556
Journal of the Royal Society of Medicine Volume 85 September 1992
Empirical use of exclusion diets in chronic disorders: discussion paper
A H Hodson MRCS LRCP
Coleford Allergy Clinic, The Marshes, Coleford, Glos GL16 8BD
Keywords: environmental medicine; abnormal reactions; masking; challenge; withdrawal symptoms; physiological healing
Introduction In 1978 the Clinical Ecology Group was formed for the purpose of mutual discussion between doctors whose personal observations seemed to deviate from the conventional. My letter to the JRSM1 is an example. Ultimately the Group became the British Society for Allergy and Environmental Medicine (BSAEM) which co-operates with the American Academy of Environmental Medicine, the product of original pioneers like Albert Rowe2 and Shannon3.
Masking The British and American organizations are agreed that adverse immune reactions to environmental stimuli may become masked4. Masking means that the clinical consequences of adverse immune reactions are removed, but the adverse reactions continue underground, in so far as they are not yet detectable by conventional immunological methods. Children who are said to 'grow out of their allergies' are likely to represent early clinical advantages of masking. Apparent good health may continue for years, but ultimately an insidious process may lead to some form of degenerative disease of obscure aetiology. Masking may continue without any obvious relationship with illness, but if environmental stimuli are withheld from body contact for a short period, commonly assessed as 5-7 days, masking goes away5'6. Then by systematic re-introduction of abstained items, known as challenge, patients are commonly able to recognize and isolate individual offending items. As described by Mackarness7, Rinkel collapsed when, having abstained from eggs for 5 days, he consumed a piece of birthday cake, not knowing it contained egg. Withdrawal symptoms While the masking is going away withdrawal symptoms commonly occur. These consist of accentuation of present symptoms or resurrection of old symptoms which had resolved. The importance of withdrawal symptoms is (1) they are always temporary, usually 3 or 4 days, and (2) they represent precise evidence of the presence of hitherto masked
immune reactions. Hypothesis Although there are likely to be genetic variables, abnormal immune reactions are stimulated by overloading the immune processes beyond an acceptable capacity. The consequences include a variety of disorders, but, given the survival of the individual, masking occurs. The effect of masking is to remove symptoms. An affected individual is restored to good health, but the abnormal immune reactions continue,
and insidiously undermine the whole body. At some later stage morbidity of a degenerative nature presents, the precise aetiology being obscure. The simplest way to test this hypothesis is to select the dietary field. Masking of abnormal dietary reactions can be removed by abstention from selected items of diet, usually for 5-7 days, in the course of which withdrawal symptoms may occur. The items abstained from are then re-introduced systematically in order that, should a reaction occur, the patient can recognize which items have caused the reactions.
Clinical observations The following describes my personal experience as a general practitioner. I was able to receive instruction from Dr Richard Mackarness at his clinic at Park Prewett Hospital in general terms, but I had no practical experience when, in 1982, I introduced the new methods into my NHS general practice. In spite of inexperience, significant inroads were made into the hard core of patients, presumably present in all general practices, who appeared to defy the endeavours of general practitioners and consultants. These were the patients who were invited to attend for 'food allergy' management outside surgery hours. They were introduced as a group to the Stone Age Diet (Table 1). This diet was first composed by Mackarness7. It excludes completely those items which, because we consume them daily for years, are most likely to overload immune systems. Mackarness permitted fructose, but this sugar activates candida (a yeast) as do other sugars. His original Stone Age Diet was used in my early endeavours, whereas Table 1 which I use now limits fructose. The diet also tries to exclude chemical dietary contaminants. What is left is a 'dull' diet, but it is fully balanced. In spite of an initial fall out of about 50% in patients not prepared to undertake the prescribed diet, the extra time was repaid in due course by reduction in out of hours and emergency calls, the major stress factors of general practice. Of those who attended a second session a week later to tell me their experiences, an encouraging number had had withdrawal symptoms and then felt better, while others felt better without detectable withdrawal symptoms. Comments like 'I haven't felt so well for years' encouraged others in the group. This is the stage which follows 'unmasking' of abnormal immune processes. It is a clear signal that whatever the prior diagnosis, there is dietary involvement in the aetiology. Of particular interest were patients who said they felt so happy. One said she had felt unhappy for her whole life, but had never said anything about it because she thought that unhappiness must be normal and everyone else was like her.
