CHAPTER XXVII. Treatment of Gout (_continued_)

TREATMENT OF GOUT (continued)

REGULATION OF DIET IN THE GOUTY

The victim of gout is easier led than driven. Show no “bowels of compassion” for his failings, talk to him in the spirit of a dehumanised disciplinarian, and your tenure of his confidence will likely be short. You deal with a man more often wise than foolish, not merely a digestive tube.

The physician must be authoritative and yet tactful. Thus if the victim be a hearty eater, and you think he eats too much, try and get him to eat less. But do not bid him straightway live as an anchorite. Be a little more diplomatic. A good appetite is not a sin. An appetite over-stimulated by condiments or endless varieties of courses is. He should eat to satisfy his hunger, not to gratify his palate.

Do not irritate the patient with a strict dietary if avoidable. Far more often than not it is the quantity, not the quality, of the food that is at fault. Frequently mere reduction in bulk of the pabulum of all kinds taken will suffice. In short, restriction, not elimination, is the wiser maxim, especially so in indolent or sedentary persons in whom we may with advantage limit the food intake to the minimum consistent with the due maintenance of nutrition.

On the other hand, there is a widely prevalent idea among “gouty” subjects that if they take enough exercise they can eat and drink what they please and as much as they please. That active habits do counteract to some extent the evil effects of overeating and overdrinking is certainly true. Nevertheless, as Sir Thomas Watson reminds us, gout was extremely common in the old time squire, who not only “rode hard,” but “lived hard” also. It is so, though to a less extent, even to-day, and often such subjects prove very refractory. Often a reference to their “weight” will appeal more than any hygienic considerations. Make use, therefore, of their sensitiveness on this point, and so by diplomacy attain your end.

Overeating often goes with overdrinking at meals. I well recall a gouty old sportsman of bucolic type who was accustomed to swill his food down with several whiskies and sodas. Very conservative in all ways, it was not easy to break him of the habit. Fortunately it occurred to me to ask him, “Did you ever see a horse eat and drink at the same time?” Reflecting solemnly, with obvious reluctance came the reply, “Damme, I never did, now that I come to think of it.” That settled the question. I had no more trouble, neither had he. Not often is one so lucky. But “Eat your meals dry” is not a bad rule in cases of sheer overeating. The appetite is sooner blunted.

As to the quality of the food, always recollect that “gouty” people are very prone to idiosyncrasies; but the idiosyncrasy is purely personal, not applicable to the “gouty” as a class. With them it is very much a case of “What’s one man’s meat is another man’s poison.” The physician who rides rough-shod over idiosyncrasies in the matter of foods rides for a fall. Let him rely on his own experience and knowledge in the matter of general dietetic principles; but when it comes to details—the eschewing or not of this or that—let him trust, not in his own, but in his patient’s, experience.

Many of these subjects know perfectly well what suits them and what does not. Their experience is your best guide. Having elicited this information, an appeal to their common sense rarely fails. Of the “gouty” it is especially true that “every man at forty is either a fool or his own physician.” For the fool there is but one corrective—dolor acerrimum naturæ pharmacum. The wise has only to be reminded of his own experience, viz., that certain articles of diet infallibly disagree with him—verbum sapienti satis.

In dieting the “gouty” we should never forget that the main groups of foodstuffs must be duly represented. We may reduce this or that, but never for long will they do well if one or other of the essential ingredients of human food be wholly eliminated. It is, as Sir Archibald Garrod remarks, doubtful whether even a minor constituent, such as the purins, can be continuously withheld with impunity.

Still, even from the more extreme dietaries advocated by some one may glean this useful lesson, that the temporary benefit that often accrues points the moral that simplicity of meals is best for these subjects. If they crowd soup, fish, meat, game, sweets, etc., all into one meal, they always pay the penalty. As Burney Yeo wisely says: “We should not mix up albuminates, fats, and carbohydrates, or flesh, vegetables, fat, and fruit in the same meal. One meal should be composed almost exclusively of nitrogenous food, another of fats and carbohydrates, and another of fruit, at proper intervals, and they will all agree and be suitable, but the contrary will be the case if they are mixed together in the same meal, one hindering the digestion of the other.”

I have often found the old rule, “One meal of meat, one meal of fish, and one of neither,” an excellent way of impressing on these patients the importance in their instance of simple, as opposed to elaborate, meals. Arrangement of their daily bill of fare along these or similar lines is well worth the trouble.

If the food of the “gouty” needs to be carefully selected, it is no less necessary that the cooking be simple and appropriate. For the manner of the cooking is, I am sure, in many instances, more responsible for “gouty” outbreaks than the nature or the quantity of protein or other intake. Twice-cooked food, made-up dishes rich in extractives, are unquestionably pernicious. Nor are pickled or salted meats desirable. Similarly, strong meat consommés, hare soup, and beef extracts are best avoided. The same applies to rich gravies, sauces, spices, etc., all obviously likely to upset the digestion. Again, as to fish, it is better boiled or grilled than fried, and still better not fried in fat. In short, it is the “trimmings” more often than not that do the mischief, these strongly abetted by “second helpings.”

The physician may well insist upon a sufficient interval elapsing between meals. To attain due space between lunch and dinner, I invariably forbid “gouty” subjects to eat anything with their tea. The repasts should be taken in a leisurely fashion, if possible in a cheerful atmosphere. “Unquiet meals make ill digestions.” The nerve element in these cases is so pronounced that caution is anything but superfluous, viewing the inhibitory effects of worry and mental excitement on the secretory mechanisms of the alimentary tract.

The importance, too, of thorough mastication and regularity in meal-times should be impressed upon them. The desirability, too, of postponing the drinking of fluids to the end of the meal, and then only in small amounts, should be emphasised.

Strenuous exercise, mental or bodily, immediately after a meal is undesirable, and if, as is so often the case, there be any gastric disorder, the subject should rest both before and after meals. This is best taken lying down, especially if there be any tendency to gastric dilatation or visceroptosis. The same in hyperacidity, but in this latter sleep is contra-indicated. For it has been shown experimentally that the acidity of the stomach content is greater during rest than movement. But this is just one of those points on which authorities differ, and decision may have to be left to the patient’s own experience.

