Personally I am not enamoured of purin-free diets for the “gouty,” any more than I am of the purely vegetarian regime, so extolled by some as the means of averting gout. The purin-free diet, if I may say so, smacks too much of the laboratory, its raison d’être the baseless assumption that uric acid is the fons et origo mali.
I am very doubtful of the intrinsic merits claimed for it. I do not think it exerts a direct or specific anti-gouty influence. Such advantages as do accrue are referable, in my opinion, to the greater measure of intestinal asepsis that such a regimen promotes. It is suitable, therefore, in cases in which there are evidences of intestinal putrefaction. Distinctly unappetising, it is useful, too, as a disciplinary measure for those prone to overeating.
Its advocates claim that it tends to diminish the excess of uric acid in the blood. But, as was pointed out when dealing with uricæmia, variations may occur in the uric acid content of the blood independently of diet. Moreover, acute attacks have been observed even when the uric acid blood content was at a sub-normal level.
To place all “gouty” subjects on a purin-free diet as a routine procedure is to my mind wholly impermissible. The fact that prolonged adherence thereto is usually found impracticable is surely an indication that we are violating nature’s laws. It may prove beneficial in a few isolated cases, and then only for a time; but in the vast majority of instances it is frankly prejudicial. Given a carefully revised mixed diet, it will, in my experience, be rarely, if ever, necessary to subject “gouty” individuals to this dietetic penance.
The Reduction of Obesity.—Unfortunately obesity is a common associate of gout, and with it not infrequently comes glycosuria. Middle-aged “gouty” subjects have in their youth often been given to strenuous exercise. But notwithstanding that with advancing years their capacity and disposition for exercise lessens, they nevertheless take the same amount of food as of yore.
It is most difficult to make them realise that, with the alteration of their habits, the amount of food which at one time was but adequate is now excessive. I have found it useful to remind such of Ebstein’s dictum, “The gouty who have grown old in spite of their disease are almost always those who have been able to avoid obesity.” Still it is only fair to add that in some of the gouty obese no accusation of overeating or overdrinking can be lodged, and their aptitude for fattening seems often hereditary.
Reduction of the body weight when excessive in gouty subjects is hardly, I think, sufficiently emphasised. The victim himself is but too often convinced, however, that he ought not to be “lowered,” and sometimes, I think, infects the physician with his apprehensiveness on this score. But, as Harry Campbell rightly observes, “people do not die of starvation so easily as is generally thought, and it is very difficult for the physician to kill his patients in this way.” Yes, and, on the contrary, how often do gouty people “dig their graves with their teeth.”
Again, there is the static element to be considered in these cases. The articular manifestations of gout are by preference located in the lower extremities. It is clear then that excessive stoutness, particularly if of recent development, must inevitably throw increased strain on the already-hampered articulations. The feet of the “gouty” are their most vulnerable point, and the number who are flat-footed is noteworthy. In the presence of this static fault, “strains” or “sprains”—those fertile excitants of gouty outbreaks—are much more liable to occur, and I myself feel sure that in this way the frequency of attacks in the feet and, for that matter, in the knees also, is favoured.
Lastly, the gouty obese is frequently elderly, his vessels somewhat the worse for wear. Also he may show signs of cardiac weakness or a trace of albumen or sugar in his urine. Even so his weight should be reduced if possible. His watchword should, like Falstaff’s, be:—