TREATMENT OF GOUT (_continued_)
REGULATION OF DIET IN THE GOUTY
The victim of gout is easier led than driven. Show no “bowels of
compassion” for his failings, talk to him in the spirit of a dehumanised
disciplinarian, and your tenure of his confidence will likely be short.
You deal with a man more often wise than foolish, not merely a digestive
tube.
The physician must be authoritative and yet tactful. Thus if the victim
be a hearty eater, and you think he eats too much, try and get him
to eat less. But do not bid him straightway live as an anchorite. Be
a little more diplomatic. A good appetite is not a sin. An appetite
over-stimulated by condiments or endless varieties of courses is. He
should eat to satisfy his hunger, not to gratify his palate.
Do not irritate the patient with a strict dietary if avoidable. Far more
often than not it is the _quantity_, not the quality, of the food that is
at fault. Frequently mere reduction in bulk of the pabulum of all kinds
taken will suffice. In short, _restriction_, not elimination, is the
wiser maxim, especially so in indolent or sedentary persons in whom we
may with advantage limit the food intake to the minimum consistent with
the due maintenance of nutrition.
On the other hand, there is a widely prevalent idea among “gouty”
subjects that if they take enough exercise they can eat and drink what
they please and as much as they please. That active habits do counteract
to some extent the evil effects of overeating and overdrinking is
certainly true. Nevertheless, as Sir Thomas Watson reminds us, gout was
extremely common in the old time squire, who not only “rode hard,” but
“lived hard” also. It is so, though to a less extent, even to-day, and
often such subjects prove very refractory. Often a reference to their
“weight” will appeal more than any hygienic considerations. Make use,
therefore, of their sensitiveness on this point, and so by diplomacy
attain your end.
Overeating often goes with overdrinking at meals. I well recall a gouty
old sportsman of bucolic type who was accustomed to swill his food down
with several whiskies and sodas. Very conservative in all ways, it
was not easy to break him of the habit. Fortunately it occurred to me
to ask him, “Did you ever see a horse eat and drink at the same time?”
Reflecting solemnly, with obvious reluctance came the reply, “Damme, I
never did, now that I come to think of it.” That settled the question.
I had no more trouble, neither had he. Not often is one so lucky. But
“Eat your meals dry” is not a bad rule in cases of sheer overeating. The
appetite is sooner blunted.
As to the _quality_ of the food, always recollect that “gouty” people
are very prone to _idiosyncrasies_; but the idiosyncrasy is purely
_personal_, not applicable to the “gouty” as a class. With them it is
very much a case of “What’s one man’s meat is another man’s poison.” The
physician who rides rough-shod over idiosyncrasies in the matter of foods
rides for a fall. Let him rely on his own experience and knowledge in the
matter of general dietetic principles; but when it comes to details—the
eschewing or not of this or that—let him trust, not in his own, but in
his patient’s, experience.
Many of these subjects know perfectly well what suits them and what
does not. Their experience is your best guide. Having elicited this
information, an appeal to their common sense rarely fails. Of the
“gouty” it is especially true that “every man at forty is either a fool
or his own physician.” For the fool there is but one corrective—_dolor
acerrimum naturæ pharmacum_. The wise has only to be reminded of his own
experience, viz., that certain articles of diet infallibly disagree with
him—_verbum sapienti satis_.
In dieting the “gouty” we should never forget that the _main groups
of foodstuffs must be duly represented_. We may reduce this or that,
but never for long will they do well if one or other of the essential
ingredients of human food be wholly eliminated. It is, as Sir Archibald
Garrod remarks, doubtful whether even a minor constituent, such as the
purins, can be continuously withheld with impunity.
Still, even from the more extreme dietaries advocated by some one may
glean this useful lesson, that the temporary benefit that often accrues
points the moral that _simplicity_ of meals is best for these subjects.
If they crowd soup, fish, meat, game, sweets, etc., all into one meal,
they always pay the penalty. As Burney Yeo wisely says: “We should not
mix up albuminates, fats, and carbohydrates, or flesh, vegetables,
fat, and fruit in the same meal. One meal should be composed almost
exclusively of nitrogenous food, another of fats and carbohydrates, and
another of fruit, at proper intervals, and they will all agree and be
suitable, but the contrary will be the case if they are mixed together
in the same meal, one hindering the digestion of the other.”
I have often found the old rule, “One meal of meat, one meal of fish, and
one of neither,” an excellent way of impressing on these patients the
importance in their instance of simple, as opposed to elaborate, meals.
Arrangement of their daily bill of fare along these or similar lines is
well worth the trouble.
If the food of the “gouty” needs to be carefully selected, it is no less
necessary that the cooking be simple and appropriate. For the manner
of the cooking is, I am sure, in many instances, more responsible for
“gouty” outbreaks than the nature or the quantity of protein or other
intake. Twice-cooked food, made-up dishes rich in extractives, are
unquestionably pernicious. Nor are pickled or salted meats desirable.
Similarly, strong meat _consommés_, hare soup, and beef extracts are
best avoided. The same applies to rich gravies, sauces, spices, etc.,
all obviously likely to upset the digestion. Again, as to fish, it is
better boiled or grilled than fried, and still better not fried in fat.
In short, it is the “trimmings” more often than not that do the mischief,
these strongly abetted by “second helpings.”
The physician may well insist upon a sufficient interval elapsing between
meals. To attain due space between lunch and dinner, I invariably forbid
“gouty” subjects to eat anything with their _tea_. The repasts should
be taken in a leisurely fashion, if possible in a cheerful atmosphere.
“Unquiet meals make ill digestions.” The nerve element in these cases
is so pronounced that caution is anything but superfluous, viewing the
inhibitory effects of worry and mental excitement on the secretory
mechanisms of the alimentary tract.
The importance, too, of thorough mastication and regularity in meal-times
should be impressed upon them. The desirability, too, of postponing
the drinking of fluids to the end of the meal, and then only in small
amounts, should be emphasised.
Strenuous exercise, mental or bodily, immediately after a meal is
undesirable, and if, as is so often the case, there be any gastric
disorder, the subject should rest both before and after meals. This is
best taken lying down, especially if there be any tendency to _gastric
dilatation_ or _visceroptosis_. The same in _hyperacidity_, but in this
latter sleep is contra-indicated. For it has been shown experimentally
that the acidity of the stomach content is greater during rest than
movement. But this is just one of those points on which authorities
differ, and decision may have to be left to the patient’s own experience.
Lastly, we should always endeavour to ascertain as nearly as possible
the actual amount of the food intake per diem. This then must be
weighed in light of the subject’s age, body weight, and mode of life.
The middle-aged “gouty” person tends more often than not to obesity,
and it will fall to the physician to decide whether the food intake be
excessive or his habits too sedentary. Far more often than not it will be
found that it is not that he walks too little, but that he eats too much.
The appetite of youth goes ill with the inactivity of middle age. With
these general considerations we will now pass to a discussion of the main
elements of diet.
THE INDIVIDUAL FOODSTUFFS
_Proteins._—Ruthless cutting off of _protein_ foods, though not so
usual as of yore, is still far too commonly practised. The number
of unfortunate wretches who are docked of their red meats is still
astonishing. The “uric acid” bugbear dies hard. Unless red meat is
known to disagree, I never advise a “gouty” subject to abstain wholly
therefrom. I feel sure that it is rarely, if ever, called for, and when
enjoined has frequently wrought much harm. As far as I know, there is
no scientific reason for the very prevalent idea that for the “gouty”
white meat is preferable to red. It is certain that both contain an equal
quantity of extractives, and equally certain that for some, _mirabile
dictu_, white meat, _e.g._, rabbit, is more indigestible than red.
Accordingly let your “gouty” patient eat animal food, at any rate at
_one_ meal, but let it be of _one_ sort only. Let his appetite be his
only sauce, his meat plainly cooked and well masticated. It matters
not if it be red or white. What does matter is whether for _him_ it be
_digestible_. Mutton or lamb are more likely to prove so than beef or
pork, and chicken, turkey, or fresh game more easily assimilable than
duck or goose.
From Walker Hall’s experiments Luff thinks “it would appear reasonable
to administer sweetbread to gouty patients, since its nuclein portion
is only slightly absorbed, for thymus sweetbread contains principally
adenin, which is rapidly excreted, and pancreas sweetbread contains
mainly guanin, an amino-purin incapable of increasing the urinary purin
output and of exerting any injurious effects upon the tissues.”
