Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

But, obviously for the success of vaccine therapy, it is essential that an accurate bacteriological diagnosis of the case under consideration be accomplished, which of course is comparatively easy if we are able to isolate the particular organism by direct cultural experiment. To this end cultures should be made from the roots of extracted teeth, the gums, tonsils, or nasal or other discharges. Albeit, we must never be content to select haphazard any organism that we may isolate from the patient’s mouth, nose, urine, fæces, or elsewhere. Doubtless the true clue will lie in the institution of complement fixation tests for the organisms responsible for local infections. Research to this end is now in course of progress at the Royal Mineral Water Hospital, Bath, for it is becoming increasingly clear that nothing short of “team-” work will suffice for the full elucidation of the “gouty” and the non-gouty arthritides.

Diet

Truly in respect of diet the gouty have “suffered much of many physicians,” have been the butt, so to speak, of all the fads and frailties of medical opinion. Should that chemical outcast “uric acid” but appear in excess in the urine, it was, and still is for many, an infallible index, not only of gout, but of gout maintained and nurtured by improper feeding. The inference seemed obvious: the ideal diet for the gouty was a diet free from any uric acid-forming material. This achieved, the gouty “will be free from his leprosy, and henceforward, if he abide by the prescribed regime, all will be well with him.” But, as Sir James Goodhart, from whom we take this last passage, pertinently asks, “is this so?” The answer is, I fear, in the negative. For who has not met with gouty veterans who, having run the gamut of endless dietetic experiments, still remain “gouty,” though, mirabile dictu, still avid for fresh ventures?

For myself, I know of no stereotyped diet for the “gouty,” for in this respect every man is a law unto himself. “Get the acid out of your system,” is the watchword of many, and, I fear, often to the undoing of their victims. Bent on the annihilation of the disease, they overlook the individual. But, weary of futile chasing of uric acid out of the economy, most students of gout now agree that the aim of all dietetic measures should be to secure, as far as possible, gastro-intestinal asepsis. For, as experimental studies have shown, it is possible, by means of a judiciously selected and varied diet, to modify the character and even to inhibit the growth of the intestinal flora. The far-reaching nature of such an influence is clear when we reflect that all abnormal fermentative and putrefactive processes in the alimentary canal appear to be referable to the action of microbial agents.

Diet in Acute Paroxysms.—The initial outbreak of gout may occur at any age, and respect must be had to this as well as to other individual peculiarities. If the subject be young, say in the forties, and a free liver, he may at the onset experience distaste for food, if not actual nausea. If so, let him follow his bent, and confine himself to hot water, barley-water, or hot weak tea. Such a modified process of starvation is beneficial rather than harmful. Drinking freely of bland diluents promotes the elimination of toxic or waste materials, while the intake of hot water stimulates the hepatic cells and promotes the excretion of bile.

Milk, easy of digestion and rapid absorption by a febrile patient, is the ideal form of nourishment. Moreover, a milk diet constitutes the most effectual means of attaining a comparative degree of intestinal asepsis. From two and a half to three pints may be taken in the twenty-four hours. While some will find no difficulty in assimilating it, others soon experience nausea, vomiting, and even diarrhœa, from the passage of undigested curds. It is therefore advisable to begin with small amounts given at regular intervals. If ill digested, it may be diluted with some alkaline water, or three to five grains of citrate of soda added to each tumblerful.

To obviate monotony the intake may be varied by oatmeal or barley gruel, veal, mutton, chicken, or vegetable broth, but strong soups and animal extracts must be avoided. There is no objection, however, to bread and milk, tapioca, semolina, or sago puddings.

With the disappearance of fever and the decline of acute symptoms fish may be introduced into the dietary, with later on a little white meat or chicken. This may be safely done when local pain and tenderness decline, and alike the tension of the parts, as shown by pitting. Moreover, at this stage the appetite usually asserts itself. Still the return to regular diet must be made slowly and cautiously, if we wish to combat the very common tendency in these patients to functional gastro-intestinal and hepatic derangements. Lastly, in acute sthenic gout occurring in a robust subject there is no need whatever for alcohol in the febrile stage. Also, it may be added, the younger and the stronger the patient, the better will he thrive on a pure milk or a lacto-farinaceous diet, and the less urgent the necessity for relinquishing the same until all fear of a relapse has passed.

On the other hand, in acute asthenic gout in an elderly and perhaps somewhat debilitated subject one must more than ever have regard to the individual, especially if he be an old time sufferer, perhaps with multiple joint involvement. Such a man “has not so much the gout as the gout has him.” He has to be helped to support his burden. In short, the diet for the young and plethoric differs from that suitable for the old and asthenic.