0141-0768/92
090556-04/$02.00/0 ( 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 September 1992 Table 1. The Stone Age Diet (modified from Mackarness by limitation of fructose)
Allowed Fresh meat Fresh fish Fresh vegetables Fresh fruit Drinks
Seasoning Olive oil/ sunflower oil Fresh nuts
Animal or bird and offal Preferably free swimmers. Flat fish and shellfish being less mobile, if contaminated may remain so All vegetables including potato. No factory frozen products But limit to equivalent of two items, eg an apple and orange a day No dried fruit. These concentrate fructose Pure fruit juices have a high fructose content Spring water - do not accept 'mineral' water Tap water (a) if boiled enough (2 or 3 min), kettles with automatic switch-off do not boil for long enough (b) if filtered, cheap filters seem adequate 'Herbal teas' are permitted because herbs are vegetables. The word 'teas' should correctly be applied only to products of tea plant. Factory mixed herbal 'teas' should be avoided because cereals may be included Fresh pepper ground with own pepper mill. Factory ground products are suspect Sea salt (table salt and many cooking salts contain a chemical drying agent) For cooking and salad dressing. Sunflower oil is perhaps less safe now it is sold in quantity
Avoid mixtures. Most nuts are from different plant families. Excessive nuts can lead to excessive lectin consumption
Forbidden All items in tins, bottles or packets All cereals: common cereals include wheat, rye, barley, oat, rice, millet, corn and corn oil. Pure vegetable oil is made from cereals. Cereal produce (eg bread, biscuits, cakes) Sugar, sweets, chocolate, fizzy drinks, fruit squashes Milk, cream, butter, margarine, eggs, cheese All preserved meat or fish (eg bacon, ham, kippers, smoked fish) Crisps, packaged nuts, packaged flavourings, gravy powder Yeasts and mushrooms Coffee, tea, alcohol
I next instructed them in the art of challenge, to seek out dietary culprits. In this first experience I failed to impress on patients the need to challenge with primary ingredients like wheat, milk and egg, before embarking on 'cocktails' like biscuits, cake, wine and supermarket own brands. The result was confusion, but patients who had had their first taste of good health for years were prepared to cooperate by returning to the Stone Age Diet. Further discussions were a unique experience of co-operation between doctor and the sort of patient who had hitherto represented doctor's despair or even hostility.
Prescribed drugs Most patients had been prescribed drugs for years. These could be gradually reduced and commonly stopped altogether. Further clinical observations In the course of management of a number of groups in the NHS according to the methods already described, the introduction of intra-cutaneous testing9 led to success in some previous failures. They eventually proved too time consuming for NHS general practice but are mentioned because they were used for statistics following retirement into private practice. From 1984 the first 200 private patients, except those who attended once only, were entered on punch cards which were collated in 1987 for statistical purposes. Motivation Patients who were prepared to accept the diet were usually well motivated, but many private patients had already experienced acupuncture, homoeopathy or other complementary medicine. They were somewhat demoralized yet had a greater determination to
'try anything'. They represented a challenge when it became clear that the successful results achieved in NHS patients, using simpler methods only, must have represented the 'easy' cases. At least the initial fall out among private patients was small, compared with NHS patients. The Stone Age Diet was continued, slightly modified (Table 1). Because it is relatively extensive it is less 'efficient' from the point of view of inducing withdrawal symptoms, but, with the help of intracutaneous testing methods, abnormal reactions to items on the diet could in due course be isolated. The diet was extended to 2 weeks when it was found that for dermatological, arthritic and bowel problems the withdrawal symptoms which appeared to be settling after a week were liable to be supplanted by different withdrawal symptoms in the second week, and the patient did not reach the phase of feeling well until the end of the second week. 'Eccentricity of dieting'0 refers to the frequent loss of weight of a half stone after 2 weeks, even though the Stone Age Diet is fully balanced.