Nevertheless I still think that “gouty” subjects are better without
thymus, pancreas, and other highly nucleated substances. Despite
our ignorance of the true nature of gout, we do know that there is
generally _an excess of uric acid in the blood_, and that to increase
the content thereof is undesirable. Again, we know that in _normal_ men,
after ingestion of pancreas and thymus gland, the _uric acid_ output
in the urine is _markedly increased_. But, on the other hand, many
observers—Magnus-Levy, Vogt, etc.—have noted that after the eating of
thymus by gouty individuals they found far less uric acid in the urine
than in the case of normal persons. In short, such purin-rich foods in
their instance is followed by _uric acid retention_.
More pointed still is the fact that _acute_ outbreaks of gout have been
repeatedly brought on by administering _thymus_ to the subjects of
_chronic_ gout. Surely, in light of this, it is impolitic to approve of
_sweetbreads_ as desirable ingredients of a “gouty” dietary, this even
if only on empirical as opposed to scientific grounds. That some “gouty”
persons eat sweetbreads with impunity is undeniable. But certainly if on
inquiry a subject overtly gouty admits a _penchant_ for these foods, we
should at any rate advise their restriction or elimination.
_Fish._—This pre-eminently, with certain exceptions, is very desirable
food for the “gouty,” especially those whose digestive powers seem
unequal to coping with the stronger kinds of animal food. The white-flesh
fishes, _i.e._, sole, whiting, turbot, brill, cod, plaice, flounder, are
the preferable. On the other hand, the red-flesh fish, _i.e._, salmon,
mackerel, herring, sprat, pilchard, eel, etc., contain much fat, and are
more likely to upset the “queasy” stomachs of the “gouty.”
But fish, it must be recollected, is less stimulating and satisfying
than the flesh of birds and mammals. If wholly denied butcher’s meat and
restricted to white fish, the subjects soon tire of it. It is best to
prescribe fish for one meal, say lunch, and in addition one type of meat
for dinner. Also it is important even in white fish to choose those most
easy of digestion, viz., sole, whiting, or flounder, in preference to cod
and haddock. Above all, let the fish be fresh, and not “out of season.”
Again, fish which is dried, salted, smoked or pickled, is much less
digestible than when fresh. If, even when taken in moderation and only
occasionally, it has been found to upset digestion, then abstinence is
the better course. Caviare is, I think, best abstained from, and hard or
soft roes generally only taken in strict moderation.
As to shell-fish, they have the reputation of being most unfriendly to
the “gouty.” Toxic symptoms after lobster and crab are held to be more
common in their instance than others. But many are, I fear, ready to
extend a personal idiosyncrasy on the part of some particular “gouty”
subject into a law for _all_ “gouty” subjects. I myself have seen no harm
follow them when taken in moderation, this as regards the fleshy parts,
more digestible in the lobster than the crab. It is, I think, wise to
abstain from the spawn of the female lobster, still more from the sauces
for which it is so largely used. As to oysters, I do not think there is
any objection to a “gouty” individual eating them raw, and when “in
season,” but in moderation.
In conclusion, there is, in the matter of flesh or fish, no rule
applicable to all “gouty” persons. Far from being harmful, it is both
necessary and beneficial if taken in moderation. No small part of the
objections raised to red meat is referable to the other rich foods that
often accompany it rather than to the meat itself.
_Carbohydrates._—If it be wrong to withdraw recklessly all proteins, it
is no less inadvisable, in the absence of special indications, wholly to
eliminate sugar or starchy foods. Nevertheless far more often than not
“gouty” subjects get the impression that if they wholly eschew _sugar_
all will be well. Latterly, too, I have noticed that the ban is being
extended to _starchy_ foods also.
Surely this as a routine procedure is wrong, the more so if, as too often
happens, the unhappy subject is left without any guidance as to how long
he is to suffer this deprivation. As a _temporary_ measure it is often
beneficial. But “gouty” subjects form no exception to the ordinary law
that if nutrition is to be maintained, their diet must contain a due
proportion of the main groups of foodstuffs. A “due” proportion, not
excess, for though _quâ_ _uric acid_ carbohydrates may appear ideally
suitable, yet the “gouty” are unfortunately no more immune than others
from the _dyspeptic_ disturbances that almost infallibly ensue when sweet
foods are taken immoderately.
It is this tendency in some “gouty” subjects to amylaceous dyspepsia that
has been wrongly extended into a law for _all_ gouty subjects, whether
they exhibit any carbohydrate intolerance or not. The only law is that
for the “gouty,” as well as for the non-gouty, carbohydrates, whether
taken as starch or sugar, are harmful if eaten to excess.
With this reservation, bread may be given as crisp toast, or rusks, or in
the form of _Zwiebach_. Nor is there any objection to milk puddings—sago,
tapioca, etc.—always provided that they are found digestible when taken
in moderate quantity. Similarly in regard to sugar there is, as Sir
Archibald Garrod says, “no reason to believe that to a gouty man a lump
of sugar is poison, and provided that it is digestible it must surely be
immaterial whether the allowance of carbohydrates be taken in the form of
sugar or starch.”
_Fats._—Apart from _obesity_, there does not seem to be any scientific
reason why fats should be denied to the “gouty.” All depends on their
_digestibility_, and in this they display variations. The fat of ducks
and geese is well dispensed with in favour of bacon fat and pork fat,
which are much more digestible. The fats of meat, when roasted or
browned, are best avoided.
Similarly there is no harm in a moderate amount of butter or cream,
but fatty sauces and soups are, I think, best refrained from. Ebstein
considered the best form of fat for the gouty was good fresh butter. As
to cream, Sir James Goodhart, discussing the treatment of uric acid,
observes: “In strict moderation it is seldom hurtful, for there is very
little in the common objection that it makes one bilious. Those who avoid
it are commonly ‘bilious’ because all their organs are starved.” But he
makes this further observation for our guidance, that “after middle age
cream taken in any excess may associate itself in some with the output of
uric acid.”
_Vegetables._—The various green vegetables are eminently suitable for the
“gout,” not so much on account of their nutritious qualities, but because
of the important inorganic salts they supply, notably salts of potash.
They give a wholesome variety and relish to food, render the urine more
alkaline, and do not favour the deposit of fat. Their indigestible
residue, too, stimulates the intestinal coat, and so promotes regular
action of the bowels.
Cabbages, greens, savoys, Brussels sprouts, cauliflower and broccoli
are familiar examples. These, provided they are fresh and well cooked,
are preferable to root vegetables, with the exception of potatoes. Nor
must we overlook the fact that green leaves are rich in fat-soluble
vitamine. Fortunately, too, in the case of this particular vitamine,
the loss involved by ordinary cooking is not serious. Spinach, too, is
rich in vitamines, and is laxative, but, being rich in oxalates, is
contra-indicated in oxaluria. Sorrel, by reason of its acid oxalates, is
also undesirable under such conditions, and the same is true of rhubarb.
Tomatoes also in former days were forbidden in gout under the erroneous
idea that their content of oxalic acid was high. Cucumbers, I think, when
eaten raw, are apt to upset “gouty” people. Asparagus and onions should
be taken sparingly, as they are rich in purins.
For “gouty” subjects, of all vegetables, the cruciferous or cabbage tribe
is the most suitable, provided they are young, fresh, well cooked, and
taken in moderation. In addition to its rich vitamine content, cabbage,
like cauliflower and lettuce, is almost _purin-free_. The excessive
intake of meat may often to some extent be counteracted by encouraging
such gluttons to eat freely of green vegetables. In this way we obviate
that sinking sensation which habitual overeaters suffer on limitation of
their pabulum. Lastly, vegetable soups are most suitable, preferably
those easily digestible, relatively poor in purins, or rich in potassium
salts.
Of the roots and tubers even of potatoes the “gouty,” I think, should eat
sparingly. The large percentage of starch in potatoes is apt to upset
those of feeble digestion. Much depends on whether they are “mealy”
or “floury,” and not “waxy” and “watery.” Steaming is the best method
of cooking them. Turnips are best abstained from, and also carrots,
parsnips, beetroot and radishes, save at any rate in minimal quantities.
Lastly, the legumes—peas, beans, lentils—because of their high purin
content, should always be partaken of sparingly, though perhaps it may
yet be found that their purin content may be more than compensated for by
their contained vitamines. The edible fungi, mushrooms and truffles are
best dispensed with.
_Fruits_ are a valuable food for the “gouty.” They impart alkalinity to
the urine, and promote intestinal action, always provided they are not
partaken of immoderately or when unripe or overripe, when they are apt to
set up gastro-intestinal irritation.
