If, as is probably the case, the toxin or toxins of gout are produced in the intestinal tract, it is obvious that the first efforts at treatment should be directed to obtaining a healthy alimentary tract, and to modifying those habits of living which have caused gastro-intestinal derangement.
Before deciding how these objects can be obtained, it is first necessary shortly to consider some points in the digestive processes which take place in the small intestine. Under normal conditions bacterial decomposition does not take place in the upper part of the small intestine, as the duodenum and upper portion of the jejunum are practically sterile. The conditions which favour increased bacterial growth in the intestine are (1) increase in the amount of protein food (the number of bacteria in the intestine varying directly with the amount of protein food), and (2) the reaction of the intestinal contents. As long as the contents are acid, bacterial growth is inhibited, but when, owing to gastric or intestinal dyspepsia, the intestinal secretion is changed, the reaction of the intestinal contents changes, and great increase in the number of intestinal bacteria takes place, while at the same time their pathogenicity is increased. Therefore, the growth of bacteria in the intestinal tract and their pathogenicity will vary directly with the amount of protein food and the amount of catarrh present.
These facts obviously have a great bearing on the treatment of gout, and explain how it is that excess of protein food, and those forms of alcohol which tend to produce intestinal catarrh, have such a strong influence on the production of gout.
As regards the amounts of protein, fat, and carbo-hydrate that the ordinary individual of average body weight needs during the twenty-four hours to satisfy the normal nutritive requirements of the body, it may be answered in a general way that he requires enough of these food-stuffs to establish physiological and nitrogen equilibrium sufficient to keep up that strength of body and mind that is essential to good health, to maintain the highest degree of physical and mental activity with the smallest amount of friction and the least expenditure of energy, and to preserve and heighten if possible the ordinary resistance of the body to disease germs. Chittenden's opinion is that the smallest amount of food that will accomplish these ends is the ideal diet. There must be enough to supply the true needs of the body, but any surplus over and above what is really called for may in the long run prove an undesirable addition. It is therefore necessary to have definite and concise knowledge of the amount of protein, and the total calorific value needed by the body to maintain the latter in the highest state of efficiency, before any very exact estimate of what constitutes over-nutrition or under-nutrition can be found.
It must be understood that no diet contains an adequate amount of protein food that does not keep up a condition of nitrogenous equilibrium. If the nitrogen output persistently exceeds the nitrogen intake, it is obvious that the body is feeding on its own tissue, which means that the protein of the food is insufficient in amount. On the other hand, a diet that suffices to maintain body weight, with establishment of nitrogen equilibrium should, so far as our present knowledge goes, be quite adequate to meet all the wants of the body for protein matter.
Chittenden considers that the daily consumption of protein food, far beyond the amount required to maintain health, strength, mental and physical vigour, body weight, and nitrogen equilibrium, constitutes a form of over-nutrition as serious in its menace to the health and welfare of the human race as many other evils more striking in character. He believes that there are more people suffering to-day from over-eating and over-nutrition, than from the effects of alcoholic drink. He maintains that if people, as shown by experiments, can maintain nitrogen equilibrium and body weight, gain in strength, show greater freedom from muscular fatigue, lose their rheumatic and gouty symptoms, regain a smooth and soft skin, exhibit greater freedom from colds, retain the normal haemoglobin content of their blood, and in every recognizable way manifest a good condition of health on a low protein diet, there should be no hesitation in accepting the teaching which the scientific data point to. Chittenden's experiments show that it is quite possible to maintain body weight, and keep up nitrogen equilibrium and preserve strength, vigour, and good health on from 34 grammes to 56 grammes of protein matter per day. My own experience is that, on a diet containing this amount of protein, gouty persons maintain their nitrogen equilibrium and body weight, become free from most of their gouty symptoms, and generally enjoy a good condition of health.
As regards the question of meat, it must be remembered on the one hand that animal foods constitute to the majority of people the most attractive and appetizing forms of diet, and are therefore likely to be taken in excess; hence the necessity for limiting the amount to be taken. But, on the other hand, it must be borne in mind that it is most desirable to increase the combustion and the oxidative powers within the tissues. In my opinion it is absolutely erroneous to exclude from the dietary of the gouty such articles as meat, fish, and tea, because they are assumed to contain uric acid.
The so-called estimations of uric acid in those articles of diet are not, as I have elsewhere pointed out, estimations of uric acid at all. Moreover, the deduction is an erroneous one that because uric acid is a nitrogenous body, it must therefore be directly derived from nitrogenous constituents of the food, the consumption of which must consequently be avoided.
The contention that a meat diet is poisonous to the human body, on account of the uric acid that it contains, or produces, is preposterous, in view of the facts that many races have maintained robust health on such a diet, and that, for centuries, the beef-eating Englishmen have managed to spread and advance knowledge and civilization, and to acquire territory in all parts of the world. Surely, if meat is the poison which a certain class of enthusiasts and fanatics maintain it to be, we as a nation should have ceased to exist long ere this. Harry Campbell, in his interesting series of articles on "The Evolution of Man's Diet," has shown that man has evolved from the ape on a highly animalized diet, and that it was on such a diet that the intellectual faculties, and the faculty of language, which distinguish him from the beast, were developed. It is interesting to note that the recent remarkable advance of the Japanese to the position of a first-class power amongst the nations is concurrent with the adoption of a more animalized diet by them. The fact that many races in the past have been largely carnivorous as regards their diet, and that some are so even at the present time (Esquimaux, Andamanese, etc.) shows that the assumption that animal foods are necessarily poisonous to man is an entirely erroneous one. No class of food-stuff gives so great an amount of energy and produces so much heat as animal food, and no class is more easily digested by the majority of gouty people. On the other hand, the tendency with most people in this country, as I shall have occasion to remark later on, is to eat too much, and to masticate too little, and this applies not only to the consumption of meat, but of all other solid articles of diet.
On the whole, it may be stated that animal food, such as fish, chicken, game and meat, is best suited to the majority of gouty cases, whilst foods of the farinaceous class are most likely to disagree. White meats, such as chicken and fish, are more digestible than red meats. The quantity of meat, and especially of red meat, must be restricted in those cases in which the kidneys are imperfectly performing their eliminating functions, as evidenced by a pale urine, of low specific gravity, and deficient in urea and purin-bases.