Carbohydrates

The fact that gout is unknown in countries like Japan, where a strict vegetarian diet is common, clearly proves that, as a class, carbohydrates can by no means be the direct cause of the disturbance of metabolism characteristic of gout. On the other hand, taken in considerable amount and with rich, nitrogenous foodstuffs, their use is frequently accompanied by some evidence of local disturbance in the alimentary canal, or general disturbance of metabolism in the tissues, either of which may be characteristic of a gouty condition. When this tendency is pronounced, the sum of the local and general effects produces typical gout in a more or less acute form, the manifestations depending on the age and constitution of the individual. In other subjects we find manifestations of irregular gout, and these, when well marked, may be regarded as equally typical of the gouty condition.

Carbohydrates, and especially those of the saccharine group, are as a class to be regarded as more potent noxious agents than meat. A good rule with regard to them is to reduce the amount and simplify their form. Much information as to the diet appropriate for cases of gouty disorders may be obtained from the application of the test of the "pancreatic reaction in the urine" (see p. 377). A marked positive reaction is a special indication to restrict the carbohydrate and saccharine foodstuffs.

Saccharine foods and dietetic accessories, e.g., jams marmalade, sugar, sweet cakes, are only to be partaken of occasionally and in small quantity, and in not a few cases, especially of stout adults, are to be studiously avoided.

With regard to the strict vegetarian diet so eloquently advocated by Haig and others, the good effects undoubtedly derived in many instances depend, in the writer's opinion, on the simplicity of the whole diet, with the limited quantity of the chief nitrogenous ingredients, these being the two primary essentials in the dietetic treatment of confirmed gout. The following illustration may be given (Haig): -

Breakfast

1 pint of milk.

Bananas.

Apples.

Pears.

Plums (fresh, dried, or cooked).

Any other fresh fruit ad libitum.

Lunch

Vegetable soup made with milk.

Plate of potatoes (with butter, oil, or milk).

2 ounces cheese, eaten with potatoes and any other vegetables in season. Stewed fruit or tart. Fresh fruit 1 pint of milk drunk during the meal.

Dinner

Much as Lunch. I pint of milk. I ounce cheese.

A close analysis of this diet, which is recommended for a person in health, shows that it is not quite so simple as at first sight apparent, and while a diet for the gouty framed on very similar lines is undoubtedly a very beneficial method of treatment in some cases, in others it is altogether unsuitable; see also "Lacto-vegetarian diet" (p. 520).

Popular belief, partly supported by medical opinion, condemns potatoes, but if used in moderation, and cooked and served with due precaution, there is no reason for prohibiting them, except in those special cases where they are definitely determined to be unsuited to the digestive capacity.

When new and moist they are indigestible; the best form is a well-boiled mealy potato in its skin, or the same put through a potato masher. A thoroughly well-baked potato is also good. When fried, or roasted in mutton dripping, or mashed with milk and butter, they are unsuitable in most cases. The other roots - turnips, carrots, parsnips, radishes, beetroots (also rich in sugar), artichokes, also cabbages, curly greens, brussels sprouts, broccoli, and the green of cauliflower - should only be taken in small amount on account of their tendency to induce flatulence, etc. The following are more suitable: Spinach, flower of cauliflower, savoys, endive, lettuce, watercress, kale, leeks, onions, celery, cucumber, vegetable marrow, green peas, French beans. Asparagus has been condemned by some writers on account of the nucleins in the young shoots; also tomatoes and sorrel on account of the acids present; but, as many typically gouty subjects can partake of them freely, it is probable that these objections have only theoretical importance.

The green vegetables above mentioned can be freely partaken of in the form of salads, provided oily dressings and hard-boiled eggs are avoided. Mushrooms and truffles and other fungi are quite permissible in small quantities. The pulses (lentils, peas, beans, haricot beans) are not as a rule advisable, because it is not an easy matter to make the patient realise that their nutritive value is such that their use must influence markedly the amount and quality of the other articles consumed.

With regard to puddings, the simpler the better. Milk puddings, such as rice, sago, semolina, ground rice, etc., should be made without eggs in many cases. Suet puddings of all kinds are as a class to be avoided, but if made with breadcrumbs in place of flour, well boiled, and unaccompanied by a heavy sauce, they may be taken. If custards and omelets, sweet or savoury, are taken, the nutritive value of the eggs must be recognised. Jellies, blancmanges, lemon sponge, and creams may be taken in very sparing amount, and, as with other foods, a wise discretion is necessary both by the physician and by the patient. Fruits of all kinds in themselves are permissible, but must be taken with caution, especially in later adult life, and it is well to bear in mind the old saying, " Fruit is golden in the morning, silver at midday, and lead at night." Much depends on the amount of sugar used in the cooking and the accessories used at table. Crystallised fruits are quite unsuitable on account of the large amount of sugar present. For the same reason special care has to be taken with regard to dried fruits, such as plums, raisins, dates, and figs.