Most fresh ripe fruits are wholesome. Their content, too, of vitamines
cannot be overlooked, especially that of oranges. Moreover, the fact
that vitamines, as a rule, are destroyed at cooking temperatures seems
to indicate that some uncooked food should on principle be taken daily
by the “gouty” as well as others. Raw ripe fruits in this respect, like
salads, have an advantage over cooked fruits or vegetables.
In my own experience I do not know that there is any fruit, even
strawberries, that will infallibly disagree with the “gouty.” One
meets now and again with gouty subjects who are unable to eat certain
fruits with impunity, but one meets with quite as many of the same
idiosyncrasies in the _non-gouty_. The objections to certain fruits,
_e.g._, strawberries, as to certain vegetables, _e.g._, asparagus,
are largely theoretical rather than practical. Let the subject’s own
experience be your guide in this matter, or if he be unobservant, teach
him to observe for himself what fruits, if any, disagree with him.
With this reservation I am of opinion that, taken in moderate quantity,
fruits are most useful constituents of diet for the “gouty.” In some
cases it will be found that they cannot take fruit when mixed up with
other food, but both enjoy and derive benefit from it when taken by
itself. It is well, again, in others to restrain their immoderate
indulgence in lemons, as these frequently, as Sir James Goodhart pointed
out, upset gastric or intestinal digestion. It is advisable also to warn
them that plums, currants, gooseberries, and other fruits containing
large quantities of free acids are apt to have the same effect, while
the melon, too, is prone to give rise to gastric disturbance. Peaches and
nectarines, on the other hand, are eminently suitable for the “gouty,”
also apples, pears, oranges, grapes, cherries, etc.
_Condiments._—These substances give a flavour and relish to food, while
their carminative properties stimulate appetite and favour digestion.
On the other hand, their excessive use is a potent source of gastric
irritation. Thus, for example, they are valuable in atonic dyspepsia,
though liable to aggravate a condition of chronic gastritis.
The most important and most extensively used is common salt. Some
incline to think that its use by persons of the “uric acid diathesis” is
prejudicial. But unquestionably it is a necessary and wholesome article
for the “gouty” when taken in moderation. In cases of gout complicated
by _hyperchlorhydria_ strict moderation in or abstinence from salt seems
indicated, this because, the HCL of the gastric juice being wholly
derived from the chlorides of the blood, it seems irrational to increase
the supply. Some therefore forbid its use both as a condiment or in the
cooking of food, making the subject depend on the salts naturally present
in foodstuffs.
Vinegar, I am sure, upsets some “gouty” persons’ digestion, and I think
Sir Dyce Duckworth is right when he counsels abstinence therefrom. Thus
some “gouty” subjects can digest raw cucumber, but not with vinegar.
Others find salmon if combined with the same condiment upsets them,
but not without. As to the various other condiments—mustard, pepper,
horseradish, etc.—there is no objection whatever to their use by the
“gouty” in moderation and in the absence of any definite gastric disorder.
So much for our consideration of the individual foodstuffs—their
suitability or not—for the subjects of gout. That such a general survey
is advisable may perhaps be conceded, but in so far as it may approximate
to _fixed rules_ it savours of evil, this at any rate as far as the
dieting of _dyspeptic_ derangements of the “gouty” is concerned. To bring
into prominence my point, I would lay down the postulate that there is
_no specific form of “gouty” dyspepsia_.
The gastric derangements met with in gout are in no sense peculiar
thereto. In other words, they present no symptoms specific of gout,
despite the term “gouty dyspepsia.” The term “hyperacidity” as commonly
invoked is far too laxly used in regard to “gouty dyspepsia.” The
“acid risings” of the “gouty” are of two kinds. Hyperacidity may be
due to _organic acids_, butyric, lactic, or acetic, the outcome of
fermentation, or the condition may be one of hyperchlorhydria, or
excessive secretion of HCL.
_Hyperacidity_ due to _organic acids_ is met with in some cases of
_atonic dyspepsia_, _chronic gastritis_, and _dilatation of the stomach_.
The free HCL is either diminished or absent. Differentiation of this type
from _hyperchlorhydria_ may be impossible without examination of the
stomach contents.
Hyperchlorhydria _per se_ sometimes occasions pyloric spasm, and minor
degrees of dilatation follow, this the more commonly as the subjects of
gout are middle-aged or elderly. In others the dilatation is part of a
general _neurasthenia_ from which the “gouty” no more than others are
immune.
Again, gout of long standing is often associated with _chronic gastric
catarrh_. Such is very common in beer-drinkers or men employed in
breweries. A state of _atonic dilatation of the stomach_ is a common
sequel. In these cases of chronic gastritis in the “gouty” the free
HCL may be normal, diminished or absent. Eventually, as the result of
oft-repeated gastritis, the parts involved undergo widespread _fibrotic
degeneration_. Also we have to recollect that the “gouty” are very
subject to obstinate _gastralgias_.
We see therefore that the “dyspepsias” of the “gouty” may be not only
of varied nature, but may also demand differential dieting at different
phases of their evolution. The subject in the early stages of his gout
may suffer from hyperchlorhydria, while later chronic gastritis may
ensue, with the reverse condition, _hypochlorhydria_. The _protein_
dietary suitable for the former has in the presence of the latter to be
replaced by _carbohydrates_, despite their tendency to fermentation.
Again, if either condition be complicated by _dilatation_ other
exigencies must be met. The meal content must be light, not bulky, and
the fluid intake restricted.
Again, the foregoing gastric disorders may be complicated by _glycosuria_
or _albuminuria_, each with separate dietetic indications. How inevitably
futile then must be any attempt at stereotyped diet for the “gouty.”
In short, the dyspepsias and other morbid states of the “gouty” call
for eclectic, not routine, dieting, and to this end I append a few
suggestions.
SPECIAL DIETARIES
_Amylaceous Dyspepsia._—Not a few “gouty” subjects suffer from
atonic dyspepsia, with _acidity_ due to _organic acids_ arising from
fermentation. Frequently it appears to be the outcome of some previously
prescribed regimen forbidding all flesh food, or of too frequent or
irregular meals or habitual overfeeding, food-bolting, excessive smoking,
etc. Correction of such faulty habits is an essential prelude to any
dietetic rules.
In such cases it is advisable to reduce the intake of starchy and
saccharine foodstuffs, such as bread, potatoes, pastry, sugar, milk
puddings, and the like. Bread should be stale, or dextrinised by dry
heat, as in thin toast and rusks. Potatoes, if taken, should be in the
form of purées. Sweet dishes should be partaken of sparingly, if at all.
They should be encouraged to take the more digestible forms of meat and
the lighter kinds of fish. Green vegetables and fresh ripe fruit, raw
or cooked, are valuable. _Fats_ of the more digestible sorts are also
desirable. Grilled but not fried fat bacon is easily digested.
As to beverages, light China tea is more suitable than strong Indian
kinds. Frequently I have found substitution of cocoa most beneficial. But
in any case the amount of fluid at meal-times should be restricted.
As a guide to the formulation of a dietary in such cases the following
may be suggested:—
On awaking in the morning a tumbler of hot water should be slowly sipped.
A squeeze of lemon may be added if liked.
_Breakfast._—Boiled or plainly grilled sole, whiting, or flounder, or a
slice of crisp grilled bacon or lean cold tongue, or a soft-boiled egg.
A slice or two of crisp dry toast or stale bread and a little butter. At
close of meal sip slowly one cup of weak China tea, or the same of cocoa
or milk and water.
_Lunch._—Chicken or game, or lamb, mutton, or beef, hot or cold, roast or
boiled. Gravy to be free from fat. One only of the former kinds of meat
to be taken with a reasonable quantity of tender, well-boiled vegetables.
Spinach, kidney or French beans, sea or Scotch kale, vegetable marrow, or
salad may be taken, but without oil, vinegar, or beetroot. Dry toast or
rusks. Half a tumbler of water sipped _after_ eating.
_Afternoon Tea._—One or two cups of weak tea with milk or one cup of
cocoa.
_Dinner_ (two courses only).—Fish of the kinds allowed for breakfast
without potatoes, or a slice of any tender meat, _e.g._, saddle or loin
of mutton or thick part of an underdone chop, or small portion of fresh
game, without bread sauce or crumbs. One or two slices of stale bread
or dry toast. A little well-stewed fruit or custard, junket, or jelly.
Half a tumbler of water with from one to two tablespoonfuls of spirit if
desired.
If there be any suspicion of chronic gastritis, condiments and stimulants
must be renounced, but not in purely atonic dyspepsia, in which they are
of value. In either disorder the patient should abstain from salted and
cured meats, tinned foods, pastry, sweets, raw vegetables, and cheese.
Before retiring a tumbler of hot water with a squeeze of lemon may be
sipped slowly.
