hot water taken at night.
(iii.) Attention to the bowels. As the bowels move daily without an aperient, all that is required is the use of a mild yet active saline every week or ten days. Further measures will probably be necessary at the monthly periods, as the patient, like many others of a like habit of body, is prone to undue states of depression in the premenstrual period.
1. Peripheral neuritis and vascular disturbances. ii. Lumbago, iii. Headaches, iv. Tophi.
Mrs D. is a stout, typically gouty-looking subject, of plethoric habit, who has lived an active town life and has lived well. Of late years she has restricted her diet slightly, more, however, in accord with the teachings of her own experience than as a result of medical advice, which she seeks but does not readily follow. There is a distinct hereditary history, a brother and two uncles being afflicted with well-defined gouty manifestations. Patient has on the whole been a very healthy woman; she has had ten children.
Owing to the long-standing nature of the disease, with the associated greater instability of tissue metabolism and lessened power of resistance in the intestinal tract, the treatment will obviously differ in detail from any of those previously recorded. It may be well, in the first place, to give in full the diet which she has taken and finds well adapted to keep her free from gouty manifestations: -
Avoiding kidneys, steak, liver, and all made-up dishes, and only taking one solid, e.g., fish of any kind (except salmon and fatty fishes which do not agree with her), one or two eggs, or bacon and egg; one breakfastcupful of freshly made tea with not more than one piece of sugar. Toasted bread, Vienna rolls, or other bread (not too new or doughy), with butter. Marmalade or jam to be taken only in very small quantity, and even then not to be taken every day.
Selections from the following: tomatoes cooked or raw, macaroni dressed in various ways, salads, celery, cauliflower au gratin. Bread, brown bread, Vienna rolls, or any form of unsweetened biscuit; small piece of mild cheese, if desired. Small quantity of fruit, one of the following: an orange, raisins, apples, figs, dates, walnuts. Half an ounce of whisky in half a tumblerful of soda-water.
One or two small cups of tea, with a very thin slice of bread and butter, or a piece of very light cake. Very little solid should be taken, and especially no rich cakes.
The dinner to consist of three courses, to which fruit can be added, if not taken to lunch. The diet to be arranged on the following plan -
I Soup, Meat, Pudding, Fruit.
2 Fish, Meat, Savoury.
3 Soup, Entree,1 Pudding, Fruit.
4 Fish, Meat, Pudding.
5 Soup, Fish, Savoury.
Care has to be taken that on the nights when meat is taken the soup should be of a lighter character, e.g., clear brown, rice, or fish soup. Similarly on nights 2 and 4, the fish should be of the lighter kind, e.g., whiting, haddock, or sole. On the 5th night the soup can be richer, e.g. oxtail or kidney with a light fish, or the soup may be light and the fish more rich, e.g., turbot, halibut, or skate. No more than two vegetables are to be allowed, and then in sparing amount - a sauce to be reckoned as a vegetable. (Half an ounce of whisky in not more than half a tumblerful of water the only safe beverage for constant use.) Claret, champagne, and whisky are the only drinks for which patient has any regard. The puddings recommended are milk puddings of various kinds, and stewed fruits made with small quantity of sugar.
1 Sweetbread, tape, chicken, rabbit.
Suet puddings only to be taken in sparing amount, and then only when the other courses are of the lighter nature. Jellies and creams can be taken sparingly, meringues (a special weakness) to be avoided. Bananas and strawberries are best avoided. Small cup of cafe noir prepared without sugar.
Are any medicinal remedies called for? As the patient is a sensible woman and fully appreciates the very small influence which drugs have exerted in her disease, none should be recommended with the exception of the constant use of a vegetable pill, and frequent use of the saline already referred to.
This case is a fair illustration of a not uncommon type in which the purely vegetarian diet, so eloquently advocated by Haig, is not applicable in treatment, and even if it were advisable, there is not the remotest possibility of its being carried out. With regard to exercise, as the patient is of an active temperament, and has a considerable amount of muscular exercise in connection with her household duties and numerous outdoor interests, no further recommendations are called for. Further, it would be well for her to arrange to have her annual holiday occasionally at a health resort, where a full course of hydropathic treatment under medical directions will be useful in working off the effects of the occasional or frequent deviations from the paths of physiological righteousness, which may be regarded as a part of the clinical history of the disease; and in the intervals, and for the same, purpose, an occasional course of diuretic remedies will be found of the greatest service.
It may be well now to tabulate the principal points which should be kept in view in the general management of all cases.
1. When a hereditary tendency exists in children, habits of extreme sobriety in eating and drinking should be cultivated, and the diet should be mainly a milk, vegetarian, and light meat one (pp. 200, 526).
2. When the disease is established there is no routine treatment, and the details will not be the same in any two cases. Attention should, however, be directed in turn to the following: -
(a) The diet and state of the digestive tract.
(b) The amount and nature of the exercise indulged in.
(c) The functional activity of the skin and kidneys.
(d) The state of the central nervous system.
3. The quantity of food should be determined by the amount of active exercise. Three meals a day only to be taken, and those to be of a simple character.
4. When in doubt as to which set of food constituents to cut off, begin with the carbohydrates, and especially the saccharine substances. In not a few cases the latter may require to be completely cut off, and in every instance special care must be exercised in the admixture of carbohydrates with the fats and nitrogenous foodstuffs. As already pointed out, the examination of the urine for "the pancreatic reaction" is of special value as a guide to dietetic treatment.
5. Thorough mastication of the food is all-important, and strict attention to the evacuation of the bowels a necessity (with, in addition, an occasional saline).
(a) Alcohol in any form is better avoided, except in subjects who are more or less habituated to its use, in which case the liquor taken should be the one which is known by the patient to be least detrimental to him. On no account should drinks be mixed. All sweet wines and malt liquors should be avoided, unless the patient is satisfied from careful observation that these are not prejudicial to him. The stimulant should be taken in a measured quantity and with meals.
(b) The free use of the alkaline table-waters is to be commended, care being taken that an excessive amount of fluid is not taken with the meals.
(c) A tumblerful of hot water at night and an occasional course of mineral waters taken on an empty stomach are useful eliminants.