(2) The incidence of a first attack in a young man should be the signal for abstinence from alcohol in all forms.
(3) Given its occurrence in an older subject who has used alcohol but sparingly and stands in no need of it as a stimulant, the same total abstinence should be inculcated.
(4) In middle-aged or old subjects habituated to the use or abuse of alcohol abstemiousness, not abstinence, is the safer course.
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—