_Hyperchlorhydria._—This, the true “acid gouty dyspepsia,” is the most
troublesome type of dyspepsia met with in the “gouty.” Regulation of
the diet is the best means whereby to combat the excess of HCL in the
stomach. All irritating spices or condiments, mustard, vinegar, etc.,
should be avoided. Salt especially should be used sparingly or wholly
abstained from. As a rule, alcoholic stimulants are not well borne, and
may, in the absence of special indications, be prohibited. In a limited
number of instances a light wine may be allowed as a stomachic. To avoid
irritation, hard substances, such as nuts, should be interdicted, and
food thoroughly masticated, and taken neither too hot nor too cold.
Bolting large morsels of food may readily excite pyloric spasm.
In these cases of superacidity the most suitable foods are _proteins_,
which combine and neutralise the excess of acid. A liberal meat diet
consisting in the main of chicken, beef, mutton or ham, is indicated.
Also fish, eggs, hard or soft boiled, are permissible. _Farinaceous_
foods are not well tolerated, and if given must be of the most digestible
kind. Vegetables should be mashed and strained to rid them of cellulose,
and only the more digestible kinds taken, and in the form of purées.
Fats tend to lessen acidity, and are therefore indicated in the form
of butter, cream, olive oil, and such like. Of beverages alkaline and
mineral waters, Apollinaris, Seltzer, and Vichy, prove very beneficial.
Their contained carbonic acid exerts a sedative effect and diminishes the
secretion of acid. Milk or stimulants may be profitably diluted therewith.
Coffee is best abstained from, and cocoa and tea freshly made with half
milk substituted. Soups are best avoided. If with the _hyperacidity_
there be associated any degree of _atonic dilatation_, the fluid taken
at meals should be restricted. Also in this instance the food should be
taken in small quantities and at frequent intervals. Otherwise these
cases of _hyperacidity_ do well on three meals per diem provided they are
separated by an adequate interval.
If the foregoing measures prove ineffectual the _carbohydrate_ content
of the food should be withdrawn, and the patient limited to a strictly
_meat_ diet, taken either raw or very slightly cooked. It goes best
when finely minced or grated on stale bread. According to Osler, an
ample dietary is afforded if three and a quarter ounces of meat and two
medium slices of stale bread be taken three times a day, with a glass
of Apollinaris water or soda-water, or what in this authority’s opinion
is just as satisfactory—spring water. For the bread a little dry toast
or twice baked (_Zwiebach_) bread may be substituted. Some advocate the
meals being taken wholly dry, or with two ounces of fluid only; but two
hours later a half to two pints of hot water should be slowly sipped. A
month or six weeks of such a diet will usually suffice, after which a
gradual return may be made to a mixed dietary.
Apart from the binding of excess of acid by the protein substances
and consequent relief of discomfort, the so-called Salisbury diet has
other advantages. Abstraction of the carbohydrates obviates intestinal
fermentation and flatulence. Also, the food administered being small in
bulk, and taken more or less dry, a dilated or atonic stomach tends to
revert to its normal size.
In conclusion, in regard to these cases of hyperchlorhydria it must
be realised that not only their diet and the manner of their eating,
but their general habits of living, must also be revised. They must be
warned of the great tendency to recurrence and the necessity of orderly
and regular habits and of strict abstemiousness in regard to not only
alcohol, but tobacco. The nerve element in some of these cases is very
pronounced, and sometimes nothing short of a rest cure will suffice.
_Hypochlorhydria._—Chronic gastric catarrh due to overeating and
overdrinking is not an infrequent complication of gout in its later
stages. Such subjects suffer with daily or periodical vomiting of
stringy mucus. In such cases the HCL of the gastric juice is deficient
or absent. Consequently protein foods are digested with difficulty, and
carbohydrates are more easily disposed of. The lighter forms of meat,
such as chicken or fish or raw scraped beef, are indicated. Nor, in view
of the chronic nature of the derangement and the necessity of maintaining
nutrition, should we hesitate to allow such “gouty” subjects other
digestible forms of meat, such as sweetbreads, brains, etc. Fats also and
carbohydrates up to the limit of tolerance should be allowed. Ingestion,
however, of fluid at meals should be reduced as far as possible. Of
beverages milk, and especially buttermilk, is particularly suitable.
Despite the deficiency of HCL, they may suffer much with acid eructations
or flatulency owing to organic acids arising through fermentation. If
so, farinaceous foods must be restricted, particularly potatoes and the
coarser vegetables, while of course pastry and sweet foods should be
prohibited. Bread should be taken in the form of dry toast or rusks.
_Hyperuricæmia._—As far as is known, the endogenous moiety of urinary
uric acid is uninfluenced by diet. On the other hand, as has been shown
in previous chapters, the exogenous fraction can be reduced by suitable
dieting. To this end, in order to prevent the intake of food containing
uric acid precursors, the purin-free dietary was devised. Under such a
regime both red and white meats must be proscribed, also fish and the
legumes—peas, beans, lentils, asparagus, onions and oats—as these last
are all rich in purins. Tea, coffee, and chocolate must also be eschewed.
In lieu of these substances more or less poor in purin bodies must be
exclusively taken: milk sour or curdled, buttermilk and whey, white
bread, butter, cheese, eggs, rice, tapioca, macaroni, sago, cereal foods,
nuts and fruit. Even strawberries are permissible, for Weiss noted
that the addition to an ordinary diet of 1 lb. of strawberries, 1½ lb.
cherries, or 2 lb. of grapes, diminishes the amount of uric acid excreted
by almost 50 per cent. With the exception of those interdicted above, all
vegetables are allowable, cabbage, cauliflower and lettuce being almost
purin-free.
Personally I am not enamoured of purin-free diets for the “gouty,” any
more than I am of the purely vegetarian regime, so extolled by some as
the means of averting gout. The purin-free diet, if I may say so, smacks
too much of the laboratory, its _raison d’être_ the baseless assumption
that _uric acid_ is the _fons et origo mali_.
I am very doubtful of the intrinsic merits claimed for it. I do not
think it exerts a direct or _specific anti-gouty_ influence. Such
advantages as do accrue are referable, in my opinion, to the greater
measure of _intestinal asepsis_ that such a regimen promotes. It is
suitable, therefore, in cases in which there are evidences of _intestinal
putrefaction_. Distinctly unappetising, it is useful, too, as a
disciplinary measure for those prone to overeating.
Its advocates claim that it tends to diminish the _excess of uric acid
in the blood_. But, as was pointed out when dealing with uricæmia,
_variations_ may occur in the _uric acid content of the blood
independently of diet_. Moreover, acute attacks have been observed even
when the uric acid blood content was at a _sub-normal_ level.
To place all “gouty” subjects on a _purin-free_ diet as a routine
procedure is to my mind wholly impermissible. The fact that prolonged
adherence thereto is usually found impracticable is surely an indication
that we are violating nature’s laws. It may prove beneficial in a few
isolated cases, and then only for a time; but in the vast majority of
instances it is frankly prejudicial. Given a carefully revised mixed
diet, it will, in my experience, be rarely, if ever, necessary to subject
“gouty” individuals to this dietetic penance.
_The Reduction of Obesity._—Unfortunately obesity is a common associate
of gout, and with it not infrequently comes _glycosuria_. Middle-aged
“gouty” subjects have in their youth often been given to strenuous
exercise. But notwithstanding that with advancing years their capacity
and disposition for exercise lessens, they nevertheless take the same
amount of food as of yore.
It is most difficult to make them realise that, with the alteration of
their habits, the amount of food which at one time was but adequate is
now excessive. I have found it useful to remind such of Ebstein’s dictum,
“The gouty who have grown old in spite of their disease are almost
always those who have been able to avoid obesity.” Still it is only fair
to add that in some of the gouty obese no accusation of overeating or
overdrinking can be lodged, and their aptitude for fattening seems often
hereditary.
Reduction of the body weight when excessive in gouty subjects is hardly,
I think, sufficiently emphasised. The victim himself is but too often
convinced, however, that he ought not to be “lowered,” and sometimes, I
think, infects the physician with his apprehensiveness on this score.
But, as Harry Campbell rightly observes, “people do not die of starvation
so easily as is generally thought, and it is very difficult for the
physician to kill his patients in this way.” Yes, and, on the contrary,
how often do gouty people “dig their graves with their teeth.”
