Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

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.