No hard-and-fast lines as to dietary can be laid down in the treatment of gout. Each individual must be carefully considered as regards his habit of body, his capacity for the digestion of different articles of food, the amount of exercise he is able to take, and the nature of his work. Derangements of the gastro-intestinal tract constitute a most important factor in the development of acute, chronic and irregular gout; in all forms of gout, whether regular or irregular, there is one invariable symptom, viz., digestive disturbance. It is, therefore, of the utmost importance to secure and maintain a healthy condition of the gastro-intestinal mucous membrane, and a normal daily evacuation, in order to guard against autointoxication, which is undoubtedly an early factor in the development of the gouty condition. The individual who is subject to gouty attacks can certainly diminish the number and severity of the attacks, and in many cases can prevent their recurrence, by careful attention to diet, to the quality and the quantity of fluid taken, to exercise, and to a sufficient daily action of the bowels.
Gouty people may for the purposes of the consideration of diet be roughly grouped into three classes : -
(1) Those who suffer from more or less frequent attacks of acute gout; (2) those who have never suffered from an acute attack, but who are constantly subject to some chronic form of regular or irregular gout, especially after slight indiscretion in diet; and (3) those who are only affected with gouty symptoms (generally of the irregular kind) when they eat or drink certain articles, and who therefore in order to avoid these gouty symptoms have to be specially watchful over their diet. As Mouillot has observed, it will usually be found that patients in classes 2 and 3 are the offspring of those who have suffered from acute gout.
In advising as to the diet of any particular gouty individual the personal factor is a most important one to consider, and it is wise to gain some knowledge as to the likes and dislikes of the individual with regard to food. In this connexion it is well to remember the saying of Sydenham, that " more importance is to be attached to the desires and feelings of the patient, provided they are not excessive, than to doubtful and fallacious rules of medical art".
It is well known that the excessive consumption of rich nitrogenous food, combined with excesses in wine and malt-liquors, both induces and excites gout. The comparative immunity of females and young people from gout is mainly explained by the absence of such determining causes of the gouty attack, combined, in the case of young people, with the absence of predisposing cause, and also with the fact that the secreting functions are in full activity. The subjects of gout are generally persons who live well and consume a large amount of animal food. Budd, speaking from a long and extensive professional connexion with a large rural district, states that he never knew an instance of gout occurring in an agricultural labourer.
Gout, which is a toxaemia originating to a great extent in the alimentary tract, derives its toxic products from the improper digestion of food-stuffs. Whatever articles of food can be properly digested by the gouty, are therefore suitable articles for their dietary. The physical condition of an article of food to a very great extent determines its digestibility. By digestibility is meant not necessarily the extent to which it is absorbed into the blood, but the power of disposing of the food by the stomach, without the production of discomfort or pain. The digestibility of the various kinds of fish, and of the flesh of birds and animals, depends on the length of the muscular fibres, and on the amount of fat deposited between the fibres. The shorter the fibres, and the smaller the amount of fat deposited between them, the more digestible will the article of food be.
If an article of food tends to be swallowed in a solid lump, such for instance as new bread or new potatoes, so as to prevent the ready permeation of the substance by the digestive juices, it tends to be indigestible purely by virtue of its physical condition. If such article were first reduced to minute subdivision by thorough mastication and insalivation, its indigestibility, as far as ordinary individuals are concerned, would disappear.
It is not so much a matter of importance to know whether any particular article of food contains uric acid or its antecedents or not, as it is to know what its properties are as regards digestibility and as regards its influence on the processes which are concerned in the conversion of food-stuffs into body-stuffs. The researches of Pawlow have shown that the food value of any particular article of diet must depend to a large extent upon the amount of energy necessary for its digestion.
If gouty persons partake of meals of too complex a character, then, owing to the abnormal intestinal and hepatic metabolism of such subjects, excessive production and imperfect elimination of toxic products may result. Although both excessive production and imperfect elimination of these abnormal products of digestion go more or less together, yet it is a matter of fairly frequent observation that some gouty persons seem to be specially the victims of excessive production of toxic products, and others to be mainly affected by defective elimination.
In regulating diet it is very important to bear in mind that it is in many cases not advisable to change too suddenly the diet to which the patient is accustomed. The composition of the various digestive secretions is adapted to the food they have to digest, so that the individual who habitually eats an excess of protein in time comes to have gastric and pancreatic secretions which will digest protein well, and if the carbo-hydrates of the food have been limited he will also have a limited capacity for their digestion; so that if a sudden change of diet is ordered, it takes a little time for the constituents of the digestive secretions to adapt themselves to the altered food, and in the meantime the patient may feel worse for the change of diet which will ultimately benefit him. The diet suitable to any patient will depend on the digestive capability of that patient, and should be regulated accordingly; it is important to remember to treat the individual as well as the disease.