Gout, with a section on ocular disease in the gouty

by Llewellyn J. Llewellyn

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If the foregoing measures prove ineffectual the carbohydrate content of the food should be withdrawn, and the patient limited to a strictly meat diet, taken either raw or very slightly cooked.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.