Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

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.”