Gout

The more persistent inflammatory lesions of the skin, such as eczema and psoriasis, which are characterized by long-continued hyperæmia with hyperplasia, are now recognized as among the possible transformations of gout. They are certainly often observed alternating with arthritic lesions, and associated with all the characteristic derangements of nutrition which belong to the gouty habit. The frequency of the various forms of acne, the inflammatory, as well as those which result from excessive function of the glands, in persons having a strong gouty inheritance, is recognized by many dermatologists. I have noticed these lesions especially in young women belonging to gouty families. They are generally accompanied by marked dyspeptic symptoms, and not infrequently by neurotic derangements.

Garrod, in a paper read at the International Medical Congress in 1881 on "Eczema and Albuminuria in Relation to Gout," affirms that each year strengthens his conviction that gout and eczema are most closely allied. Since his attention was first called to this relation in 1860, he has found a gradually increasing percentage of eczema in the cases of gout that have come under his observation. Dividing all the cases from 1860 to 1881 into ten groups, he found the percentage rose from 10 in the first group to 47 in the tenth. He accounts for this rapid increase in the percentage in the fact that in the first few years the eczema was only observed when it was very patent; during the past two or three years he has had made more careful inquiries as to the presence of eczema or other skin eruption in every case of gout, and by these means has frequently discovered its presence when it might otherwise have been overlooked. Garrod believes that eczema is the special skin-lesion of gouty subjects, and does not regard psoriasis as having anything more than an accidental connection with gout. He admits that the latter is often associated with rheumatoid arthritis. It must be remembered, however, that Garrod does not admit that gout ever exists without lithatic deposits.

Cantani’s dietary regime involved periods of energy restriction, however the German physiologist Wilhelm Ebstein cites Cantani as an authority for the use of pure fat in diabetic diets. In 1892 Ebstein published his comprehensive review of the literature on diet, lifestyle, and diabetes, Über die Lebensweise der Zuckerkranken, which includes the statement that “up to about 200 grams of fat is well tolerated by the majority of diabetics” [7]. Also in 1892, Ebstein’s book on Corpulence and its Treatment on Physiological Principles, which contained brief summaries of his findings on fat and diabetes, was translated into English [8]. In this book and his subsequent work On the Regimen to be Adopted in Cases of Gout Ebstein discussed experimental evidence on the metabolism of protein and the desirability of limiting both protein and carbohydrate, and increasing fat, in the treatment of metabolic diseases [9].

German Txt (Very hard to read)

https://archive.org/stream/diefettleibigkei00ebst/diefettleibigkei00ebst_djvu.txt

English Translation Scanned PDF:

https://dlcs.io/pdf/wellcome/pdf-item/b21050533/0

Ebstein describes Rabbit Starvation:

Page 37:

Notwithstanding the vastly important part played by nitrogenous food in human dietetics, those substances that contain no nutritive ingredients except albumen, as for instance flesh destitute of fat, are not proper food for man. As flesh satisfies his demand for carbon only when it is consumed four times in excess of the quantity required to yield the nitrogen needed for his nourishment, such a course would in the first place be far from economical, seeing that meat is one of the dearest articles of food. And then we should very soon find it impossible to consume every day the 90 oz. of pure flesh required for this purpose.

The dietetic systems of treatment now in vogue are based on an almost exclusively albuminous diet. In 1850 Chambers had already pronounced in favour of this regimen, his system excluding all fat substances such as fat, oil, butter, milk, cream, as well as sugar. Of starch-flour in the form of potatoes and even of bread he remarked, that they should be looked on with the greatest suspicion. He also insisted on a diminished consumption of liquids. 

We thus perceive that strictly speaking Chambers' cure differs in no respect from that, by which Banting grew lean in the hands of his physician Harvey, and which has received the name of the Banting cure from the patient, who has written an account of his malady and curative process. From it's specially operative factor Kisch has named it the "Anti-Fat Cure".

Cantani has gone still more vigourously to work. He bars not only all fats - fat meat, fat fish, cheese (owing to its sebacic acid), but all farinaceous preparations, all saccharine foods, sweet and aromatic fruits. Only when the patient is unable to continue this diet long enough, either through excessive repugnance to meat, or nausea of the stomach, or muscular debility, he combines it with the Harvey-Banting system, which also no doubt anathematises the fats, but allows a certain quantity of carbohydrates. 

