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.