Derangements in the digestive system play an exceedingly important role in the development both of acute and chronic gout, and these derangements usually depend either on immoderate eating or drinking, or on the ingestion of articles of diet especially unsuited to the individual. The relationship of these digestive disturbances to the phenomena of acute and chronic gout is an important one, and the importance of a well-regulated and healthy intestinal mucous membrane cannot be overestimated. Autointoxication or infection is certainly a primary factor in the disease, and has to be guarded against by careful dieting, healthy intestinal secretion, and normal intestinal evacuation. It is advisable to insist at all times on the closest attention being paid to the action of the bowels. While we have yet to learn much about the secretory or excretory influence of the large intestine, we may safely assume that by judicious purgation much more is done than merely free the system of the undigested foodstuffs present in the gut Not infrequently in the course of subacute or chronic gout there is developed a subacute or chronic catarrh of the gastric and 444 intestinal mucosa, which in turn aggravates and complicate the general gouty state. Such a complication merely leads to a more strict application of the general principles of the dietetic treatment appropriate to the disease.

It is sometimes maintained that the influence of different food ingredients on the gouty constitution has been too much magnified, this assertion being based on two clinical facts - firstly, that a child fed entirely on milk may continue to excrete large quantities of uric acid; and, secondly, that an adult patient who has been excreting a similar excess on a light vegetarian diet may speedily improve and return to a normal excretion when his diet is changed to meat. This view is based on too narrow a conception of the problems. The little we know with certainty regarding gout seems to indicate that the radical defect is in the metabolism of the proteins of the food. The metabolic changes of the proteins of milk or vegetables are essentially similar to those in meat, and there is no reason to believe that the decomposition products arising from the normal metabolism of the one are in any way different from those in the other. Any differences there may be are those of degree and not of kind. Everything depends on the form in which the foodstuffs are presented. It sometimes strikes me that in this question of feeding we find an interesting analogy in the art of agriculture. A scientific farmer in the feeding of his land has not only to consider the natural quality of the soil, but also the climate, rainfall, and nature of the product desired. Of the food required by the growing plant the element nitrogen is also one of the mainstays, and it is usually provided in one of two forms - potassium nitrate or ammonium sulphate. Now it is by no means immaterial to him in which of these forms the land is fed. His choice depends on many things, one of the most important from our present point of view being their relative solubility. If the land is badly drained, and especially if the rainfall be considerable, he uses the less soluble ammonium sulphate in order to minimise the risk of the nitrogen being washed away and so rendered unavailable for the growth and maintenance of his grain. So it is with the human subject, but only in a more elaborate way. The individual qualities of the tissues, their drainage system, and the relative solubilities of the different food ingredients as commonly prepared, constantly demand careful consideration. The question of diet is certainly the paramount one. Its influence is profound, not only on the individual, but on the race, and its importance was well defined by Sir William Roberts, when he wrote that one generation of scientific dietetics would produce an influence upon humanity second only to a new creation of the race.

Meats, Etc

From the earliest times some writers have regarded all or at any rate most kinds of muscle food as injurious to the gouty, and as in other debated points in the subject history of the disease, many experimental observations have been brought forward to prove this point; but as a rule, these observations have been made in the much too narrow field of uric acid excretion. The most recent observations indicate that the commonly accepted view that a meat diet is associated with an increase in the uric acid excretion is an erroneous one, and on the whole it may be taken as definitely shown, both by practical experience and theoretical experiments, that, as a rule, a gouty subject may take a measured quantity of meats in an easily digested form.

In the use of meats it is not only important that these should be taken in an easily assimilable form, but that they should not be accompanied by an undue admixture of other foodstuffs. It is held by some that in such cases the fact of the carbohydrates and fats being more readily oxidised in the tissues, leads to defective combustion of the albuminous foods. We must look for the cause of any injurious effects of meat more in its quality and in the form in which it is administered. If too little nitrogenous food be taken, an increased decomposition of nuclear-holding tissues may result, as has been proved in a case of complete starvation, in a subject in whom typical acute gout developed in the course of the observation.

We must, however, bear in mind that a strong meat diet, that is, meat twice or thrice daily, is an acid food, owing to the imperfect neutralising of the sulphuric and phosphoric acid present in the diet. This may be in part rectified by the consumption of the alkaline table-waters referred to later.

We have also to consider that the tastes and inclinations of the greater number of gouty subjects demand a certain supply of meat, and, by taking it in moderate amount, the supply of nitrogenous food necessary for the maintenance of the albumin in the body is more readily obtained.

With regard to the different kinds of animal food, white meats, e.g. fish and chicken, are more suitable than red meats owing to their more ready digestibility, and also in the case of fish to the smaller proportion of nitrogen present in equal bulk. The confirmed gouty subject is wise to limit his consumption of red meat to one meal in the day or even less, and further, to make as a routine a selection of the red and white meats similar to that indicated in case Mrs D. (p. 460). The whole question of a meat diet is summed up in its digestibility, which in turn bears a definite ratio to the simplicity of the meal in which the meat is a component part. The temporary diet of meat and hot water (p. 534) which is of much value in suitable cases is a simple one, and to its simplicity we must largely look for an explanation of its beneficial effects. What has been said of meat holds also good for other animal foods. The various kinds of fish and game can all be taken by a gouty subject, but what must be specially attended to is the amount of admixture with other foods and drinks. Not infrequently innocent substances taken at the end of a highly nitrogenous mixed meal are regarded as the noxious agents, when in reality they have played a quite subordinate role. High game and very fatty meats should be avoided. The relationship of an excessive meat diet to gout is further considered on p. 612.

Under this heading a few practical points may be mentioned about the culinary aspects of soups, meats, and fish. It is impossible to overestimate the importance of this subject; the want of recognition of its importance is, in the writer's opinion, one of the causes of the very diverse differences of opinion entertained as to the beneficial or noxious influence of various dietetic substances.