Diseases of Civilization

GOUT.

BY W. H. DRAPER, M.D.

DIET.—The prevention of the accumulation of azotized matters in the [p. 128]blood involves, first, a consideration of the question of the diet appropriate to the gouty dyscrasia. The almost uniform counsel upon this point of all the authorities from Sydenham to the present time is, that albuminous foods should be sparingly allowed in the diet of the gouty patient, and that vegetable foods, especially the farinaceous, should constitute the principal aliment. This counsel is based upon the theory that uric acid is the offending substance, and, this being the outcome of a nitrogenous diet, the nitrogenous element in diet must be reduced. My own observation has led me to believe that while this may be a legitimate deduction from the uric-acid theory of gout, it is not supported by the results of clinical experience. If there is one signal peculiarity in the digestive derangements of gouty persons, it is their limited power to digest the carbohydrates, the sugars and starches. In whatever form these foods are used, they are more commonly the source of the dyspeptic troubles of sufferers from gout than the albuminous foods. They provoke the acid and flatulent dyspepsia which so generally precedes the explosion of the gouty paroxysm; and it must have attracted the attention of every observer who has studied the dyspeptic disorders of sufferers from inherited gout, who have sought to control their unhappy heritage by abstemious habits, that these disorders are especially provoked by over-indulgence in saccharine and amylaceous foods.

It is not possible to explain satisfactorily why the lithæmic condition should be induced by the carbonaceous aliments, but we believe there can be no question as to the fact. If, as modern physiological investigations tend to show, the liver is the organ in which urea as well as glycogen is formed, it may be that the overtaxing of its functions manifests itself more readily in the conversion of the albuminous than in that of the carbonaceous foods; or it is possible that the carbonaceous foods are destined chiefly for the evolution of mechanical energy, and that when this destiny is not fulfilled through indolence and imperfect oxygen-supply, they escape complete combustion, and so vitiate the blood. But whatever may be the cause of this anomaly, the clinical fact remains that in gouty persons the conversion of the azotized foods is more complete with a minimum of carbohydrates than it is with an excess of them—in other words, that one of the best means of avoiding an accumulation of lithates in the blood is to diminish the carbohydrates rather than the azotized foods.

The diet which a considerable experience has led me to adopt in the treatment of the gouty dyscrasia is very similar to that which glycosuria requires. The exclusion of the carbohydrates is of course not so strict. Abstinence from all the fermented preparations of alcohol is perhaps the most important restriction, on account of the unfermented dextrin and sugar which they contain. This restriction accords with the common experience respecting the part which wine and beer play as predisposing causes of the gouty disease and as occasional exciting causes of gouty lesions.

Next to the fermented liquors, the use of saccharine food in the diet of gouty persons needs to be restricted. This limitation also is one which common experience confirms. Sweet foods cannot be said to be as provocative of the dyspeptic derangements of the lithæmic subjects as wine and beer, but they are certainly often responsible for the formation of [p. 129]the dyscrasia and for perpetuating many most distressing ailments. Their more or less strict prohibition may constitute the essential point of treatment not only in controlling the progress of the constitutional vice, but in subduing some of the most rebellious lesions. It is important to observe that this prohibition sometimes involves abstinence from sweet and subacid fruits, in the raw as well as in the preserved state. Paroxysms of articular gout have been known to follow indulgence in strawberries, apples, watermelons, and grapes, and the cutaneous and mucous irritations which follow even the most moderate use of these fruits in some gouty persons are certainly not uncommon.

Next in order to the saccharine foods as the source of indigestion in gouty persons come the amylaceous aliments. These constitute, necessarily, so large an element in ordinary diet that the limitation of them in the dietary of gouty persons applies, in the majority of cases, only to their excessive use. This excessive use, however, is often observed. There is a popular prejudice in favor of this class of foods, and a corresponding prejudice against the too free indulgence in animal foods. The purely starchy aliments, such as potatoes and the preparations of corn and rice, and even those which contain a considerable portion of gluten, like wheat, oatmeal, and barley, often provoke in gouty subjects a great deal of mischievous and painful indigestion. This feeble capacity for the digestion of farinaceous foods is most frequently observed in the children of gouty parents, and especially in persons inclined to obesity, and in those whose occupations are sedentary and whose lives are passed for the most part in-doors, and they are least common in those whom necessity or pleasure leads to much active muscular exercise in the open air.

