FOOTNOTE:
[155] “Diet in Health and Disease,” p. 399, by Friedenwald and Ruhräh.
CHAPTER XXII
GOUT, OBESITY, EMACIATION
Gout is a constitutional disease characterized by an inflammatory condition of the joints. It is caused by or associated with a retention of uric acid in the blood. Gout is also characterized by the deposit of uric acid or sodium salts which occurs in different parts of the body, the joints, the lobe of the ear, the knee and the elbow being common points where the deposit of these salts ordinarily occurs. The amount of uric acid is lessened in the urine in cases of true gout, except in acute attacks, and in this way it is distinguished from the so-called goutiness in which a urinalysis shows an excess of uric acid. According to Strouse, this excess of uric acid in the urine “means a physical-chemical change in the urine and is quite different from the small amount usually excreted.”[156]
Source of Uric Acid.—In man the uric acid which is eliminated in the urine is derived from two sources. It may be taken with the body as purins in food, in which case it is spoken of as being an “exogenous” product, or it may be formed in the body from the breaking down of the nucleoproteins (the highly nucleated cells of the glandular organs particularly). When the uric acid is formed in this manner as the result of the metabolism of the body tissues, it is known as “endogenous.” In the normal body approximately one-half of the uric acid formed is oxidized, while the remaining half is eliminated from the body by way of the urine.
Elimination of Uric Acid.—In gout such is not the case, the body loses to a certain extent the ability to eliminate the uric acid, hence it is retained within the body, causing an excess in the blood stream, and it is this excess uric acid in the blood which causes the acute attacks and general pain and discomfort which inevitably occur in chronic gout.
Purin-bearing Foods as Sources of Uric Acid.—Formerly no difference was made in food; all were supposed to cause uric acid formation, but with the exhaustive investigation of food materials this sweeping condemnation has been to a great extent removed or narrowed down to a few foods, those rich in purins being the chief offenders.
Chief Causes of Gout.—Without a doubt, overeating, overindulgence in alcoholic stimulation, lack of exercise, etc., are chiefly to blame for the large percentage of the cases, but upon investigation it will be seen that those individuals are as a rule large protein eaters and that their mode of living is not such as to assist the body in throwing off the poisons which form as the result of their self-indulgence.
Rules to Combat Gout.—To successfully combat the retention of a large percentage of uric acid in the blood there are certain definite rules to be observed: (1) The general diet must be reduced not only in amount but also in purin-bearing foods; (2) All foods which are liable to cause digestional disturbances, with the attending evils of intestinal putrefaction and constipation, must be avoided.
Alcohol in Gout.—If the patient is accustomed to alcoholic stimulants and has been in the habit of taking them constantly for years, the amount of alcohol consumed daily must be radically reduced and only the amount prescribed by the physician taken. Alcohol without a doubt assists in the retention and increases the difficulty of uric acid elimination by the body. In view of the present knowledge of the cause and effect of uric acid in the body, the treatment of gout is directed with the object of relieving the condition (1) by facilitating the elimination of uric acid from the body, and (2) by so regulating the diet as to exclude as far as possible those purin-bearing foods which, by reason of their chemical composition, augment the general amount of uric acid formed within the organism.
In gout, as in other abnormal conditions, no set rule can be laid down to cover the treatment of every case. The individual must be taken into consideration, his daily habits studied and the extent and character of the disease known before it is possible to prescribe a treatment or formulate a diet which would adequately meet his needs under the existing conditions.
Obesity and Glycosuria.—Gouty individuals often become obese and show evidences of glycosuria. Consequently it is important to regulate the carbohydrates as well as the purin-bearing foods in the diet. Only the simplest foods are permissible. In acute attacks it has been found that milk and alcohol cause less disturbance than meat and alcohol. While the acute symptoms exist all meat should be avoided and the daily allowance of alcohol cut down. Tea and coffee both contain purins and should be avoided while the acute stage of the disease continues. Cereal coffee, hot water tea, hot milk or buttermilk may be substituted.
Purin-free Diet.—A purin-free diet is advisable during the acute attack. The following is a sample menu of such a diet:
| Purin Per Cent. | ||
| Cocoa | contains | 1.00 per pint |
| Tea | “ | 1.20 per pint |
| Coffee | “ | 1.70 per pint |
Purins are soluble in water, hence those foods that are boiled contain less than those prepared by other methods of cookery.
Foods More or Less Condemned.—Salt has a tendency to bring about a deposit of sodium urates in the body, and for this reason should be sparingly used in the preparation of the diet. Alkaline waters are inclined to produce a like result, consequently should be avoided by the gouty individual. Condiments and spices are conducive to constipation, a condition to be avoided if possible under the circumstances. Certain physicians prohibit the use of oranges in the diet of gout, while others do not. Strawberries are likewise condemned and should be eliminated from the diet for both chronic and acute gout.
Diet in Chronic Gout.—In chronic gout it is necessary to maintain the general health of the patient by a well-balanced diet. This is not difficult even if the dietary is so regulated as to be well within the limits of his energy requirements. It is necessary to limit the purin-bearing foods. Meats are used sparingly and these should be boiled rather than roasted or broiled. Eggs and cheese and milk should be substituted for at least part of the regular allowance of meat.
Exercise and Massage.—The patient should be recommended to take a certain amount of mild exercise in the open air, or massage if he is accustomed to living an indoor life or is confined to office work. He must be warned against overindulgences of all kinds, especially of overeating and drinking. A glass or two of hot water before breakfast is recommended.
Treatment of Obesity.—The treatment of obesity when occurring in gouty patients is much like that used in other conditions. Ebstein regards obesity under such circumstances as an unfavorable symptom. He advises a reduction in the carbohydrates to the smallest possible amount and allows meat and fats in the diet.
Allowable Foods.—The following foods are practically purin-free and may be used in the diet of gout:[157] Milk, cheese, butter, eggs, nuts, gelatin, fruits, sugar, breads made with white flour, cereals, cream of wheat, farina, rice, hominy, tapioca, cornstarch, potatoes and other root vegetables, green vegetables, except asparagus, spinach, and all fats.
Avoidable Foods.—The following foods are rich in purins and should be avoided in the diet for gout: Sweetbreads, liver, kidneys, beef, mutton, veal, pork, turkey, chicken, goose, rabbit, duck and other game, fish, with the exception of cod, sardines, and anchovies, tea, coffee, and cocoa.
The following list shows the purin content of some of the above-mentioned foods. The purins are computed by Hall as follows: 1 kilogram contains,
To keep the body in good condition and to help rid it of accumulated poisons, the following diet lists are recommended:
Daily Dietaries: