Fish are well calculated to form a large proportion of the dietary of the gouty. They contain on an average one-third less nitrogen than an equivalent amount of ordinary meat, and usually contain little or no fat. Fat fishes (salmon, mackerel, eels, pilchards red mullets) are equal in nitrogenous value to an equal amount of moderate fat beef. There is a very large proportion of water in the flesh of fish. When ordering, it is well to suggest those known to be in season and plentiful, as they will probably be in the best condition. As has already been mentioned, many nutritious soups can be made from them.
Before leaving the subject of meat, reference may be made to the value of an exclusively red-meat diet in certain cases of chronic gout. The essentials of this treatment are the drinking of three to four pints of hot water daily, a pint to be taken before each meal, and the same quantity at bedtime, and the administration of one to three pounds of meat in the twenty-four hours. The details of this treatment are given elsewhere (p. 534).
As in the case of various other foods, there is much difference of opinion as to the value or necessity of a diet composed largely of milk, milk products and vegetables. In many cases a course of a strict milk diet is the most suitable, particularly in young and otherwise healthy subjects, but it is much less suitable for adults and the aged. Milk is highly nutritious, and when it is easily digested and no undue fermentation processes induced by its use, a limited course of milk diet is to be commended, the amount and duration being regulated by the effects on the digestive system and by the attitude of the patient towards it. Alkalinity of the urine is favoured or increased by a full milk diet, yet an exclusively milk regime is probably in the main unfavourable. However, there is no doubt that the children of gouty parents should be brought up systematically on a diet in which milk and its products are the staple, and meat given in very limited quantities. This is specially important in those by no means infrequent cases where there is, in addition, a marked neurotic strain in the family. With the active and fixed habits of later life a meat-free diet is very rarely practicable, and is very seldom called for.
Cream, forming as it does the most appropriate form of fatty food in the dietary of the aged, likewise constitutes an excellent form of fat administration in gouty subjects. It should preferably be taken with milk pudding or stewed fruit in an otherwise simple meal, or it may be used in the preparation of chicken cream, fish cream, or in various combinations with vegetables, when it takes the place of butter.
Skimmed milk is more digestible than ordinary milk in all cases where fat is not readily digested, but in recommending it as a beverage or food regard must be paid to the amount of proteins and lactose present in it.
Whey is a useful article in many cases. It is a pleasant and stimulating drink, with a certain food value from the lactalbumin, lactose, and mineral matter present. In some cases whey with cream make an admirable combination.
The pure caseinogen of milk, now prepared by the Protene Company in the form of a flour, and made into biscuits and bread, is an appropriate form of protein administration. The taste, however, is an acquired one (p. 158).
There is no reason why cheese should be forbidden. The ill-effects frequently attributed to it arise from the manner in which it is taken at the end of a meal, already excessive and badly assorted. Being a rich, albuminous food, and varying in the proportion of fat present according to the variety of cheese, it should not be taken in large quantity; it should be well masticated, and it should be carefully distributed through the various vegetables or breadstuff's of the meal.
It is well to recommend patients who are very fond of cheese to partake of one of the softer varieties, as, although less digestible, they are much less likely to be taken to excess (see p. 42).
Eggs are an excellent dish for the gouty, and should form one of the staple breakfast dishes. They also constitute a very appropriate food constituent for the children of gouty parents, in whom the consumption of meat, and especially red meats, should be very limited indeed. It is well to remember that a hard-boiled egg takes three hours, and a soft-boiled or raw one, from one and a half to two hours for complete digestion.