Fresh fruits and vegetables are generally to be recommended for the nourishment of the gouty. But such as contain oxalic acid and its compounds (rhubarb, pie-plant, beets, spinach, sorrel, etc.) should be avoided because of the tendency of the acid to attack the tribasic phosphates in the tissues, reducing them to the condition of soluble acid phosphates which quickly appear with oxalate of calcium in the urine, to the decided detriment of the patient. This, it should be remembered, is not the only source of oxalic acid in the body. Whenever the oxidation of uric acid is retarded oxalic acid appears ; consequently, the presence of oxalates in the urine is indicative of imperfect combustion of nitrogenous compounds iu the tissues, unless it can be shown that their presence is only the accidental result of a diet that is surcharged with those salts.
From these observations, then, it appears that a nitrogenous diet is the form of aliment that chiefly predisposes to the occurrence of gout ; but that the excessive consumption of starches, sugars, and fats —the alimentary carbohydrates and hydrocarbons in general—may indirectly effect the same result by impeding the oxidation of nitro genous compounds. This, however, is not likely to occur, excepting ill the case of individuals who consume large quantities of nutritious food and do not by active exercise promote the full exchange of oxygen in their tissues.
In his valuable work on "Uric Acid in the Causation of Disease" (second edition, 1894) Haig has shown that uric acid as excreted nor mally in the urine is derived from the oxidation of nitrogenous • stances that have been received into the body, and also from the urates that are always present in the meats, soups, gravies, etc., that are ingested with the food. It thus becomes possible to vary the quantity of urates that are excreted in the urine, and to study at pleasure the effect of artificially loading the blood with uric acid, or the reverse. When the blood is thus overcharged, the quantity that passes into the urine, if due alkalescence of the circulating fluid be maintained, is sufficient to clear the system in a short time; but, if the blood be in any way rendered more than normally acid, the sur plus urates are retained in the tissues, are not conveyed to the kid neys, and do not appear in the urine. When this occurs in a suscep tible individual, pricking pains may be felt in the joints, an attack of headache may be experienced, and other of the premonitory symp toms of gout may be developed. Thus it can be shown that many of the phenomena that are associated with gout can be produced by the ingestion of uric acid and the nitrogenous compounds out of which it is formed in the body.
From the remotest antiquity the deleterious influence of wine and other fermented beverages upon the production of gout has been a matter of constant remark. Sir A. Garrod inclined to the belief that acute gout could not exist in their absence. It is not, however, by virtue of the alcohol which they contain that these liquids exercise their baneful influence. The inhabitants of southern Europe, who drink large quantities of wine, seldom suffer with gout. The same thing is true of the consumers of brandy and whiskey in northern Europe and Scotland. They are victims of alcoholism to a frightful degree, but of gout—hardly ever. In fact, the chronic gastritis that has its origin in the use of distilled liquors destroys the appetite, and effectually prevents that inordinate consumption of food which is one of the prime requisites for the evolution of gout.
Among the wines that are used upon the tables of the rich, the researches of Garrod have also indicated a difference. The rare old crusted ports and sherries lead the way as the most efficient adju vants in the production of gout. Then, at a considerable distance, may be placed the lighter wines of Burgundy and Champagne ; last of all those of the valley of the Rhine and its affluents. Still, it is an interesting fact that in the wine-growing countries the laborers who indulge to excess in their use do not become gouty—they sink into a condition of chronic alcoholism. Only those who at the same time over-eat and over-drink themselves fall victims to the arthritic disease. Sweet and effervescent wines do indeed aid in its develop ment, but they cannot create the malady without the concurrence of an immoderate consumption of flesh and the other dainties of the table. It must never be forgotten that gout is not the consequence of alcoholism but of gluttony. For this reason the use of malt liquors is especially injurious. Porter, ale, and beer contain a considerable quantity of sugar, dextrin, etc., besides the alcohol that is present. The lower price at which these beverages are furnished leads to their inordinate consumption—sometimes to the extent of forty to sixty glasses a day. Budd stated that among the watermen of the Thames
it was a common thing to drink twelve quarts of porter every day. Naturally they rapidly became gouty, though not handicapped by hereditary predisposition, since the majority of them were Irish, who were brought up in abstemious poverty. Scudamore, 'Watson, Todd, and other English authors have noted the strong predisposition to gout that prevails among the people who contract a fondness for porter. Similar results have been remarked in Holland, Belgium, and other beer-drinking countries. There is, however, a very important differ ence in the effects that are produced by the various kinds of malt liquor. Porter, a compound of hops and torrefied malt, has by far the worst reputation. Ale, a beverage obtained from non-carbonized malt, though often containing a larger percentage of alcohol than exists in porter, is less deleterious. In Germany, notwithstanding the enormous consumption of lager-beer, gout is an infrequent disease. If valued according to their nutrient qualities, porter obtains the highest rank, though containing less sugar and alcohol than ale. The German beers contain the least of all. In England and Holland, moreover, the people are more abundantly nourished than in Germany and in many parts of France, consequently their nutritious beverages promote over-feeding and its consequences. The hot summers of the Continent must he also taken into consideration, for the copious per spiration that they induce serves to relieve the overburdened kidneys, while the inhabitants of the clamp and chilly lowlands of Holland and England obtain comparatively little help from that source. For this same reason, probably, the inhabitants of the western coasts of France suffer more severely with gout than the dwellers in the southern and central portions of the republic.. Some have thought that the difference should be ascribed to the extensive use of cider among the Bretons and Normans ; but in other countries where cider is largely consumed, as was formerly the case in the New England States of America. gout is seldom known. Its excessive use produces alcohol ism, just as vinous excess among the laboring classes in wine-raising countries is followed by that result. Something more than the mere drinking of alcoholic beverages is needed for the development of gout. There must be taken with the drink an abundance of nitrogenous food before the symptoms of arthritism can be induced. These con ditions are seldom realized among the laborious peasantry ; conse quently, it is among the rich and idle classes, even in cider-drinking countries, that we find the manifestations of a gouty predisposition. While it is true that alcoholic beverages facilitate the development of gout, and that the fermented malt-liquors are more prejudicial than distilled mixtures of equivalent alcoholic strength, it is incorrect to suppose that they can alone produce arthritic disease. Alcohol certainly retards the processes of oxidation in the tissues, but unless their protoplasm is, by reason of excessive nitrogenous feeding, sur charged with substances that must be thoroughly oxidized before they can be normally eliminated, there can be no accumulation of uric acid—hence no gout. It has long been known that the use of brandy and other distilled liquors causes a decided reduction in the quantity of urea that appears in the urine. Haig has shown that the relation between the formation of urea and of uric acid is compara tively uniform—hence there will be less uric acid under such circum stances. A part of this reduction is probably due to the catarrhal state of the alimentary mucous membrane, and the consequent loss of appetite; but it cannot be thus entirely explained. The parallel reduction of urea and of urates in the urine indicates a condition in which a tendency to uricinia does not exist. The mere use of alco hol as a beverage, therefore, cannot be counted among the causes of gout. But when alcohol is drunk in a watery solution that is also charged with nutritious substances, such as are found in malt liquors, a step has been taken in the direction of a nitrogenous surplus in the tissues. And when to all these substances an abundant flesh diet is added, a very large amount of urea and of uric acid must be elimi nated in order to prevent a storage of urates in the body, and the final explosion of arthritic disease as the consequence of their deposit in the It is this retarded elimination that is effected by damp weather, a chilly atmosphere, immoderate eating, alcoholic beverages, and lack of exercise.