Normal physiological processes Environmental medicine accepts the presence of physiological healing provided that such processes have the opportunity to operate normally. Methods are therefore aimed at analysis of environmental stimuli which obstruct normal healing by the creation of abnormal immune responses. Co-operation The essential requirement of co-operation between patient and doctor leads to individual patient knowledge of those environmental stimuli which are specifically harmful to the individual. This gives each patient, who has achieved complete remission,
557
558
Journal of the Royal Society of Medicine Volume 85 September 1992
Table 2. Irritable bowel (n=47; 21% male, 79% female)
Age (years) Results
0-20 2% Good 42%
20-39 28%
Improved 30%
40-59 60% Poor 17%
60+ 11% Not known 11%
Most patients with irritable bowel had been previously diagnosed either by general practitioners or consultants Table 3. Arthritis: Definition by translation, arthron (joint) -itis (inflammation) (n=75; 22% male, 77% female) Age (years) M F 0-20 1 10 0 *Osteo- (n=11) 5 12 1 *Rheumatoid (n=17) All others (n=47) 11 36 2
Results OsteoRheumatoid All others Total
Good 45% 35% 45% 42%
20-39 40-59 60+ 0 1
5 6
6 9
11
24
10
Improved Poor Not known 18% 18% 18% 24% 6% 35% 28% 19% 8% 28% 20% 9%
Many patients were taking anti-inflammatory drugs, sometimes for years. Relatively few had seen consultants. Rheumatoid figures showed fewer good results than others, but the overall total results were singularly similar to those of irritable bowel *Diagnosis by consultant a
knowledge of personal preventive medicine for the of maintaining good health.
purpose
Outcome Statistics derived from punch cards were originally intended for self-information. They do not represent a formal trial, but the results seemed likely to be of wider interest (Tables 2-5). The results were classified as follows: Good This represents a complete remission of all symptoms with a clinical and psychological return to good health, expected to continue. Improved There was an initial promise of good result, but though patients were generally better, recovery was incomplete. Poor The results were disappointing in spite of good follow up. Not known This applied to patients who did not follow up. Worse There were patients who did not improve and ceased to attend, but there was no positive evidence that any became worse. Reasons for other than good results may be either (1) incomplete removal of processes which inhibit physiological healing; or (2) physiological healing processes vary with the individual. There are probably hereditary determinations should this be so, but more detailed analysis represents a potential for fascinating
research.
Table 4. Comparison of results (n=200)
Irritable bowel (n=47) All arthritis (n=75) Non-infective skins (n=77) Asthma (n=35) Migraine (n=24) Depression (n=55)
Good
Improved
Poor
42% 42% 42% 43% 42% 30%
30% 28% 31% 26% 13% 40%
17% 20% 14% 23% 29% 16%
The numbers indicate that many patients had more than one of the syndromes selected to represent a short list of common but essentially different presentations. The singular similarity of good results persisted with the exception ofthe psychological presentation (depression) where the confident assessment of complete remission expected to continue is more difficult. Even a 30% freedom from depression without the use of drugs is important
Table 5. Withdrawal symptoms Irritable bowel All arthritis Non-infective skins Asthma Migraine Depression
25% 28% 29% 26% 26% 33%
Withdrawal symptoms indicate the presence of a dietary influence in the aetiology of widely differing presentations. The timing of symptoms followed by release from them does not suggest a psychological involvement. These figures show a degree of similarity. They would be expected to be generally higher in the course of a more 'efficient' exclusion diet, such as lamb, pears and spring water. The most reliable restriction is complete starvation for 5 days, but this usually means hospital admission
Discussion The trend among members of the BSAEM inclines increasingly towards environmental medicine, and the word 'allergy' has been avoided in this paper. It is a mistake to dismiss, with a word like 'alternate', the empirical evidence of environmental medicine which is commonly also disregarded by 'holistic' organizations. Members of the BSAEM are all conventionally qualified doctors who, in the manner of scientists, are interested in finding answers to what is not understood. This article has indicated how any general practitioner who is so inclined may significantly reduce the stress of general practice. In the past 40 years the increasing success of pharmaceutical products has led to decreasing interest in the physiological potential within the body which, if given a chance, has powers of healing. Environmental medicine depends on successful analysis, with minimal positive management except to maintain patients' morale until the resumption of normal physiological processes. These appear to be common to syndromes conventionally managed as separate entities. Consistent co-operation between patient and doctor provides the patient with essential knowledge for extending successful remission by individual preventive medicine, in order to avoid the re-introduction of adverse immune reactions which inhibit the physiological processes responsible for healing. In most of the conditions named in the statistical tables, there is commonly some degree of concomitant
Journal of the Royal Society of Medicine Volume 85 September 1992
psychological imbalance, but it is unsafe to conclude a primary psychological diagnosis in the absence of a prior programme of restricted diet. Acknowledgments: I thank Dr K K Eaton, Dr George Hearn and Dr D L J Freed for their help and advice.