The fats are as a rule easily digested by gouty dyspeptics. This is a fortunate circumstance, for the reason that in the anæmia which is frequently one of the consequences of chronic gout the fatty foods are of inestimable value. In cases of persistent and rebellious lithæmia an exclusively milk diet constitutes a precious resource.

The succulent vegetables, such as tomatoes, cucumbers, cauliflower, cabbage, and the different varieties of salads, constitute for the gouty as well as the diabetic subject agreeable and wholesome additions to a diet from which the starchy and saccharine vegetables have to be largely excluded.

Abstract

Background: The consumption of omega-3 (n-3) and omega-6 (n-6) essential fatty acids in Western diets is thought to have changed markedly during the 20th century.

Objective: We sought to quantify changes in the apparent consumption of essential fatty acids in the United States from 1909 to 1999.

Design: We calculated the estimated per capita consumption of food commodities and availability of essential fatty acids from 373 food commodities by using economic disappearance data for each year from 1909 to 1999. Nutrient compositions for 1909 were modeled by using current foods (1909-C) and foods produced by traditional early 20th century practices (1909-T).

Results: The estimated per capita consumption of soybean oil increased >1000-fold from 1909 to 1999. The availability of linoleic acid (LA) increased from 2.79% to 7.21% of energy (P < 0.000001), whereas the availability of α-linolenic acid (ALA) increased from 0.39% to 0.72% of energy by using 1909-C modeling. By using 1909-T modeling, LA was 2.23% of energy, and ALA was 0.35% of energy. The ratio of LA to ALA increased from 6.4 in 1909 to 10.0 in 1999. The 1909-T but not the 1909-C data showed substantial declines in dietary availability (percentage of energy) of n-6 arachidonic acid, eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). Predicted net effects of these dietary changes included declines in tissue n--3 highly unsaturated fatty acid status (36.81%, 1909-T; 31.28%, 1909-C; 22.95%, 1999) and declines in the estimated omega-3 index (8.28, 1909-T; 6.51, 1909-C; 3.84, 1999).

Conclusion: The apparent increased consumption of LA, which was primarily from soybean oil, has likely decreased tissue concentrations of EPA and DHA during the 20th century.

The government family allowances, distributed to the Eskimos by the Hudson's Bay Company, have been precious help, especially to large families, and have been of great assistance in enabling the Eskimo people to bridge the gap created by the change in their economy wrought by the introduction to fox hunting. One deficiency of the allowance system is that it does not encourage Eskimos to teach their children to live off the country wherever possible. If the Eskimo takes his allowance every month or two, he can only obtain such items as fruit, tinned milk, jam, and so forth--things he doesn't particularly care for or need. It is fat, fish, and meat that a man wants in this country. To acquire credit for nets and ammunition an Eskimo must refrain from drawing his allowance until it amounts to forty dollars. Some arrangement should be made that would encourage the Eskimo to hunt, rather than to live on foods that are unsuitable. 

Whatever the deficiencies of the new dispensantion, it is certainly true that the Inuk is less abandoned than he was a year, two years, ten years ago. And this we must applaud, for when we look at certain statistical data we are forced to shudder at what the figures demonstrate of man's inhumanity toward man.

Monez, in the wake of Diamond Genness, estimated the number of Canadian Eskimos to be twenty-two thousand before the arrival of the white man. Some eight thousand were left in 1921, six thousand in 1931, and about five thousand in 1950. 

We are told that the Eskimo population trend has been reversed, that next year, and the year after, there will be more of them.

Will they be the same caliber of Eskimo, energetic, tough, healthy?

Or will they be a people broken in spirit and health, like the Chippewas to the south?

A single glance at the specimens now growing up seems to show that we may be gaining in quantity only what we have irretrievably lost in quality. The answer to this problem is in better government, better medical services, better police work. Only if epidemics are prevented, tuberculosis checked, ignorance ameliorated, and the methods of trade improved will the Eskimo people have a real chance of surviving with their own peculiar usefulness and beauty intact.

Are we white men harbingers of a new and brilliant era, or simply advance agents of destruction?

Do we bring with us anything more than dollar corruption, and the corporal and moral germs that have afflicted our own civilization?

If the future is to provide a satisfactory answer to these thorny problems, it is imperative that all those who work for the Eskimo, in any field or capacity whatsoever (the government, the civilian commercial enterprises, the Christian Churches), dedicate all their endeavors with supreme determination and utter selflessness not only to save the poor Inuk from extermination, but also to assure him a human "modus vivendi" compatible with the unique environment in which Providence wishes him to work out not only his temporal existence, but his eternal salvation. Then, and only then, will the Inuk, out there on the ice, perceive at last the promise of a bright new dawn that will scatter the darkness forever.

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The Eskimo used to hunt only what he needed--bear, seal, caribou.

The little foxes--Tiriganiak--he despised. In the old days the Copper Eskimo hardly recognized the existence of the fox. If he met one on the trail he might risk an arrow on him, just to try his skill, but never because he wanted the animal. Fox meat makes poor eating, and fox fur is too frail for anything but baby clothes.

But fashionable women in Paris and New York did not share the Inuk's contempt for the fox. They regarded Tiriganiak's silvery fur as a perfect complement to their gleaming shoulders. What women want, men will get, and so the white man came to the Arctic after foxes and dinned into the Eskimo's ear the value of fox pelts.

"Do you want a rifle, eh, Inuk? Ammunition? Then go and get us foxes, plenty of foxes. Plenty of foxes."

The Eskimo wanted the white man's rifle, steel knife, fish net, boat. So he went after foxes. And soon he found he was so busy getting the miserable little animals that he had no time left in which to hunt for real meat--for bear and caribou. Observing the white traders, he saw them eating bread and jam, and tea with sugar. The new food was no good. It had no taste, and certainly didn't stay with one on the trail. But the Inuk wanted to imitate the Krabloonak. He ate the white man's sugar, and soon it became a habit. He found that he could not do without it. 

"Sugar!" he says. "The Eyebrows offered it to us for nothing, just to try, and we threw it away. The taste of that sand was so bad. Now we have got to like it, but they no longer give it to us. They sell it, and dearly. Mamianar! Calamity!"

Systematically, the white traders ensared the Eskimos, making them slaves to commodities of which they had felt no need before the Eyebrows came, unnecessary luxuries such as flour, silk, sugar, even chewing gum. All these things the Inuit paid for--by giving up his healthy, free life in exchange for trivial luxuries. He ceased to be a hunter, in many cases, and became a trapper, a slave to the little foxes he despised. Thus Tiriganiak--the smallest of all--revolutionized the Eskimo's life, at least the lives of those Eskimos close enough to the traders' posts to come under their influence.

Not too long ago, all Eskimos hunted to clothe and feed themselves. Now they go after foxes, with which to buy some jam, or a Micky Mouse watch, or a cheap, tinny-sounding phonograph. They haven't time to hunt fo seal to provide oil for their lamps, so they buy the white man's kerosene. More foxes. There is no caribou meat on hand, so he eats the white man's flour. More foxes. Soon he lives in a vicious circle, like a knifegrinder's dog in his wheel cage.

Thus, in those areas where the traders hold sway, the happy hunter of old has become a kind of clerk. Once fierce and independent, ignoring tomorrow and contemptuous of anyone who mentioned it, now he is always in debt, as badly off as a petty office worker caught in the clutches of the race-track bookmaker. Once his life was diversified--today hunting, tomorrow sealing, the next day fishing--whatever satisifed the whim of the moment. Now he must turn all his energies toward the capture of the fox. And the supreme irony, of which he is aware, is in the fact that he, the Agun, the male, must outstrip himself to satisfy the desires of the scorned Arna--the woman. And the Krabloonak's woman, at that.

Along the coast, noawadays, one often hears from the Eskimos a bitter, disillusioned cry. "Kakertogot taima"..."We are always hungry now."

Of course they were hungry. The Eskimo is a carnivore. His body craves meat--seal, bear, caribou, fish--and the climate and his hard life aren't satisfied by anything else. Half a grapefruit and a couple of pieces of toast are not the breakfast for the Inuk at all, but for another class of people.

