There are few chronic diseases in which special attention to the gastro-intestinal tract by means of diet and other measures is of greater importance than that group of diseases comprised under the term Rheumatoid Arthritis.

The disease is one which attacks young people, adults, and elderly subjects, and its onset may be acute, subacute, or chronic. The dietetic treatment will therefore vary according to the age of the patient and the stage of the disease. The exact causation of this disorder is unknown, but there is good reason for believing that it is of bacterial origin, the source of the infection being the gastro-intestinal tract (including the oro-pharynx) or the genito-urinary tract. In support of the view that the gastro-intestinal tract is a source of the toxaemia, we have the fact that the stools are usually profoundly deranged, being for the most part ill-formed, pultaceous, and extremely foetid. Whether this derangement is a primary or secondary factor in the disease is for practical purposes immaterial; the important point is to recognise its existence, and to aim at its correction by means of diet and other measures, since there is ample evidence that this can frequently be done, with a corresponding improvement in the symptoms, or apparent cure.

The view is often expressed by authoritative writers that there is an important distinction between gout and rheumatoid arthritis in regard to the diet appropriate to the two diseases, the former necessitating a "sparing" diet, the latter a "generous dietary." This distinction is only partially true, and much harm has, in the author's opinion, followed from the general adoption of a dietary based on the assumed correctness of this view. Cases of rheumatoid arthritis are frequently seen, which have previously been treated with little or no success on a "generous" diet, in which the substitution of a dietary of less than half the nutritive value is followed by a striking and permanent improvement. These are invariably cases in which the careful examination of the stools has shown an unusually septic condition of the alimentary tract, a state of affairs which, it should be added, may exist without subjective symptoms of gastro-intestinal disorder. More commonly, however, there is a history of constipation, diarrhoea, flatulence, discomfort after food, or other symptoms of gastrointestinal derangement.

In many cases of rheumatoid arthritis, in which there is reason to believe that the infection of the system is taking place from a neglected catarrh of the uterus or bladder, there is an associated derangement of the large intestine, shown by the septic state of the intestinal evacuations, and in these cases it is of equal importance to pay special attention to the diet. In contrast to the large group of cases of rheumatoid arthritis referred to as having been fed, to their detriment, on an over-generous diet, reference must be made to other cases in which the reverse holds good. We occasionally see cases, often of an advanced character, in which the patients have dieted themselves on a "system," usually of a vegetarian or pseudo-vegetarian character, where the diet in use, either from its poor nutritive value or from its unfavourable influence on the growth of the intestinal bacteria, has accelerated the progress of the disease.

As already indicated, the onset of the disease may be acute, associated with a varying amount of febrile disturbance, which may persist for weeks; as a rule, however, the onset is slow and insidious. The dietetic treatment of the acute phase of the disease is the same as that for acute fever (see Chap. XVI.); the diet for the subacute and chronic stages of the disease is a more difficult matter. The one point which has to be kept in mind is that the patients have frequently been living on a diet which has been favourable to the pathogenic action of the bacteria which normally abound in the intestine, as a result of which poisonous substances are absorbed into the system, and the intestinal evacuations are at the same time foetid in character. The diet must be altered in a manner which will lead to a more satisfactory state of the intestinal contents, as revealed by the passage of healthy stools. The diet appropriate to any given case can only be determined after a careful inquiry has been made into the past history of the case. There is good reason to believe that a diet which is rich in meat and other rich albuminous foodstuffs promotes the multiplication of the intestinal bacteria in an unfavourable manner. Hence it is important to reduce the amount of meat, and more especially red meat, and further, to see that the meat when taken is given in a simple and easily digested form. There are some cases, however, which are beneficially treated in the early stages of the disease by a protein dietary, the protein being given in a simple and easily digested form (see Protein dietary in Auto-intoxication, p. 347). We also know that a diet which is rich in vegetables, and especially green vegetables, leads to the formation of organic acids in the intestinal tract, which exercise a restraining influence on the bacteria in the bowel. On these grounds a lacto-vegctarian diet is to be commended. Great care has, however, to be taken in the selection of this diet, because of the flatulence and other disturbance that may be induced by a too largely vegetarian regime. Again, we know that the digestive secretions are, as a rule, weakened in this disease, and hence the diet must be framed in such a way as to throw the minimum strain on the digestive functions, while supplying ample nutritious material for the needs of the tissues. Hence the diet should be simple, the proteins, fats, and carbohydrates all being presented in a form which is easily digested and assimilated. In some patients it is a useful plan to give for two or three days at the outset of treatment nothing but skimmed milk and buttermilk. The last general point to which I would direct attention is the value of soured milk as an article of diet in this disease. Metchnikoff has pointed out that lactic acid bacilli exercise a restraining influence on the pathogenic action of the Bacillus coli communis and other intestinal bacteria, and one of the forms in which this can be administered is buttermilk. In recent years soured milk has proved of decided value in the treatment of this disease. A fuller account of this regime is given on page 540.

So long as there is intestinal derangement, as shown by the presence of foetid stools, with, it may be, constipation alternating with diarrhoea, the dietary should be framed along the following lines. Thorough mastication of the food, careful attention to the cleanliness of the teeth, and the avoidance of constipation, are of great importance in treatment.

8 A.M.: Breakfast. - Cup of tea or coffee, with little or no sugar; an egg, boiled, poached, not fried; or fish of a white variety, steamed, boiled or fried; or well-cooked bacon, not combined with egg; or slice of ham or tongue. Only one solid food should be taken. A crisp roll, or slice of toast, or bread not too new, with a little butter; no marmalade or jam.

11 A.M. - Half a pint of soured milk, with a biscuit.

Dinner

Restricted to two courses. Fish and meat on alternate days. Avoid oily fishes, and made-up meats. No sauces with the meat. One vegetable only - cauliflower, celery, spinach, onion, or fresh beans. Potatoes and other tubers to be avoided. For pudding - custard, jelly, curds, stewed fruit, with little or no added sugar. Avoid milk puddings, pastry, suet, pancakes, and omelets. Half a pint of soured milk.

4.30 P.M. - Cup of tea, with little or no sugar; dry biscuit or rusk.

Supper

Either a cereal, e.g., porridge or gruel with milk, and a little cream, or strong meat tea or chicken essence with toast. Half a pint of warm soured milk to be taken late at night.

As soon as the bowel condition is improved, the diet, which is, so far, a non-fermentative one, may be increased in variety and nutritive value by the addition of more bread-stuffs and butter at breakfast, a third course, e.g., soup or biscuits and cheese to dinner, and the addition of fish or egg to the evening meal. As soon as possible, extra fat should be added in the form of cream and butter.