Lastly, we should always endeavour to ascertain as nearly as possible the actual amount of the food intake per diem. This then must be weighed in light of the subject’s age, body weight, and mode of life. The middle-aged “gouty” person tends more often than not to obesity, and it will fall to the physician to decide whether the food intake be excessive or his habits too sedentary. Far more often than not it will be found that it is not that he walks too little, but that he eats too much. The appetite of youth goes ill with the inactivity of middle age. With these general considerations we will now pass to a discussion of the main elements of diet.

THE INDIVIDUAL FOODSTUFFS

Proteins.—Ruthless cutting off of protein foods, though not so usual as of yore, is still far too commonly practised. The number of unfortunate wretches who are docked of their red meats is still astonishing. The “uric acid” bugbear dies hard. Unless red meat is known to disagree, I never advise a “gouty” subject to abstain wholly therefrom. I feel sure that it is rarely, if ever, called for, and when enjoined has frequently wrought much harm. As far as I know, there is no scientific reason for the very prevalent idea that for the “gouty” white meat is preferable to red. It is certain that both contain an equal quantity of extractives, and equally certain that for some, mirabile dictu, white meat, e.g., rabbit, is more indigestible than red.

Accordingly let your “gouty” patient eat animal food, at any rate at one meal, but let it be of one sort only. Let his appetite be his only sauce, his meat plainly cooked and well masticated. It matters not if it be red or white. What does matter is whether for him it be digestible. Mutton or lamb are more likely to prove so than beef or pork, and chicken, turkey, or fresh game more easily assimilable than duck or goose.

From Walker Hall’s experiments Luff thinks “it would appear reasonable to administer sweetbread to gouty patients, since its nuclein portion is only slightly absorbed, for thymus sweetbread contains principally adenin, which is rapidly excreted, and pancreas sweetbread contains mainly guanin, an amino-purin incapable of increasing the urinary purin output and of exerting any injurious effects upon the tissues.”

Nevertheless I still think that “gouty” subjects are better without thymus, pancreas, and other highly nucleated substances. Despite our ignorance of the true nature of gout, we do know that there is generally an excess of uric acid in the blood, and that to increase the content thereof is undesirable. Again, we know that in normal men, after ingestion of pancreas and thymus gland, the uric acid output in the urine is markedly increased. But, on the other hand, many observers—Magnus-Levy, Vogt, etc.—have noted that after the eating of thymus by gouty individuals they found far less uric acid in the urine than in the case of normal persons. In short, such purin-rich foods in their instance is followed by uric acid retention.

More pointed still is the fact that acute outbreaks of gout have been repeatedly brought on by administering thymus to the subjects of chronic gout. Surely, in light of this, it is impolitic to approve of sweetbreads as desirable ingredients of a “gouty” dietary, this even if only on empirical as opposed to scientific grounds. That some “gouty” persons eat sweetbreads with impunity is undeniable. But certainly if on inquiry a subject overtly gouty admits a penchant for these foods, we should at any rate advise their restriction or elimination.

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.”

Vegetables.—The various green vegetables are eminently suitable for the “gout,” not so much on account of their nutritious qualities, but because of the important inorganic salts they supply, notably salts of potash. They give a wholesome variety and relish to food, render the urine more alkaline, and do not favour the deposit of fat. Their indigestible residue, too, stimulates the intestinal coat, and so promotes regular action of the bowels.

Cabbages, greens, savoys, Brussels sprouts, cauliflower and broccoli are familiar examples. These, provided they are fresh and well cooked, are preferable to root vegetables, with the exception of potatoes. Nor must we overlook the fact that green leaves are rich in fat-soluble vitamine. Fortunately, too, in the case of this particular vitamine, the loss involved by ordinary cooking is not serious. Spinach, too, is rich in vitamines, and is laxative, but, being rich in oxalates, is contra-indicated in oxaluria. Sorrel, by reason of its acid oxalates, is also undesirable under such conditions, and the same is true of rhubarb. Tomatoes also in former days were forbidden in gout under the erroneous idea that their content of oxalic acid was high. Cucumbers, I think, when eaten raw, are apt to upset “gouty” people. Asparagus and onions should be taken sparingly, as they are rich in purins.

For “gouty” subjects, of all vegetables, the cruciferous or cabbage tribe is the most suitable, provided they are young, fresh, well cooked, and taken in moderation. In addition to its rich vitamine content, cabbage, like cauliflower and lettuce, is almost purin-free. The excessive intake of meat may often to some extent be counteracted by encouraging such gluttons to eat freely of green vegetables. In this way we obviate that sinking sensation which habitual overeaters suffer on limitation of their pabulum. Lastly, vegetable soups are most suitable, preferably those easily digestible, relatively poor in purins, or rich in potassium salts.

Of the roots and tubers even of potatoes the “gouty,” I think, should eat sparingly. The large percentage of starch in potatoes is apt to upset those of feeble digestion. Much depends on whether they are “mealy” or “floury,” and not “waxy” and “watery.” Steaming is the best method of cooking them. Turnips are best abstained from, and also carrots, parsnips, beetroot and radishes, save at any rate in minimal quantities.

Lastly, the legumes—peas, beans, lentils—because of their high purin content, should always be partaken of sparingly, though perhaps it may yet be found that their purin content may be more than compensated for by their contained vitamines. The edible fungi, mushrooms and truffles are best dispensed with.

Fruits are a valuable food for the “gouty.” They impart alkalinity to the urine, and promote intestinal action, always provided they are not partaken of immoderately or when unripe or overripe, when they are apt to set up gastro-intestinal irritation.

Most fresh ripe fruits are wholesome. Their content, too, of vitamines cannot be overlooked, especially that of oranges. Moreover, the fact that vitamines, as a rule, are destroyed at cooking temperatures seems to indicate that some uncooked food should on principle be taken daily by the “gouty” as well as others. Raw ripe fruits in this respect, like salads, have an advantage over cooked fruits or vegetables.

In my own experience I do not know that there is any fruit, even strawberries, that will infallibly disagree with the “gouty.” One meets now and again with gouty subjects who are unable to eat certain fruits with impunity, but one meets with quite as many of the same idiosyncrasies in the non-gouty. The objections to certain fruits, e.g., strawberries, as to certain vegetables, e.g., asparagus, are largely theoretical rather than practical. Let the subject’s own experience be your guide in this matter, or if he be unobservant, teach him to observe for himself what fruits, if any, disagree with him.

With this reservation I am of opinion that, taken in moderate quantity, fruits are most useful constituents of diet for the “gouty.” In some cases it will be found that they cannot take fruit when mixed up with other food, but both enjoy and derive benefit from it when taken by itself. It is well, again, in others to restrain their immoderate indulgence in lemons, as these frequently, as Sir James Goodhart pointed out, upset gastric or intestinal digestion. It is advisable also to warn them that plums, currants, gooseberries, and other fruits containing large quantities of free acids are apt to have the same effect, while the melon, too, is prone to give rise to gastric disturbance. Peaches and nectarines, on the other hand, are eminently suitable for the “gouty,” also apples, pears, oranges, grapes, cherries, etc.

Condiments.—These substances give a flavour and relish to food, while their carminative properties stimulate appetite and favour digestion. On the other hand, their excessive use is a potent source of gastric irritation. Thus, for example, they are valuable in atonic dyspepsia, though liable to aggravate a condition of chronic gastritis.

The most important and most extensively used is common salt. Some incline to think that its use by persons of the “uric acid diathesis” is prejudicial. But unquestionably it is a necessary and wholesome article for the “gouty” when taken in moderation. In cases of gout complicated by hyperchlorhydria strict moderation in or abstinence from salt seems indicated, this because, the HCL of the gastric juice being wholly derived from the chlorides of the blood, it seems irrational to increase the supply. Some therefore forbid its use both as a condiment or in the cooking of food, making the subject depend on the salts naturally present in foodstuffs.

Vinegar, I am sure, upsets some “gouty” persons’ digestion, and I think Sir Dyce Duckworth is right when he counsels abstinence therefrom. Thus some “gouty” subjects can digest raw cucumber, but not with vinegar. Others find salmon if combined with the same condiment upsets them, but not without. As to the various other condiments—mustard, pepper, horseradish, etc.—there is no objection whatever to their use by the “gouty” in moderation and in the absence of any definite gastric disorder.

So much for our consideration of the individual foodstuffs—their suitability or not—for the subjects of gout. That such a general survey is advisable may perhaps be conceded, but in so far as it may approximate to fixed rules it savours of evil, this at any rate as far as the dieting of dyspeptic derangements of the “gouty” is concerned. To bring into prominence my point, I would lay down the postulate that there is no specific form of “gouty” dyspepsia.

The gastric derangements met with in gout are in no sense peculiar thereto. In other words, they present no symptoms specific of gout, despite the term “gouty dyspepsia.” The term “hyperacidity” as commonly invoked is far too laxly used in regard to “gouty dyspepsia.” The “acid risings” of the “gouty” are of two kinds. Hyperacidity may be due to organic acids, butyric, lactic, or acetic, the outcome of fermentation, or the condition may be one of hyperchlorhydria, or excessive secretion of HCL.

Hyperacidity due to organic acids is met with in some cases of atonic dyspepsia, chronic gastritis, and dilatation of the stomach. The free HCL is either diminished or absent. Differentiation of this type from hyperchlorhydria may be impossible without examination of the stomach contents.

Hyperchlorhydria per se sometimes occasions pyloric spasm, and minor degrees of dilatation follow, this the more commonly as the subjects of gout are middle-aged or elderly. In others the dilatation is part of a general neurasthenia from which the “gouty” no more than others are immune.

Again, gout of long standing is often associated with chronic gastric catarrh. Such is very common in beer-drinkers or men employed in breweries. A state of atonic dilatation of the stomach is a common sequel. In these cases of chronic gastritis in the “gouty” the free HCL may be normal, diminished or absent. Eventually, as the result of oft-repeated gastritis, the parts involved undergo widespread fibrotic degeneration. Also we have to recollect that the “gouty” are very subject to obstinate gastralgias.

We see therefore that the “dyspepsias” of the “gouty” may be not only of varied nature, but may also demand differential dieting at different phases of their evolution. The subject in the early stages of his gout may suffer from hyperchlorhydria, while later chronic gastritis may ensue, with the reverse condition, hypochlorhydria. The protein dietary suitable for the former has in the presence of the latter to be replaced by carbohydrates, despite their tendency to fermentation. Again, if either condition be complicated by dilatation other exigencies must be met. The meal content must be light, not bulky, and the fluid intake restricted.

Again, the foregoing gastric disorders may be complicated by glycosuria or albuminuria, each with separate dietetic indications. How inevitably futile then must be any attempt at stereotyped diet for the “gouty.” In short, the dyspepsias and other morbid states of the “gouty” call for eclectic, not routine, dieting, and to this end I append a few suggestions.

SPECIAL DIETARIES

Amylaceous Dyspepsia.—Not a few “gouty” subjects suffer from atonic dyspepsia, with acidity due to organic acids arising from fermentation. Frequently it appears to be the outcome of some previously prescribed regimen forbidding all flesh food, or of too frequent or irregular meals or habitual overfeeding, food-bolting, excessive smoking, etc. Correction of such faulty habits is an essential prelude to any dietetic rules.

In such cases it is advisable to reduce the intake of starchy and saccharine foodstuffs, such as bread, potatoes, pastry, sugar, milk puddings, and the like. Bread should be stale, or dextrinised by dry heat, as in thin toast and rusks. Potatoes, if taken, should be in the form of purées. Sweet dishes should be partaken of sparingly, if at all. They should be encouraged to take the more digestible forms of meat and the lighter kinds of fish. Green vegetables and fresh ripe fruit, raw or cooked, are valuable. Fats of the more digestible sorts are also desirable. Grilled but not fried fat bacon is easily digested.

As to beverages, light China tea is more suitable than strong Indian kinds. Frequently I have found substitution of cocoa most beneficial. But in any case the amount of fluid at meal-times should be restricted.

As a guide to the formulation of a dietary in such cases the following may be suggested:—

On awaking in the morning a tumbler of hot water should be slowly sipped. A squeeze of lemon may be added if liked.

Breakfast.—Boiled or plainly grilled sole, whiting, or flounder, or a slice of crisp grilled bacon or lean cold tongue, or a soft-boiled egg. A slice or two of crisp dry toast or stale bread and a little butter. At close of meal sip slowly one cup of weak China tea, or the same of cocoa or milk and water.

Lunch.—Chicken or game, or lamb, mutton, or beef, hot or cold, roast or boiled. Gravy to be free from fat. One only of the former kinds of meat to be taken with a reasonable quantity of tender, well-boiled vegetables. Spinach, kidney or French beans, sea or Scotch kale, vegetable marrow, or salad may be taken, but without oil, vinegar, or beetroot. Dry toast or rusks. Half a tumbler of water sipped after eating.

Afternoon Tea.—One or two cups of weak tea with milk or one cup of cocoa.

Dinner (two courses only).—Fish of the kinds allowed for breakfast without potatoes, or a slice of any tender meat, e.g., saddle or loin of mutton or thick part of an underdone chop, or small portion of fresh game, without bread sauce or crumbs. One or two slices of stale bread or dry toast. A little well-stewed fruit or custard, junket, or jelly. Half a tumbler of water with from one to two tablespoonfuls of spirit if desired.

If there be any suspicion of chronic gastritis, condiments and stimulants must be renounced, but not in purely atonic dyspepsia, in which they are of value. In either disorder the patient should abstain from salted and cured meats, tinned foods, pastry, sweets, raw vegetables, and cheese. Before retiring a tumbler of hot water with a squeeze of lemon may be sipped slowly.

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.

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:—

“Make less thy body hence, and more thy grace; Leave gormandising; know the grave doth gape For thee thrice wider than for other men.”

There are so many dietetic methods of treating obesity that they cannot all be outlined here. The Banting method, like the Salisbury, is too severe for the average patient, while the Weir-Mitchell method has one cogent objection to general adoption, viz., the expense entailed. Nevertheless as regards the last-named, or skim milk, method, it certainly achieves marvellous results in those cases in which there is a mere accumulation of fat without any other complication.

Generally speaking, however, one has to be content with the following suggestions: All varieties of lean meat may be taken, as well as poultry, game, and fish, subject to idiosyncrasies and digestibility. Meat may be taken twice daily, not exceeding six ounces at one time. All starchy and farinaceous food is to be reduced to a minimum or wholly forbidden. Leaf vegetables may be taken freely, but the roots and tubers, such as potatoes, abstained from. Bread should be largely reduced in quantity and thoroughly torrified. Sugar must be prohibited, and saccharine or saxin substituted. Fresh fruits may be eaten, but milk should be avoided, also cream, or very strictly limited. Where feasible, it is often a good plan if the subject can for one day a week content himself with a diet of skim milk.

Alcohol, as far as possible, should be rigidly excluded, or only a very moderate quantity of good whisky or a light wine, such as hock or Moselle, permitted. As a rule, only a little hot water should be sipped at meals. But I think in these subjects of so-called “uric acid diathesis” it is well not to restrict their fluid too markedly. A pint of hot water may be drunk one and a half hours before each of the three meals, and one pint more half an hour before bedtime. Weak hot tea may be substituted, as many subjects find a difficulty in drinking so much plain hot water at one time. If while on this regime the subject lose weight and pari passu gain strength, all is well. If he lose weight and therewith lose strength, further reduction or its continuance is contra-indicated. It should be recollected that the reducing effects of dieting may be markedly enforced by an open-air life, with riding or other outdoor exercise.

Glycosuria.—This condition conjoined with obesity is not uncommon in middle-aged “gouty” subjects. It is of benign type, and the amount of sugar excreted is usually reduced to a mere trace by extraction of the carbohydrates in the food. Thus, we should forbid, e.g., sugar, pastry, sweet wines, and dishes made with flour, rice, or sugar. In these cases von Noorden considers that it is better after reduction of the amount of sugar by dieting to a mere trace to be content rather than to get rid of it wholly by a rigid elimination of all carbohydrates. To this end the patient may be allowed to eat a limited amount of bread, potatoes, and other vegetables, while he may eat freely of butter, bacon, and other fats.

One should recollect also that these “gouty” glycosurics have periods of enhanced carbohydrate tolerance, this, as Burney Yeo pointed out, quite “independently of any therapeutic interference.” In short, at times they can take quite a considerable amount of carbohydrates without passing sugar in their water.

Needless to say, the regime must be adapted to each individual case. The urine should be examined frequently, and the influence on the sugar content of different articles of food noted; also the weight should be frequently taken. It is certainly unnecessary in gouty glycosurics to wholly banish the carbohydrates. By such a plan we are more likely to do material injury than by exceeding by a little their limits of tolerance. Our remarks of course apply strictly to alimentary glycosuria. But we should also remember that exceptionally a case of gouty glycosuria may emerge into one of true diabetes.

Albuminuria.—In the so-called “gouty” contracted kidney, if the amount of albumen in the urine be very large, or when there are symptoms of nephritis, a milk diet for a few days or a week at a time may be given. More often it is unnecessary, or it is frequently badly borne or rejected. Consequently a modified milk diet has to be adopted, and a gradual return to a mixed diet permitted, provided no increase in the quantity of albumen ensues.

But at the same time it must be realised that no rigid rule can be laid down for “gouty” albuminurics. As a guide to the suitability of a diet it is better to rely on the general condition than on variations in the amount of albumen. For, as Professor H. Andrew Smith, of New York, long since said, “if on changing from a non-nitrogenous diet to a nitrogenous one we find a general improvement in the patient’s condition, it is an evidence that the change is beneficial, no matter if the albumen fills a larger portion of the test tube. On the other hand, if we cut off a large proportion of animal food from the diet, and our patient grows more dyspeptic, weaker, more anæmic, more dropsical, it is nothing to the point that only one half or one-third of the former quantity of albumen is found in the urine; the change has done harm, and the sooner we change back again the better. We should, above all things, seek that diet for the patient which he can best digest and assimilate, for we may rest assured that the products of faulty digestion and assimilation will irritate the kidneys more than any amount of normal material they may be called upon to eliminate, while, at the same time, the general system will suffer from lack of support.”