Yet the Inuk counts on the little foxes to provide his sustenance all the year round, and sometimes the foxes don't turn up. Then he's in trouble. Then there is famine. And it is usually too late before the Inuit resign themselves to going out on the ice after seals, as they should have done early in the winter. They starve. At Coppermine, in 1948, for example the whole Eskimo colony kept alive only by eating old skins, boots, and other rubbish--and this not fifteen miles from a white man's settlement.

You might blame the traders themselves, and it is true that some are mightily unscrupulous, but it is not the individuals who should be blamed, but the system, and the government that encourages it. I am told that such tragedy is not known among the Eskimos in Greenland, under Danish rule, though it matches the colonial pattern elsewhere--in the sugar islands of the Caribbean, for eample, where the natives were persuaded to forego their food crops in order to plant sugar cane, and where starvation results when the sugar crop is poor or when the market drops and the price breaks. 

The Eskimos have never heard of the seven lean kine. A trapper may bag three hundred foxes in one year and three the next, but it never occurs to him to store provisions against a bad season. Of course, we must blame him for his improvidence. But must we not also blame the white men who profit vilely from the Eskimo's ignorance, who take advantage of a good fox season by importing diamond rings, gold watches, silk dresses, chronometers, and similar goods? Of what use is a diamond ring to a woman who's going to wear it for cutting seal blubber, if she's lucky enough to have a seal to cut up? What good is a chronometer, complete with sweep second hand, to a man who doesn't care a whit for time? Of what use is a silk dress under a greasy caribou parka?

With melancholy one must watch a venal civilization displace the old Eskimo style. The white man is as devious as Sila. He takes much, and gives little. He talks big, and the rewards look inviting, but when the season is over he has the foxes and what has Inuk?

An empty belly. A forlorn view of the future. The precious watch will soon be opened to see what makes it tick and ruined by snow or water. The elegant dress will soon because a greasy snot-stained rag. The diamong ring will not be worn long before it is lost down a seals' hole. Alas!

One cannot deny the great benefits that civilization has bestowed upon the Eskimos. Certainly the white man has made life easier for the Eskimo, giving him nets, rifles, and steady trade. And the possibilities for human development implicit in the word "civilization" have at least been indicated to the Inuit.

But it would be idle to contest the contest the statement that civilization has been a mixed blessing so far as the Eskimos are concerned, and sometimes the advantages seem to be outweighed by the real harm that has been done. The trade-store rifles helped the Inuk kill his caribou more easily, but they also led to wholesale destruction of caribou and a change in the animals' migratory habits. The substitution of wool for fur clothing has not been beneficial, nor has the introduction of unsuitable foods into the Eskimo diet. The Eskimo's fur clothing is perfect for the climate, and his diet, heavy with fat, was just the thing for a man who was going to hunt on the ice in forty-below-zero weather. In one sense, civilization, by making things easier for the Eskimo, has really set the stage for the Eskimo's destruction. And the introduction of disease germs has inflicted on the Eskimos the same scourges that decimated the Indians and destroyed their pride. The ravages of disease are plain enough here, and one may deplore the havoc wrought during the last fifteen years alone.

Who is responsible[not God, obviously]?

The government, of course, since any government is always responsible for the welfare of people under its jurisdiction.

What has been Canada's attitude toward "Natives" generally?[The same attitude that Catholic schools had?]

The goverment was unfair to the Indians. After the treaty, by means of which the Indians sold their birthright--the limitless prairies and rich forests--for a mess of lentils, the government permitted tuberculosis, starvation, and loss of liberty to reduce them from a proud, self-sufficient people to a race of permanent invalids.

Was this done innocently, or through oversight? Through ignorance?

One wonders. As an official told Bishop Breynat: "it had been thought that the Indian problem would resolve itself. Their number was diminishing steadily. They would disappear."

The same policy was adopted where Eskimos were concerned.

Toward them Canada had no written obligation, as it had toward the Indians, but only the Biblical warning that we are all our brothers' keepers. Nor did the government have any specific duty toward them, except in moral terms. And so the goverment fell back on a policy that can be summed up in a word: indifference.

Indifference!