Again, there is the _static_ element to be considered in these cases. The
articular manifestations of gout are by preference located in the lower
extremities. It is clear then that excessive stoutness, particularly if
of recent development, must inevitably throw increased strain on the
already-hampered articulations. The feet of the “gouty” are their most
vulnerable point, and the number who are flat-footed is noteworthy. In
the presence of this static fault, “strains” or “sprains”—those fertile
excitants of gouty outbreaks—are much more liable to occur, and I myself
feel sure that in this way the frequency of attacks in the feet and, for
that matter, in the knees also, is favoured.
Lastly, the gouty obese is frequently elderly, his vessels somewhat the
worse for wear. Also he may show signs of cardiac weakness or a trace of
albumen or sugar in his urine. Even so his weight should be reduced if
possible. His watchword should, like Falstaff’s, be:—
“Make less thy body hence, and more thy grace;
Leave gormandising; know the grave doth gape
For thee thrice wider than for other men.”
There are so many dietetic methods of treating obesity that they cannot
all be outlined here. The Banting method, like the Salisbury, is too
severe for the average patient, while the Weir-Mitchell method has
one cogent objection to general adoption, viz., the expense entailed.
Nevertheless as regards the last-named, or skim milk, method, it
certainly achieves marvellous results in those cases in which there is a
mere accumulation of fat without any other complication.
Generally speaking, however, one has to be content with the following
suggestions: All varieties of lean meat may be taken, as well as poultry,
game, and fish, subject to idiosyncrasies and digestibility. Meat may
be taken twice daily, not exceeding six ounces at one time. All starchy
and farinaceous food is to be reduced to a minimum or wholly forbidden.
Leaf vegetables may be taken freely, but the roots and tubers, such as
potatoes, abstained from. Bread should be largely reduced in quantity and
thoroughly torrified. Sugar must be prohibited, and saccharine or saxin
substituted. Fresh fruits may be eaten, but milk should be avoided, also
cream, or very strictly limited. Where feasible, it is often a good plan
if the subject can for one day a week content himself with a diet of skim
milk.
Alcohol, as far as possible, should be rigidly excluded, or only a
very moderate quantity of good whisky or a light wine, such as hock
or Moselle, permitted. As a rule, only a little hot water should be
sipped at meals. But I think in these subjects of so-called “uric acid
diathesis” it is well not to restrict their fluid too markedly. A pint
of hot water may be drunk one and a half hours before each of the three
meals, and one pint more half an hour before bedtime. Weak hot tea may
be substituted, as many subjects find a difficulty in drinking so much
plain hot water at one time. If while on this regime the subject lose
weight and _pari passu_ gain strength, all is well. If he lose weight
and therewith lose strength, further reduction or its continuance is
contra-indicated. It should be recollected that the reducing effects of
dieting may be markedly enforced by an open-air life, with riding or
other outdoor exercise.
_Glycosuria._—This condition conjoined with obesity is not uncommon in
middle-aged “gouty” subjects. It is of benign type, and the amount of
sugar excreted is usually reduced to a mere trace by extraction of the
carbohydrates in the food. Thus, we should forbid, _e.g._, sugar, pastry,
sweet wines, and dishes made with flour, rice, or sugar. In these cases
von Noorden considers that it is better after reduction of the amount of
sugar by dieting to a mere trace to be content rather than to get rid of
it wholly by a rigid elimination of all carbohydrates. To this end the
patient may be allowed to eat a limited amount of bread, potatoes, and
other vegetables, while he may eat freely of butter, bacon, and other
fats.
One should recollect also that these “gouty” glycosurics have periods of
enhanced carbohydrate tolerance, this, as Burney Yeo pointed out, quite
“independently of any therapeutic interference.” In short, at times they
can take quite a considerable amount of carbohydrates without passing
sugar in their water.
Needless to say, the regime must be adapted to each individual case.
The urine should be examined frequently, and the influence on the sugar
content of different articles of food noted; also the weight should be
frequently taken. It is certainly unnecessary in gouty glycosurics to
wholly banish the carbohydrates. By such a plan we are more likely to do
material injury than by exceeding by a little their limits of tolerance.
Our remarks of course apply strictly to _alimentary_ glycosuria. But we
should also remember that exceptionally a case of gouty glycosuria may
emerge into one of true _diabetes_.
_Albuminuria._—In the so-called “gouty” contracted kidney, if the amount
of albumen in the urine be very large, or when there are symptoms
of nephritis, a milk diet for a few days or a week at a time may be
given. More often it is unnecessary, or it is frequently badly borne or
rejected. Consequently a modified milk diet has to be adopted, and a
gradual return to a mixed diet permitted, provided no increase in the
quantity of albumen ensues.
But at the same time it must be realised that no rigid rule can be laid
down for “gouty” albuminurics. As a guide to the suitability of a diet it
is better to rely on the _general condition_ than on variations in the
amount of albumen. For, as Professor H. Andrew Smith, of New York, long
since said, “if on changing from a non-nitrogenous diet to a nitrogenous
one we find a general improvement in the patient’s condition, it is an
evidence that the change is beneficial, no matter if the albumen fills
a larger portion of the test tube. On the other hand, if we cut off a
large proportion of animal food from the diet, and our patient grows
more dyspeptic, weaker, more anæmic, more dropsical, it is nothing to
the point that only one half or one-third of the former quantity of
albumen is found in the urine; the change has done harm, and the sooner
we change back again the better. We should, above all things, seek that
diet for the patient which he can best digest and assimilate, for we may
rest assured that the products of faulty digestion and assimilation will
irritate the kidneys more than any amount of normal material they may be
called upon to eliminate, while, at the same time, the general system
will suffer from lack of support.”
Lastly, up to this juncture all our suggested dietetic modifications
have been in the direction of reduction or abstinence. But we must
recollect that in practice we find that not a few gouty persons are
most careful and prudent in diet. They commit no indiscretions, but
nevertheless their gout is still with them. They are of the asthenic
type, thin, pale, sallow, and given to neuralgic forms of fibrositis.
They do not want “lowering”; to curtail their food is harmful. In their
instance, with due respect to digestive idiosyncrasies, a more or less
generous diet should be prescribed. Let them forsake dietetic schedules
and follow their instincts. Let your advice be that of Sir William
Temple: “Simple diet, limited by every man’s experience to his own easy
digestion, and thereby proportioning as near as can be the daily repairs
to the daily decays of our wasting system.”
BEVERAGES IN GOUT
It cannot be gainsaid that the beneficial effects of so-called “water
cures” are in great measure referable to the increased amount of _water_
ingested during their progress. Absorbed in the main in the small
intestine, it passes into the general blood stream, whence it is excreted
_viâ_ the skin, kidneys, lungs, and fæces. Its elimination through these
various channels sufficiently accounts for its value as a means of
flushing the bodily tissues and hastening the excretion of retrograde
and toxic products. Indeed, its efficiency as a depurative agent cannot
be over-estimated, and nothing is more beneficial for the subjects of a
“gouty” diathesis than regular consumption of an adequate quantity of
this admirable solvent.
By general consent, the water ingested should be preferably _hot_. Water
of a higher temperature than that of the blood stimulates the hepatic
cells, and promotes biliary excretion. It has been shown, moreover,
by Glax that while draughts of cold water raise vascular tension and
diminish pulse frequency, on the other hand hot water diminishes arterial
tension and accelerates the pulse rate.
It is also claimed that the increased elimination of water _viâ_ the
kidneys is correlated with an augmented output of the solid constituents
of the urine; that the phosphates, sulphates, sodium chloride, and
likewise urea are for the time excreted in greater amounts.
The point at issue, however, is whether or no this increase in the amount
of _urea_ excreted can be held to indicate enhanced tissue change in the
nitrogenous elements in the body fabric.
Winternitz claims that it does, in contrast to Von Noorden, who holds
that nitrogenous tissue change and the formation of _urea_ and _uric
acid_ are _uninfluenced_ by the amount of water imbibed. In further
contradistinction some contend that following the ingestion of water the
_excretion of uric acid_ is _diminished_.
Fortunately for “gouty” subjects, the beneficial effects of water
flushing of their systems occur independently of any _coincident increase
in their uric acid output_. This is true even of mineral waters. Thus
Bain and Edgecombe noted that following the ingestion of the old
sulphur water of Harrogate the excretion of uric acid was diminished.
Nevertheless cases of “gout, especially of the _asthenic_ type, derived
the most marked benefit from its use.” “This fact is mentioned,” they
say, “because some writers attach the greatest importance to an augmented
excretion of uric acid in the urine as a necessary concomitant of
successful treatment. This we firmly believe to be an erroneous view.”