Lastly, up to this juncture all our suggested dietetic modifications have been in the direction of reduction or abstinence. But we must recollect that in practice we find that not a few gouty persons are most careful and prudent in diet. They commit no indiscretions, but nevertheless their gout is still with them. They are of the asthenic type, thin, pale, sallow, and given to neuralgic forms of fibrositis. They do not want “lowering”; to curtail their food is harmful. In their instance, with due respect to digestive idiosyncrasies, a more or less generous diet should be prescribed. Let them forsake dietetic schedules and follow their instincts. Let your advice be that of Sir William Temple: “Simple diet, limited by every man’s experience to his own easy digestion, and thereby proportioning as near as can be the daily repairs to the daily decays of our wasting system.”

BEVERAGES IN GOUT

It cannot be gainsaid that the beneficial effects of so-called “water cures” are in great measure referable to the increased amount of water ingested during their progress. Absorbed in the main in the small intestine, it passes into the general blood stream, whence it is excreted viâ the skin, kidneys, lungs, and fæces. Its elimination through these various channels sufficiently accounts for its value as a means of flushing the bodily tissues and hastening the excretion of retrograde and toxic products. Indeed, its efficiency as a depurative agent cannot be over-estimated, and nothing is more beneficial for the subjects of a “gouty” diathesis than regular consumption of an adequate quantity of this admirable solvent.

By general consent, the water ingested should be preferably hot. Water of a higher temperature than that of the blood stimulates the hepatic cells, and promotes biliary excretion. It has been shown, moreover, by Glax that while draughts of cold water raise vascular tension and diminish pulse frequency, on the other hand hot water diminishes arterial tension and accelerates the pulse rate.

It is also claimed that the increased elimination of water viâ the kidneys is correlated with an augmented output of the solid constituents of the urine; that the phosphates, sulphates, sodium chloride, and likewise urea are for the time excreted in greater amounts.

The point at issue, however, is whether or no this increase in the amount of urea excreted can be held to indicate enhanced tissue change in the nitrogenous elements in the body fabric.

Winternitz claims that it does, in contrast to Von Noorden, who holds that nitrogenous tissue change and the formation of urea and uric acid are uninfluenced by the amount of water imbibed. In further contradistinction some contend that following the ingestion of water the excretion of uric acid is diminished.

Fortunately for “gouty” subjects, the beneficial effects of water flushing of their systems occur independently of any coincident increase in their uric acid output. This is true even of mineral waters. Thus Bain and Edgecombe noted that following the ingestion of the old sulphur water of Harrogate the excretion of uric acid was diminished. Nevertheless cases of “gout, especially of the asthenic type, derived the most marked benefit from its use.” “This fact is mentioned,” they say, “because some writers attach the greatest importance to an augmented excretion of uric acid in the urine as a necessary concomitant of successful treatment. This we firmly believe to be an erroneous view.”

Indeed, ignorant as we are of the exact etiology of gout, we must at any rate provisionally attribute the proved efficacy of water-drinking in gout to its flushing action on the tissues, its furtherance of the excretion of waste products. Nor can we doubt that the ingestion of hot water, involving as it does equalisation of its temperature with that of the body, must exert a profound and intimate effect upon processes of cell nutrition. Moreover, through its solvent and penetrative quality, its mineral or chemical constituents are enabled to penetrate freely the interstices of the tissues throughout the economy.

It is, therefore, well to advise “gouty” subjects to drink daily on rising from eight to ten ounces of hot water, repeating the same half an hour before lunch and dinner, and finally the last thing at night. For in my experience “gouty” subjects on the whole do better if they drink some time before their meals than during their progress. It is an old belief that hard waters are unsuitable for the “gouty.” Sir Dyce Duckworth believed so, and Sir Charles Scudamore in 1823 delivered himself as follows: “The kind of water denominated hard has always been considered as unfriendly to health, and especially injurious to persons afflicted with gravel or stone. Many probably imagine that the earthy salts which it contains assist in making up the mass of the calcareous concretion.”

But more probably, as Sir Archibald Garrod suggests, the old view that tophi were composed of chalk had probably something to do with the origin of the tradition. That hard waters may be noxious in so far as they favour constipation may be granted. But, on the other hand, we have to reconcile with this the awkward fact that earthy or calcareous waters, e.g., those of Bath, etc., are among those whose efficacy in gout is beyond question.

Again, how can we reconcile with this view the prevalent practice of placing “gouty” subjects, temporarily at any rate, on a milk diet, this although milk is especially rich in lime? That a regime of milk in the young and robust “gouty” subject is often extremely beneficial is beyond question. On the other hand, it is equally certain that others do not thrive thereon. In prescribing it, therefore, we must be guided largely by personal idiosyncrasy.

Lastly, as to tea and coffee, there is a theoretical objection that both contain methyl purins. Albeit, it must be seldom indeed that gout is met with in pure tea-drinkers who at the same time abstain wholly from alcohol. Either tea or coffee, if taken apart from food, usually agrees well with the “gouty,” always provided that they be well made and not over-strong. Of the twain tea is, I think, more generally suitable than coffee, and where both disagree cocoa is an excellent substitute.

ALCOHOL IN GOUT

Said Sir Thomas Watson: “I am sure it is worth any young man’s while who has had the gout to become a teetotaler.” Few will gainsay the wisdom of this advice. But I would fain go further and impress on gouty parents the incumbent duty of bringing up their children as total abstainers. For gout, once avowed, has a vicious tendency to recurrence. The illustrious Sydenham, I think, would have approved of such advice: “Water alone is bad and dangerous, as I know from personal experience. When taken as the regular drink from youth upwards it is beneficial.”