    Hence these cures have this in common that both alike to the very utmost exclude fats, which they regard as the chief source of the accumulation of fat in the body.

    Now I will by no means deny that a series of cures does result from the Harvey-Banting and Cantani methods, that is to say, by these means corpulent persons become thin. But on the other hand it must be allowed that: 

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Ebstein strongly supports fat for satiety.

"I would now specially insist that the suitable quantity of alimentary fat must not forsooth remove hunger in such a way as to produce dyspeptic symptoms or injure the digestion; and this I dwell upon because the question has already been more than once placed before me by competent colleagues. It is of course a tacit assumption that the fat like all other human aliments, be of unexceptionable quality. The experiments made on persons suffering from fistula in the stomach, have already shown that fat substances disturb the digestion only when they are consumed too abundantly, and I have myself often enough administered with surprising succcess alimentary fat to dyspeptics of the worst type, while limitng their allowance of carbohydrates. But my own numerous experiences have also convinced me, that in the treatment of corpulency fat agrees perfectly well even with those, who had previously regarded it with nausea. I have even noticed a total disappearance of the dyspeptic affections, which the corpulent had hitherto brought upon themselves by an improper diet. The patients preserve a good appetite, which they must learn to moderate by yielding only the actual feeling of hunger. 

The reason of this alleviation of the feeling of hunger with a proper allowance of fat in the diet is due to the circumstance, that fat checks the decomposition of albumen, and that consequently the craving to make good the waste makes itself felt more slowly and less urgently. Precisely because fewer albuminates have been decomposed, fewer require to be replaced. As by the addition of fat to the diet in the same proportion as the decomposition of albumen is diminished, the quantity of nitrogenous refuse from the assimilated substances is also limined, a smaller amount of drink is needed for its removal. Hence in this way thirst as well as hunger becomes appeased. That fats reduce the craving for food was already known to Hippocrates, who remarks in the section dealing with those that wish to become fat or lean: "the dishes must be succelent, for in this way we are easiest sated." Very interesting to me was a communication from Loew, bearing on the point that the use of fat is also effective in checking the craving for liquids. After the consumption of fat in hot climates he always noticed a diminished demand for water; thirst became decidely less irksome.

This property of fat to produce satiety more rapidly, to diminish the craving for food and abate the feeling of thirst, facilitates to an extraordinary degree the introduction of the modified diet. For to the sacrifices which after all must in any case be required of the corpulent, nothing further need be superadded at least in this direction. On the contrary, the permission to enjoy certain succulent things, always of course in moderation, as for instance salmon, pate de foie gras and such like delicacies, reconciles the corpulent gourmet to his sacrifices. These consist in the exclusion of the carbohydrates. Sugar, sweets of all kinds, potatoes in every form I forbid unconditionally. The quantity of bread is limited at most to from 3 to 3.5 oz a day, and of vegetables I allow asparagus, spinach, the various kinds of cabbage and especially the leguminous, whose value as conveyors of albumen, as Voit rightly observes, is known to few. Of meats I exclude none, and the fat in the flesh I do not wish to be avoided, but on the contrary sought after. I permit bacon fat, fat roast pork and mutton, kidney fat, and when no other fat is at hand I recommend marrow to be added to soups. I allow the sauces as well as the vegetables to be made juicy, as did Hippocrates, only for his sesam-oil I substitute butter. 

In spite of all this it would be little to the point to say that I treat the corpulent with fat, whereas I simply vindicate the full claims to which fat is entitled as an article of food. I do not suppose that the corpulent, with who we are practically concerned, will have to consume anything like the quantity of fat that Voit concedes to the working man, or that is allowed to the rank and file of the German imperial army in time of war, say from 7 to 9 oz. daily. I reduce this daily allowance of fat to from 2 to 3.5 oz on an average. The quantity of course changes with the individual relations, nor is it the same for every day. Under the influence of this diet it becomes possible to do with a less quantity of meat. This again I reduce to fully one half or three-fifths of the quantity required in the Banting system, which varies from 13 to 16 oz. a day.

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.