Indeed, ignorant as we are of the exact etiology of gout, we must at
any rate provisionally attribute the proved efficacy of water-drinking
in gout to its flushing action on the tissues, its furtherance of the
excretion of waste products. Nor can we doubt that the ingestion of hot
water, involving as it does equalisation of its temperature with that of
the body, must exert a profound and intimate effect upon processes of
cell nutrition. Moreover, through its solvent and penetrative quality,
its mineral or chemical constituents are enabled to penetrate freely the
interstices of the tissues throughout the economy.
It is, therefore, well to advise “gouty” subjects to drink daily on
rising from eight to ten ounces of hot water, repeating the same half an
hour before lunch and dinner, and finally the last thing at night. For in
my experience “gouty” subjects on the whole do better if they drink some
time before their meals than during their progress. It is an old belief
that hard waters are unsuitable for the “gouty.” Sir Dyce Duckworth
believed so, and Sir Charles Scudamore in 1823 delivered himself as
follows: “The kind of water denominated hard has always been considered
as unfriendly to health, and especially injurious to persons afflicted
with gravel or stone. Many probably imagine that the earthy salts which
it contains assist in making up the mass of the calcareous concretion.”
But more probably, as Sir Archibald Garrod suggests, the old view that
tophi were composed of chalk had probably something to do with the origin
of the tradition. That hard waters may be noxious in so far as they
favour constipation may be granted. But, on the other hand, we have to
reconcile with this the awkward fact that earthy or calcareous waters,
_e.g._, those of Bath, etc., are among those whose efficacy in gout is
beyond question.
Again, how can we reconcile with this view the prevalent practice of
placing “gouty” subjects, temporarily at any rate, on a _milk_ diet, this
although milk is especially rich in lime? That a regime of milk in the
young and robust “gouty” subject is often extremely beneficial is beyond
question. On the other hand, it is equally certain that others do not
thrive thereon. In prescribing it, therefore, we must be guided largely
by _personal idiosyncrasy_.
Lastly, as to _tea_ and _coffee_, there is a theoretical objection that
both contain methyl purins. Albeit, it must be seldom indeed that gout is
met with in pure tea-drinkers who at the same time abstain wholly from
alcohol. Either tea or coffee, if taken apart from food, usually agrees
well with the “gouty,” always provided that they be well made and not
over-strong. Of the twain tea is, I think, more generally suitable than
coffee, and where both disagree cocoa is an excellent substitute.
ALCOHOL IN GOUT
Said Sir Thomas Watson: “I am sure it is worth any _young_ man’s while
who has had the gout to become a teetotaler.” Few will gainsay the
wisdom of this advice. But I would fain go further and impress on _gouty
parents_ the incumbent duty of bringing up their children as _total
abstainers_. For gout, once avowed, has a vicious tendency to recurrence.
The illustrious Sydenham, I think, would have approved of such advice:
“Water alone is bad and dangerous, as I know from personal experience.
When taken as the regular drink from youth upwards it is beneficial.”
When, however, gout attacks a man for the first time in middle or late
life, most authorities agree that an abrupt change of habit in respect
of stimulants is of questionable wisdom. In saying this, I do not for
one moment mean that excess should be approved, but that I do not
believe that the enforcement of total abstinence is prudent. In such
cases restriction, not total elimination, is the better course. One must
recollect, too, that total abstainers are by no means exempt from gout,
while, on the other hand, many, if not the majority, of drunkards are.
The latter have their penalties, cirrhosis, etc., but not inevitably gout.
I agree that gout is infinitely more common in those who take alcohol
than in those who abstain therefrom. But nowadays, at any rate,
the “gouty” as a class cannot with fairness be ranked as among the
confessedly intemperate. With relatively few exceptions, they belong
rather to those given to what may be termed the legitimate use of
alcoholic beverages. My conclusions then are that:—
(1) The children of “gouty” parents should be brought up as
total abstainers.
(2) The incidence of a first attack in a young man should be
the signal for abstinence from alcohol in all forms.
(3) Given its occurrence in an older subject who has used
alcohol but sparingly and stands in no need of it as a
stimulant, the same total abstinence should be inculcated.
(4) In middle-aged or old subjects habituated to the use or
abuse of alcohol _abstemiousness_, not abstinence, is the safer
course.
THE VARIOUS ALCOHOLIC BEVERAGES
_Malt Liquors._—I think we should distinguish between the “strong” and
the “mild” varieties, even as we do between “heavy” and “light” wines.
“Strong” malt liquors unquestionably are most provocative of gout, and it
is not without significance that most “gouty” subjects have, frequently
on their own initiative, abandoned their use. So much importance, indeed,
do I attach to this, that if I were called to formulate any rule in the
matter of alcohol for “gouty” subjects it would be the unsuitability of
“strong” malt liquors, which not only increase the tendency to recurrence
of the paroxysms, but appreciably lengthen their duration.
The prefix “strong” I use advisedly, as the volume of alcohol contained
in different beers may vary by as much as from 1 to 10 per cent. Thus
Scotch ale contains as much as 8·5 per cent., and, generally speaking,
all “old” ales are usually “strong” ales. Albeit, to condemn malt liquors
unreservedly is, I am sure, inadvisable. The truth is that in respect
of their _gout-inducing power_ malt liquors, like wines, display great
variations.
Thus “strong” malt liquors, like “heavy” wines, are markedly provocative
of gout, whereas the “milder” ales, like the “lighter” wines, are
relatively impotent in this respect. Said the elder Garrod on this point:
“The lighter wines, as claret, hock, and Moselle, although capable of
acting as the exciting cause of an attack in gouty subjects, have when
taken in moderation but comparatively little inducing power, and in this
respect rank with the weaker kinds of malt liquors.” In this connection
is it not significant that gout is extremely rare among agricultural
labourers, who drink freely of that popular and ancient beverage mild
beer? Sydenham on this point is very definite: “This is a rule for the
gouty: they may take those liquors which neither chill the stomach
nor intoxicate in any moderate quantity. Such is the small beer in
our own country, which in foreign countries may be replaced by weak
wine-and-water.”
I hold no brief for alcohol, but of the twain I am sure it is wiser to
advise a poor man, even though “gouty,” to stick to “mild beer” rather
than urge him to betake himself instead to “ardent spirits.” For the rich
man, too, while in his prime and still capable of vigorous exercise, I am
firmly of opinion that, with due deference to _idiosyncrasy_, a _mild_
beer not containing more than from 3 to 6 per cent. of alcohol will do
him not more, but less, harm than _whisky_.
I have yet to learn that the working man who has gout and sticks to
mild, sound beer in moderation gets attacks more often or more severely
than the rich man who affects whisky. “It must,” as Sir Archibald Garrod
observes, “be confessed that among hospital patients who could not, if
they would, follow out any strict rules of dietary, who seldom pay heed
to our advice that they should give up beer, and who, as soon as an acute
attack is over, revert to their previous habits of life, the course
of gout does not seem to differ materially as regards the character,
frequency, and severity of the attacks from that followed in people
who are able to adjust their living according to the best advice to be
obtained.”
I think then in this matter of _malt liquors_, their suitability or
not for “gouty” subjects, we should be well advised to reconsider our
attitude. In other words, I would urge that we draw a distinction between
“strong” and “mild” malt liquors. By all means let us continue to condemn
the “heavy” varieties, while not extending the ban to the “lighter”
forms. I would, however, make the following reservations: that—
(1) It be a “light” beer, in which the “bitter” principles
predominate, and the extractives are small in amount[61];
(2) It be “sound” and not “turned” beer, and of course free
from any possibility of _lead_ impregnation;
(3) It be taken in moderation, not exceeding one to two pints
per diem;
(4) The “gouty” subjects by whom it is taken be physically
active;
(5) Due respect be paid to _personal idiosyncrasy_, reserving
its use for those in whom its effects are definitely
_stomachic_ and _tonic_, while discountenancing its use when
followed by _heaviness_, _drowsiness_, and _biliousness_.
As to _cider_, there is no doubt that the partially fermented or sweet
variety is more harmful than “dry” or “rough” cider. Still there is no
room for dogmatism even here, for a “gouty” man, if he be unaccustomed to
cider, may find that, whether “dry” or not, it may provoke an attack. Sir
Archibald Garrod tells us that he has known not a few gouty patients who
alleged that cider suited them admirably, but he adds: “An experience of
some months has usually modified their opinion on this point.”