When, however, gout attacks a man for the first time in middle or late life, most authorities agree that an abrupt change of habit in respect of stimulants is of questionable wisdom. In saying this, I do not for one moment mean that excess should be approved, but that I do not believe that the enforcement of total abstinence is prudent. In such cases restriction, not total elimination, is the better course. One must recollect, too, that total abstainers are by no means exempt from gout, while, on the other hand, many, if not the majority, of drunkards are. The latter have their penalties, cirrhosis, etc., but not inevitably gout.

I agree that gout is infinitely more common in those who take alcohol than in those who abstain therefrom. But nowadays, at any rate, the “gouty” as a class cannot with fairness be ranked as among the confessedly intemperate. With relatively few exceptions, they belong rather to those given to what may be termed the legitimate use of alcoholic beverages. My conclusions then are that:—

(1) The children of “gouty” parents should be brought up as total abstainers.

(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—

(1) It be a “light” beer, in which the “bitter” principles predominate, and the extractives are small in amount;

(2) It be “sound” and not “turned” beer, and of course free from any possibility of lead impregnation;

(3) It be taken in moderation, not exceeding one to two pints per diem;

(4) The “gouty” subjects by whom it is taken be physically active;

(5) Due respect be paid to personal idiosyncrasy, reserving its use for those in whom its effects are definitely stomachic and tonic, while discountenancing its use when followed by heaviness, drowsiness, and biliousness.

As to cider, there is no doubt that the partially fermented or sweet variety is more harmful than “dry” or “rough” cider. Still there is no room for dogmatism even here, for a “gouty” man, if he be unaccustomed to cider, may find that, whether “dry” or not, it may provoke an attack. Sir Archibald Garrod tells us that he has known not a few gouty patients who alleged that cider suited them admirably, but he adds: “An experience of some months has usually modified their opinion on this point.”

Wines.—When we come to consider wines, we are on very uncertain ground, this especially if we base our opinion too much on the chemical analysis of this or that variety. The current belief is that the most unsuitable wines are those that contain large amounts of alcohol, sugar, or free acid. Then we discover it is not the amount of alcohol in the fluid that determines the incidence of gout and, in witness to our perspicuity, call to note the rarity of gout in Scotland, where whisky is the favourite beverage; ergo whisky par excellence is the drink for the “gouty,” and so we find ourselves in this impasse: we fulminate against alcohol as the cause of gout, and in the same breath advise our “gouty” patients to drink precisely those fluids containing the highest percentage thereof.

True, when we turn to wines we find that it is precisely those that are richest in alcohol that most potently predispose to gout, e.g., port. But seeing that whisky contains infinitely more alcohol than port, and yet is little gout-provoking, we search round for some other constituent in wine on which to lay the blame. So we decline on the varying degrees of acidity in different wines. But this again on reflection, it is decided, is of little moment. For, on the one hand, port and sherry are among the least acid wines, and yet, like the even less acid malt liquors, most productive of gout, while, on the other hand, the more acid clarets and hocks are deemed relatively harmless. Then the varying quantities of sugar in the different wines come under the ban. But here again no definite line can be drawn. For some wines most provocative of gout have a high sugar content, while others equally potent in this direction contain but small amounts.

Now the most salient deduction from the foregoing considerations is our inability at present on chemical grounds to determine why certain wines are productive, and others are relatively nonproductive, of gout. We can impeach neither the alcohol content, the acidity, nor the sweetness. For on all these points startling exceptions preclude dogmatism. Does not the clue to these varying reactions quâ gout reside in the individual, not in the character of the wine? We are far too prone to say that this or that wine is “gouty,” to say that this wine gives you gout, and that not.

The evil potentialities that make for gout reside not in this or that particular wine, but in the individual. This or that wine does not give him gout, but evokes or brings to fruition a morbid tendency already latent in him. In the absence of this inherent proclivity, it would not have elicited those specific local reactions typical of gout. But for those who would interpret this statement as approval on my part of alcohol or an absolving thereof from any part in the genesis of gout I would issue this caveat: Alcohol will not originate gout in a non-gouty subject, but it will almost infallibly in those in whom there exists by heredity an inborn tendency to gout. In short, the “gouty” are hypersensitive to the evils of alcohol; the greater the need then for abstemiousness and self-restraint.

But, to resume the thread, in the absence of any absolute chemical criterion as to the relative suitability of this or that wine for the “gouty,” what shall be our advice to the “gouty” individual on this point? In a word, his “palate” and his “stomach” are the best criteria of the wholesomeness of this or that particular wine in his particular instance. If he is in the habit of taking wine do not forthwith, as is so often done, forbid him wine in all forms and order him whisky. This is done so light-heartedly that I do not wonder that the subject goes away frequently with the idea that whisky is not only innocuous, but desirable.

The whisky-drinker is not immune from gout, and I have no hesitation in affirming that “light” wines when fine, mature, and of a good quality are, subject to individual idiosyncrasy, quite as suitable for the “gouty” as whisky. Of the many wise warnings given us by Sir James Goodhart none is more apt for the present day than the following. Discussing the “treatment of uric acid,” he observes: “I am as much as ever an opponent of the prevalent dictum, ‘You must not touch wine; you must drink whisky,’ which too often means to the patient, ‘A glass of good wine is poison; I may take as much whisky as I like, and it is harmless,’ one of the most mistaken and mischievous beliefs that ever plagued a world.”

Again, if a “gouty” man takes wine, there is always one special variety that agrees with him, and as certainly one other or more that infallibly upset him. Putting aside all preconceived ideas, find out his personal idiosyncrasies in this respect. In this way you elicit and utilise for your ends the individual’s own experience, the only experience that counts.

A man of a certain age, he generally by the time he develops overt gout has arrived at definite conclusions as to what does and what does not suit him. He will frequently tell you he has had to give up malt liquors, perhaps port and champagne, and now finds that whisky, gin, or the lighter wines agree with him better. Or, as like as not, he may upset all your preconceived ideas. He may be of those gouty subjects—and they are not so few—who can drink champagne in moderation, or even a glass or two of port, daily with apparent impunity. On the other hand, a glass of claret or hock plays the mischief with him. He may, like some individuals cited by Burney Yeo, be one of those exceptional gouty subjects in whom even stout is well borne, Yeo thought largely because they habitually took daily large quantities of alkaline salts.

