Restriction of such to a milk diet is sometimes positively harmful. The mischief is, that, once begun, every attempt at a more varied diet immediately provokes a relapse.[60] As Sir Thomas Watson wisely observed: “They must be allowed a certain quantity of their accustomed good cheer, or they become an easier prey to the disease. In such cases you must ‘trim’ as well as you can between opposite dangers, between the Scylla of excess and the Charybdis of debility.” In short, you must maintain their vigour and their strength. For this a pure milk diet will not suffice. In addition thereto, pounded or minced chicken, a little fish, sole or whiting, may be given. When also, as often happens, they have been wont to take alcohol, two ounces of mature brandy or whisky, well diluted with Salutaris or other mineral water, may be allowed them every twenty-four hours.
Indeed, if the subject be old and broken down, it may be necessary to increase the amount of stimulant. In such cases to go on treating the disease, heedless of long-established habits, is bad policy. Wholly to withhold alcohol may well precipitate disaster. Homilies on abstinence or temperance are best postponed pending convalescence.
Moreover, these cases of acute gouty polyarthritis, whether in the middle-aged or old, very commonly run an afebrile course. If then, as not infrequently happens in these distressing cases, the patient’s progress is slow and unsatisfactory, there need be no hesitation in renouncing a strictly lacto-farinaceous regimen in favour of a more mixed diet: clear vegetable soups, well-made Julienne, mutton, veal, and chicken broths, lightly boiled fish of the digestible kinds, pounded and minced chicken, etc.
Even when in these cases pyrexia is present, it is rarely continuous, but is diversified by afebrile intervals. If then, while the paroxysm is in full flare, it be deemed advantageous to adopt a milk diet, it is all the more important that in the inter-paroxysmal stages we take full advantage of these periods of enhanced digestive capacity.
Diet in Chronic Gout.—Sydney Smith, writing to the Countess of Carlisle in his seventy-first year, humorously apostrophises his gout: “What a very singular disease it is! It seems as if the stomach fell down into the feet. The smallest deviation from right diet is immediately punished by limping and lameness, and the innocent ankle and blameless instep are tortured for the vices of the nobler organs.”
Precisely so, but what constitutes the “right” diet? We are told that this is good and that is bad for gout. Some would have us eschew red meat and cleave unto white; for others common salt is the devil that must be cast out. Some speak ill of all the fruits of the earth. Strawberries especially, they say, are the bane of gout, yet in these same Linnæus found salvation. For many, again, sugar is anathema, tea and coffee but uric acid solutions, and alcohol in all forms rank poison!
What a trial the gouty subject who, obsessed by his “acidity,” has passed through the furnace of many spas! “Everything I eat turns to acid” is his plaint. He has been all things by turns—a fruitarian, a vegetarian, no meat or all meat, etc. Such persons, in truth, are “uric acid” maniacs. But—forget it not—they are of our making, and often in their multitude of counsellors have found, not wisdom, but starvation! Well would it be if the evil done ceased with themselves, but unfortunately they seek converts to whatever cult they affect.
The Fallacy of Fixed Dietaries.—As Bacon in his “Regimen of Health” (1597) wisely observes: “Some physicians are so regular in proceeding according to art for the disease as they respect not sufficiently the condition of the patient.” The wisdom of this has, I fear, been overlooked by those who hold that the ideal diet for the “gouty” is one destitute of the precursors of uric acid. Its acceptance makes not for flexibility in dieting, but rigid, undiscriminating routine.
Apart from the violation of principle, the direct result is, that the victim runs amok among the carbohydrates, with as a frequent penalty an acute outbreak, this although uric acid is not a direct product of carbohydrate metabolism; nor, as far as is known, does the carbohydrate intake influence the rate of formation of uric acid. Thus do theory and practice come into conflict, and, as usual, the patient pays. How pernicious this obsession that uric acid is a morbid agent! Uric acid is not an etiological entity, and, as Walker Hall rightly observes, “it is high time that every practitioner made a point of fully educating the public in this respect.”
Any attempt to formulate a set dietary proves but a snare and a delusion. No regime is applicable to the “gouty” as a class, nor even to the individual “gouty” subject at all periods of his life history. His disease persists for an indefinite period, and, like most chronic maladies, undergoes variations. Pari passu his digestive capacity rises and wanes. The regime therefore must be adapted and readapted to his varying necessities. For it is the patient, and not the “gout,” dictates the diet. But only too commonly the disease is dieted, the victim ignored—hinc illæ lachrymæ!