_Wines._—When we come to consider _wines_, we are on very uncertain
ground, this especially if we base our opinion too much on the _chemical_
analysis of this or that variety. The current belief is that the most
unsuitable wines are those that contain large amounts of _alcohol_,
_sugar_, or _free acid_. Then we discover it is not the amount of
_alcohol_ in the fluid that determines the incidence of gout and, in
witness to our perspicuity, call to note the rarity of gout in Scotland,
where _whisky_ is the favourite beverage; _ergo_ whisky _par excellence_
is _the_ drink for the “gouty,” and so we find ourselves in this
_impasse_: we fulminate against _alcohol_ as _the_ cause of gout, and
in the same breath advise our “gouty” patients to drink precisely those
fluids containing the highest percentage thereof.
True, when we turn to _wines_ we find that it is precisely those that
are richest in _alcohol_ that most potently predispose to gout, _e.g._,
port. But seeing that _whisky_ contains infinitely more _alcohol_ than
port, and yet is little gout-provoking, we search round for some other
constituent in wine on which to lay the blame. So we decline on the
varying degrees of _acidity_ in different wines. But this again on
reflection, it is decided, is of little moment. For, on the one hand,
port and sherry are among the least acid wines, and yet, like the even
less acid malt liquors, most productive of gout, while, on the other
hand, the more acid clarets and hocks are deemed relatively harmless.
Then the varying quantities of _sugar_ in the different wines come under
the ban. But here again no definite line can be drawn. For some wines
most provocative of gout have a high sugar content, while others equally
potent in this direction contain but small amounts.
Now the most salient deduction from the foregoing considerations is our
inability at present on _chemical grounds_ to determine why certain
_wines_ are productive, and others are relatively nonproductive, of
gout. We can impeach neither the alcohol content, the acidity, nor
the sweetness. For on all these points startling exceptions preclude
dogmatism. Does not the clue to these varying reactions _quâ_ gout reside
in the _individual_, not in the character of the wine? We are far too
prone to say that this or that _wine_ is “gouty,” to say that this wine
gives you gout, and that not.
The evil potentialities that make for gout reside not in this or that
particular wine, but in the _individual_. This or that wine does not give
him gout, but evokes or brings to fruition a morbid tendency already
_latent_ in him. In the absence of this inherent proclivity, it would
not have elicited those specific local reactions typical of gout. But
for those who would interpret this statement as approval on my part
of alcohol or an absolving thereof from any part in the genesis of
gout I would issue this _caveat_: Alcohol will not originate gout in a
_non-gouty_ subject, but it will almost infallibly in those in whom there
exists by heredity an inborn tendency to gout. In short, the “gouty” are
_hypersensitive_ to the evils of alcohol; the greater the need then for
_abstemiousness_ and self-restraint.
But, to resume the thread, in the absence of any absolute chemical
criterion as to the relative suitability of this or that wine for the
“gouty,” what shall be our advice to the _“gouty” individual_ on this
point? In a word, his “palate” and his “stomach” are the best criteria
of the wholesomeness of this or that particular wine in his particular
instance. If he is in the habit of taking wine do not forthwith, as is
so often done, forbid him wine in all forms and order him _whisky_. This
is done so light-heartedly that I do not wonder that the subject goes
away frequently with the idea that _whisky_ is not only innocuous, but
desirable.
_The whisky-drinker is not immune from gout_, and I have no hesitation
in affirming that “light” _wines_ when fine, mature, and of a _good_
quality are, subject to individual idiosyncrasy, quite as suitable
for the “gouty” as whisky. Of the many wise warnings given us by Sir
James Goodhart none is more apt for the present day than the following.
Discussing the “treatment of uric acid,” he observes: “I am as much as
ever an opponent of the prevalent dictum, ‘You must not touch wine;
you must drink whisky,’ which too often means to the patient, ‘A glass
of good wine is poison; I may take as much whisky as I like, and it is
harmless,’ one of the most mistaken and mischievous beliefs that ever
plagued a world.”
Again, if a “gouty” man takes wine, there is always one special variety
that agrees with him, and as certainly one other or more that infallibly
upset him. Putting aside all preconceived ideas, find out his _personal
idiosyncrasies_ in this respect. In this way you elicit and utilise for
your ends the _individual’s_ own experience, the only experience that
counts.
A man of a certain age, he generally by the time he develops overt
gout has arrived at definite conclusions as to what does and what does
not suit him. He will frequently tell you he has had to give up malt
liquors, perhaps port and champagne, and now finds that whisky, gin, or
the lighter wines agree with him better. Or, as like as not, he may upset
all your preconceived ideas. He may be of those gouty subjects—and they
are not so few—who can drink champagne in moderation, or even a glass or
two of port, daily with apparent impunity. On the other hand, a glass of
claret or hock plays the mischief with him. He may, like some individuals
cited by Burney Yeo, be one of those exceptional gouty subjects in whom
even stout is well borne, Yeo thought largely because they habitually
took daily large quantities of alkaline salts.
The sum of these erratic findings is that you must respect
_idiosyncrasy_. It is said that the best wine for a “gouty” subject is
the one that causes most _diuresis_. For myself, I am equally positive
that the worst wine for a gouty man is that which upsets his _stomach_,
which gives him some hours afterwards “acidity” or a feeling of “liver.”
Often, too, it is not the wine, but the _stomach_ into which it is put,
that is to blame. Thus the “gouty” subject with _atonic dyspepsia_ finds
a glass of sound wine helps digestion. On the other hand, if he suffers
from _hyperacidity_ or _chronic gastritis_, the reverse will probably be
the case.
Again, it is not the name, but the _quality_, of the wine that counts. It
makes all the difference whether the wine taken is fine, mature, and of
good quality, or some factitious, mixed, or adulterated product, passing
muster, say, as claret. Fine mature clarets or red Bordeaux wines are
most suitable for the gouty. But, as Burney Yeo rightly says, “a more
injurious beverage than bad claret or imperfectly matured claret—and,
speaking generally, all but the more expensive or most carefully selected
clarets are bad—was never drunk.”
It seems opportune here to lodge a protest against _fashions_ in
wines for the “gouty.” At one time it was claret, then light white
wines, Moselle, etc., and anon whisky, and even cider had its vogue.
Fashions in wines, as in other spheres, postulate uniformity and lack
of discrimination. Any one of the foregoing beverages may suit some
particular “gouty” individual, but not _all_ “gouty” subjects.
We have said that in some instances the wine, in others the stomach,
is at fault. But intrinsically it may lie in neither, but simply in
the _quantity_ of the wine drunk. It may not, as judged by ordinary
standards, be an excessive amount, but it may be excessive for that
particular man. It is here that a medical man may often intervene with
advantage. For a man may, quite unbeknown to himself, be really a heavy
drinker, one of those unfortunates who are peculiarly tolerant of
alcohol. A tactful reminder of the amount he is consuming per diem will
frequently come as a shock, often a very beneficial one.
Apart from this, it is, I am sure, wise to fix the _daily amount_. The
daily habit in the “gouty” is all-important. If accustomed to take one
or two glasses, and they stick to it, all may be well; but it is on
the occasions when the glass grows into a half-bottle that the trouble
comes. Metabolically speaking, the “gouty” subject is most unstable, and
disturbance of what one may call his daily alcoholic rhythm is always
perilous. Unfortunately it works either way, too, both in the matter of
“too little” as well as “too much.” Here experience and sound judgment
will alone enable the physician to decide how far he may tamper with
long-established habits.
At other times the amount, though, strictly speaking, not excessive,
is so when judged in light of the victim’s _habits_. He may be an
intellectual worker, but _sedentary_, and he must either lessen his drink
or increase his exercise, or he may _overeat_ as well as overdrink—a
victim of the prevalent idea that the one evil counteracts the other.
Between the Scylla of overeating and the Charybdis of overdrinking there
is no safe course save by way of _reduction_ of both.
We see therefore that in the matter of the choice of a wine for a “gouty”
subject there are many points to be considered. Of these _personal
idiosyncrasy_ stands first. By this criterion, and none other, can the
_suitability_ of the wine be decided. Then the state of the _digestive_
functions, if deranged, has to be considered. Is the gastric disorder
such as will be benefited or, on the other hand, impaired by wine of any
sort? Again, _glycosuria_, _albuminuria_, _raised blood pressure_, or
_cardiac degeneration_ may intervene to complicate the issue, and so our
policy in regard to alcohol has constantly to be adapted and readapted to
the varying requirements of the organism.
It will be seen that I have largely refrained from specifying the wines
_suitable_ or _unsuitable_ for the “gouty.” To have done so would have
been alien to the general tenor of my remarks, convinced as I am that
our trend in the matter of alcohol for the “gouty” should be more in
the direction of “individualisation” than of “standardisation.” Subject
to the reservations that such an attitude portends, I would proffer the
following suggestions:—
As a general rule, wines which are “dry” are much more suitable for
the “gouty” than those which are “sweet.” Wines are termed “dry” when
nearly all the sugar of the grape is transmuted into alcohol, as in “dry”
sherries. They are termed saccharine or “sweet” when the process of
fermentation is arrested before all the sugar has been exhausted, as in
Malaga. Again, wines which are both “strong” and “sweet,” _e.g._, Malaga,
sweet champagne, Tokay, etc., are more pernicious than those which are
“strong” yet “dry,” _e.g._, port, sherry, Madeira.