The sum of these erratic findings is that you must respect idiosyncrasy. It is said that the best wine for a “gouty” subject is the one that causes most diuresis. For myself, I am equally positive that the worst wine for a gouty man is that which upsets his stomach, which gives him some hours afterwards “acidity” or a feeling of “liver.” Often, too, it is not the wine, but the stomach into which it is put, that is to blame. Thus the “gouty” subject with atonic dyspepsia finds a glass of sound wine helps digestion. On the other hand, if he suffers from hyperacidity or chronic gastritis, the reverse will probably be the case.

Again, it is not the name, but the quality, of the wine that counts. It makes all the difference whether the wine taken is fine, mature, and of good quality, or some factitious, mixed, or adulterated product, passing muster, say, as claret. Fine mature clarets or red Bordeaux wines are most suitable for the gouty. But, as Burney Yeo rightly says, “a more injurious beverage than bad claret or imperfectly matured claret—and, speaking generally, all but the more expensive or most carefully selected clarets are bad—was never drunk.”

It seems opportune here to lodge a protest against fashions in wines for the “gouty.” At one time it was claret, then light white wines, Moselle, etc., and anon whisky, and even cider had its vogue. Fashions in wines, as in other spheres, postulate uniformity and lack of discrimination. Any one of the foregoing beverages may suit some particular “gouty” individual, but not all “gouty” subjects.

We have said that in some instances the wine, in others the stomach, is at fault. But intrinsically it may lie in neither, but simply in the quantity of the wine drunk. It may not, as judged by ordinary standards, be an excessive amount, but it may be excessive for that particular man. It is here that a medical man may often intervene with advantage. For a man may, quite unbeknown to himself, be really a heavy drinker, one of those unfortunates who are peculiarly tolerant of alcohol. A tactful reminder of the amount he is consuming per diem will frequently come as a shock, often a very beneficial one.

Apart from this, it is, I am sure, wise to fix the daily amount. The daily habit in the “gouty” is all-important. If accustomed to take one or two glasses, and they stick to it, all may be well; but it is on the occasions when the glass grows into a half-bottle that the trouble comes. Metabolically speaking, the “gouty” subject is most unstable, and disturbance of what one may call his daily alcoholic rhythm is always perilous. Unfortunately it works either way, too, both in the matter of “too little” as well as “too much.” Here experience and sound judgment will alone enable the physician to decide how far he may tamper with long-established habits.

At other times the amount, though, strictly speaking, not excessive, is so when judged in light of the victim’s habits. He may be an intellectual worker, but sedentary, and he must either lessen his drink or increase his exercise, or he may overeat as well as overdrink—a victim of the prevalent idea that the one evil counteracts the other. Between the Scylla of overeating and the Charybdis of overdrinking there is no safe course save by way of reduction of both.

We see therefore that in the matter of the choice of a wine for a “gouty” subject there are many points to be considered. Of these personal idiosyncrasy stands first. By this criterion, and none other, can the suitability of the wine be decided. Then the state of the digestive functions, if deranged, has to be considered. Is the gastric disorder such as will be benefited or, on the other hand, impaired by wine of any sort? Again, glycosuria, albuminuria, raised blood pressure, or cardiac degeneration may intervene to complicate the issue, and so our policy in regard to alcohol has constantly to be adapted and readapted to the varying requirements of the organism.

It will be seen that I have largely refrained from specifying the wines suitable or unsuitable for the “gouty.” To have done so would have been alien to the general tenor of my remarks, convinced as I am that our trend in the matter of alcohol for the “gouty” should be more in the direction of “individualisation” than of “standardisation.” Subject to the reservations that such an attitude portends, I would proffer the following suggestions:—

As a general rule, wines which are “dry” are much more suitable for the “gouty” than those which are “sweet.” Wines are termed “dry” when nearly all the sugar of the grape is transmuted into alcohol, as in “dry” sherries. They are termed saccharine or “sweet” when the process of fermentation is arrested before all the sugar has been exhausted, as in Malaga. Again, wines which are both “strong” and “sweet,” e.g., Malaga, sweet champagne, Tokay, etc., are more pernicious than those which are “strong” yet “dry,” e.g., port, sherry, Madeira.

Sir James Goodhart, discussing wines suitable for the “gouty,” confesses to a “personal leaning in favour of the wholesomeness of a glass of good old sherry in those cases where a little wine seems a judicious prescription.” With this I fully agree, and would suggest that of sherries the “gouty” should favour the “Manzanilla” rather than the “Amontillado” class. The former, save for the addition of a small quantity of spirit, are mostly shipped in the natural state; also they are light and “dry” as compared with the latter, which are generally “sweet” and full-bodied.

It is interesting to recall, too, that Sydenham regarded sherry as preferable either to Rhenish or French wines. He himself in his own person found “sack” or Canary the most helpful. “I have during the fits of the last years tried many things to lessen the symptoms. Nothing, however, effected my purpose so much as a small draught of Canary wine, taken now and then, when the faintness or sickness were most oppressive.” Here one may note that sherry was the first wine to be known as “sack” in this country, and that the wine shipped in Sydenham’s time was of the “dry” variety. Chemically the “sweet” sherry differs from the natural “dry” light wine through its relatively high content of alcohol and sugar.

Turning to port, Sir Alfred Garrod absolutely tabooed its usage by the gouty. But this appears too sweeping, and nowadays, at any rate, it is well recognised that, especially in asthenic types of gout, a glass or two of old port is well borne. Consequently in such cases we should not, in the absence of any adverse symptoms, forbid its continuance. The bad reputation achieved by port is, I am sure, a relic of the Regency. But “three-bottle” men are no longer with us, and, allowing for personal idiosyncrasy, I very much question if sound port taken in moderation wholly merits the aspersions cast upon it. I do not by that for one moment suggest its general adoption by “gouty” people, but that where an old or elderly gouty subject takes port and can be trusted not to extend his glass to half a bottle his inclination may be respected. The sugar content of port varies according to the vintage, ranging from 7 to 15 per cent., and the “gouty” man should favour the “drier” varieties.

