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.”