Sir James Goodhart, discussing wines suitable for the “gouty,” confesses
to a “personal leaning in favour of the wholesomeness of a glass of
good old sherry in those cases where a little wine seems a judicious
prescription.” With this I fully agree, and would suggest that of
sherries the “gouty” should favour the “Manzanilla” rather than the
“Amontillado” class. The former, save for the addition of a small
quantity of spirit, are mostly shipped in the natural state; also they
are light and “dry” as compared with the latter, which are generally
“sweet” and full-bodied.
It is interesting to recall, too, that Sydenham regarded _sherry_ as
preferable either to Rhenish or French wines. He himself in his own
person found “sack” or Canary the most helpful. “I have during the fits
of the last years tried many things to lessen the symptoms. Nothing,
however, effected my purpose so much as a small draught of Canary wine,
taken now and then, when the faintness or sickness were most oppressive.”
Here one may note that sherry was the first wine to be known as “sack”
in this country, and that the wine shipped in Sydenham’s time was of the
“dry” variety. Chemically the “sweet” sherry differs from the natural
“dry” light wine through its relatively high content of alcohol and sugar.
Turning to _port_, Sir Alfred Garrod absolutely tabooed its usage by the
gouty. But this appears too sweeping, and nowadays, at any rate, it is
well recognised that, especially in _asthenic_ types of gout, a glass
or two of old port is well borne. Consequently in such cases we should
not, in the absence of any adverse symptoms, forbid its continuance. The
bad reputation achieved by port is, I am sure, a relic of the Regency.
But “three-bottle” men are no longer with us, and, allowing for personal
idiosyncrasy, I very much question if sound port taken in moderation
wholly merits the aspersions cast upon it. I do not by that for one
moment suggest its general adoption by “gouty” people, but that where an
old or elderly gouty subject takes port and can be trusted not to extend
his glass to half a bottle his inclination may be respected. The sugar
content of port varies according to the vintage, ranging from 7 to 15 per
cent., and the “gouty” man should favour the “drier” varieties.
As for champagne—a manufactured article rather than a natural wine—there
is no question that, if taken at all, it should be a “dry” brand. Such
contains from 9 to 12 per cent. of alcohol and from 1 to 4 per cent. of
sugar, whereas the “sweet” brands may hold as much as 16 per cent. All
depends on the _quality_ of the champagne, and, as Ewart wisely remarks,
“it is wiser for the ‘gouty’ patient not to incur considerable risks by
trying brands with which he is not familiar, though he may sometimes with
impunity, and occasionally with benefit, enjoy a glass of champagne which
he can trust from personal experience.”
If, on the whole, the most unsuitable wines for the “gouty” are the
strong sweet _spirituous_ or _liqueur_ wines, on the other hand the _red_
or astringent and _white_ wines are the most esteemed. As to the _red_
wines, there is no doubt that the delicate Gironde (Bordeaux) wines are
_par excellence_ the most suitable. They have sufficient body and alcohol
without being heavy or fiery, while their acidity and sugar content are
very low. But of course the quality of the wines varies considerably
with the vintage. Subject to this, sound, well-made clarets taken in
moderation and somewhat diluted with water are the most wholesome wines
we can prescribe for the “gouty.”
The more full, though still not coarse, wines of the Burgundy district
are by some denounced. One authority, I note, states that in elderly
gouty subjects he had often found that two or three glasses of claret or
Burgundy were in the course of a few hours followed by eczema. While such
idiosyncrasies may obtain, it is not true of the “gouty” as a class. I
should consider a “gouty” subject in any case unwise to take two or three
glasses of Burgundy. But I do not hesitate to order _one_ or perhaps two
glasses somewhat diluted with water. Being a stronger and more tonic wine
than Bordeaux, it is useful in the more _asthenic_ types of gout. The
pity is, of course, that the cheaper Bordeaux and Burgundy wines are so
largely adulterated, while the more mature clarets are available only for
the rich. As good substitutes for French wines Burney Yeo commends the
red Hungarian wines, such as Carlovitz, while we may add that some of the
Dalmatian wines are of fair quality and somewhat resemble Burgundy.
Reverting to _white_ wines, these, as compared with the red wines of the
Gironde, contain less tannin and more free acid. According to Burney Yeo,
they exert, too, a more diuretic effect, and to remove their excessive
acidity he advises their dilution with some alkaline table water. Most of
the white wines come from the Rhine or Moselle districts. The Rhenish are
relatively full-bodied and of marked vinosity, while the Moselle wines
are mostly light and of a somewhat delicate nature. Light hocks and still
Moselles are quite permissible, also the white wines of France, such
as _vin de Grave_, all varieties of the latter being fairly “dry” and
light in character. On the other hand, the _white_ wines of Sauterne,
like some of the Hungarian wines—_i.e._, Ruster—are rich in saccharine
constituents. In this respect they contrast with the Rhenish and Moselle
wines. Of these last Johannisberg contains only 0·42 per cent. of sugar,
Rudisheimer 0·39, Zeltinger 0·13, and Stein-Reisling 0·01, while Ruster
contains no less than 21·74 per cent. of sugar.
In conclusion, I would re-emphasise the fact that, if wine be taken,
the patient’s own experience is the best test as to which particular
wine is the most suitable in his case. This elicited, the subject should
be counselled to adhere to it, taking it only at _meal-times_, and
establishing a rigid rule as to _quantity_. The least excess is harmful,
and breaking of the ordinary routine in the matter of the amount drunk is
a fertile source of “gouty” outbreaks. In any case the _quality_ of the
wine should be above suspicion, and if the expense is prohibitive, he had
best eschew wine altogether in favour of mature spirits.
_Spirits._—Brandy, whisky, and gin are the spirits most in vogue in Great
Britain, and it has become an axiom with some that, if alcohol in any
form be requisite for the “gouty,” the least harmful is one or other of
these beverages when adequately diluted. Of the three whisky undoubtedly
has found most favour, and the pernicious and far too prevalent idea is
that whisky not only does not beget gout, but is actually _beneficial_
for gout. The consequence is that many “gouty” people take far more
whisky than is desirable, seemingly oblivious of the fact that, if whisky
in _moderation_ be suitable for the “gouty,” whisky in _excess_ is as
deleterious for them as for the non-gouty. In short, like any other form
of alcohol, if taken immoderately, it will bring to fruition a latent
gout, this, as suggested by Ford Robertson, not by the direct action of
the alcohol, but by the “indigestion toxæmia” it sets up.
In advising therefore a “gouty” subject to take whisky we should insist
that (1) it should be taken only at _meal-times_ and (2) only in
_moderation_. The habit of occasional “nips” at all times of the day
should be unreservedly condemned. As to what constitutes a _moderate_
quantity is often a difficult question to decide.
When feasible, I endeavour to limit the _daily allowance_ to _a
wine-glassful_, distributed over lunch and dinner. But it is quite
impossible to lay down hard and fast rules in a matter in which _personal
idiosyncrasy_ plays such a strong _rôle_. Frequently, in addition to the
above amount, one has to relent to the extent of a “nightcap,” or but
too commonly one has to be content if one can compass reduction to an
amount which for the particular individual under review seems apparently
compatible with no appreciable damage to health.
Sometimes one of the frequent accompaniments of gout comes to
our assistance. It may be _raised blood pressure_, _glycosuria_,
_albuminuria_, _obesity_, etc. In such cases a word in season may reduce
an otherwise recalcitrant subject to reason.
Needless to say, in regard to “ardent spirits,” as to wines or malt
liquors, we must, when determining the quantity to be taken per diem,
review the same in light of the person’s _habits_, whether _active_ or
_sedentary_, whether associated with overeating or not. For manifestly
all these bear on the point at issue.
Lastly, as to whether the subject should take brandy or gin in preference
to whisky is a matter for himself to decide. Whichever suits him best
is the best for him. Albeit, I confess to a leaning in favour of “dry
Plymouth” gin, this being more diuretic than other spirits by reason of
the juniper contained therein. But, in whatever form “ardent spirits” be
taken, it is most essential that it be sound. Brandy should be of the
finest quality, the whisky mature, and inferior kinds of both wholly
eschewed.