As for champagne—a manufactured article rather than a natural wine—there is no question that, if taken at all, it should be a “dry” brand. Such contains from 9 to 12 per cent. of alcohol and from 1 to 4 per cent. of sugar, whereas the “sweet” brands may hold as much as 16 per cent. All depends on the quality of the champagne, and, as Ewart wisely remarks, “it is wiser for the ‘gouty’ patient not to incur considerable risks by trying brands with which he is not familiar, though he may sometimes with impunity, and occasionally with benefit, enjoy a glass of champagne which he can trust from personal experience.”

If, on the whole, the most unsuitable wines for the “gouty” are the strong sweet spirituous or liqueur wines, on the other hand the red or astringent and white wines are the most esteemed. As to the red wines, there is no doubt that the delicate Gironde (Bordeaux) wines are par excellence the most suitable. They have sufficient body and alcohol without being heavy or fiery, while their acidity and sugar content are very low. But of course the quality of the wines varies considerably with the vintage. Subject to this, sound, well-made clarets taken in moderation and somewhat diluted with water are the most wholesome wines we can prescribe for the “gouty.”

The more full, though still not coarse, wines of the Burgundy district are by some denounced. One authority, I note, states that in elderly gouty subjects he had often found that two or three glasses of claret or Burgundy were in the course of a few hours followed by eczema. While such idiosyncrasies may obtain, it is not true of the “gouty” as a class. I should consider a “gouty” subject in any case unwise to take two or three glasses of Burgundy. But I do not hesitate to order one or perhaps two glasses somewhat diluted with water. Being a stronger and more tonic wine than Bordeaux, it is useful in the more asthenic types of gout. The pity is, of course, that the cheaper Bordeaux and Burgundy wines are so largely adulterated, while the more mature clarets are available only for the rich. As good substitutes for French wines Burney Yeo commends the red Hungarian wines, such as Carlovitz, while we may add that some of the Dalmatian wines are of fair quality and somewhat resemble Burgundy.

Reverting to white wines, these, as compared with the red wines of the Gironde, contain less tannin and more free acid. According to Burney Yeo, they exert, too, a more diuretic effect, and to remove their excessive acidity he advises their dilution with some alkaline table water. Most of the white wines come from the Rhine or Moselle districts. The Rhenish are relatively full-bodied and of marked vinosity, while the Moselle wines are mostly light and of a somewhat delicate nature. Light hocks and still Moselles are quite permissible, also the white wines of France, such as vin de Grave, all varieties of the latter being fairly “dry” and light in character. On the other hand, the white wines of Sauterne, like some of the Hungarian wines—i.e., Ruster—are rich in saccharine constituents. In this respect they contrast with the Rhenish and Moselle wines. Of these last Johannisberg contains only 0·42 per cent. of sugar, Rudisheimer 0·39, Zeltinger 0·13, and Stein-Reisling 0·01, while Ruster contains no less than 21·74 per cent. of sugar.

In conclusion, I would re-emphasise the fact that, if wine be taken, the patient’s own experience is the best test as to which particular wine is the most suitable in his case. This elicited, the subject should be counselled to adhere to it, taking it only at meal-times, and establishing a rigid rule as to quantity. The least excess is harmful, and breaking of the ordinary routine in the matter of the amount drunk is a fertile source of “gouty” outbreaks. In any case the quality of the wine should be above suspicion, and if the expense is prohibitive, he had best eschew wine altogether in favour of mature spirits.

Spirits.—Brandy, whisky, and gin are the spirits most in vogue in Great Britain, and it has become an axiom with some that, if alcohol in any form be requisite for the “gouty,” the least harmful is one or other of these beverages when adequately diluted. Of the three whisky undoubtedly has found most favour, and the pernicious and far too prevalent idea is that whisky not only does not beget gout, but is actually beneficial for gout. The consequence is that many “gouty” people take far more whisky than is desirable, seemingly oblivious of the fact that, if whisky in moderation be suitable for the “gouty,” whisky in excess is as deleterious for them as for the non-gouty. In short, like any other form of alcohol, if taken immoderately, it will bring to fruition a latent gout, this, as suggested by Ford Robertson, not by the direct action of the alcohol, but by the “indigestion toxæmia” it sets up.

In advising therefore a “gouty” subject to take whisky we should insist that (1) it should be taken only at meal-times and (2) only in moderation. The habit of occasional “nips” at all times of the day should be unreservedly condemned. As to what constitutes a moderate quantity is often a difficult question to decide.

When feasible, I endeavour to limit the daily allowance to a wine-glassful, distributed over lunch and dinner. But it is quite impossible to lay down hard and fast rules in a matter in which personal idiosyncrasy plays such a strong rôle. Frequently, in addition to the above amount, one has to relent to the extent of a “nightcap,” or but too commonly one has to be content if one can compass reduction to an amount which for the particular individual under review seems apparently compatible with no appreciable damage to health.

Sometimes one of the frequent accompaniments of gout comes to our assistance. It may be raised blood pressure, glycosuria, albuminuria, obesity, etc. In such cases a word in season may reduce an otherwise recalcitrant subject to reason.

Needless to say, in regard to “ardent spirits,” as to wines or malt liquors, we must, when determining the quantity to be taken per diem, review the same in light of the person’s habits, whether active or sedentary, whether associated with overeating or not. For manifestly all these bear on the point at issue.

Lastly, as to whether the subject should take brandy or gin in preference to whisky is a matter for himself to decide. Whichever suits him best is the best for him. Albeit, I confess to a leaning in favour of “dry Plymouth” gin, this being more diuretic than other spirits by reason of the juniper contained therein. But, in whatever form “ardent spirits” be taken, it is most essential that it be sound. Brandy should be of the finest quality, the whisky mature, and inferior kinds of both wholly eschewed.