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.