4 Rinkel HJ. Role offood allergy in internal medicine. Ann Allergy 1944;2:115-24 5 Coca AF. Familia nonreaginic fiood-alergy. Springfield, Illinois: Charles C. Thomas, Oxford: Blackwell Scientific Publications, 1942 6 Rowe AH. Elimination diets and the patient's allergies. London: Henry Kimpton, 1944 7 Mackarness R. NOT ALL in the mind. London: Pan Books, 1976:59 8 Mackarness R. Chemical victims. London: Pan Books, 1980:167-9 9 Miller J. Provocative testing and injection therapy. Springfield, Illinois: Charles C Thomas, 1972 10 Hodson AH. Eccentricity of dieting. J R Soc Med 1990;83:478
References 1 Hodson AH. Immunology of the tonsils. J R Soc Med 1991;84:58 2 Rowe AH. Food allergy. Its manifestations, diagnosis and treatment, with a general discussion of bronchial asthma. Philadelphia: Lee & Febiger, 1931 3 Shannon WR. Neuropathic manifestations in infants and children as a result of anaphylactic reaction to foods contained in their diet. Am J Dis Child 1922;24: 154-65
(Accepted 30 October 1991)
Forthcoming events
Teaching the Medical Audit Teachers 1-3 December 1992, RGCP, London Further details from: (see entry for 18-19 September 1992)
(continued from p 555)
Quality Assurance and its Implications for Clinical Research 11 November 1992, London Further details from: (see entry for 26-28 October 1992)
Pharmacokinetics in New Drug Research 12 November 1992, London Further details from: (see entry for 26-28 October 1992)
Glaucoma Management 10-11 December 1992, San Francisco, USA Further details from: (see entry for 5-7 November 1992) Techniques & Applications of Molecular Biology: A Course for Medical Practitioners 14-17 December 1992, University of Warwick Further details from: Dr Stephen Hicks, Department of Biological Sciences, University of Warwick, Coventry CV4 7AL (Tel: 0203 523540; Fax: 0203 523701)
New Horizons-General Practice at the Forefront 13 November 1992, Regent's College, London Further details from: (see entry for 18-19 September 1992)
Performance Appraisal 17-18 December 1992, RCGP, London Further details firom: (see entry for 18-19 September 1992)
38th Annual Group Therapy Symposium 13-15 November 1992, San Francisco, California Further details from: (see entry for 5-7 November 1992)
MRCP Part II Course 8-12 February 1992, Royal Free Hospital, London Further details from: Dr D Geraint James, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG (Tel: 071 794 0500)
One Day Course: Advances in Practical Arthroscopic Surgery 14 November 1992 (also 15 November), Droitwich Further details from: Mrs F Warren, Droitwich Knee Clinic, St Andrews Road, Droitwich WR9 8AE (Tel: 0905 795916; Fax: 0905 723371)
Data Handling for Medical Audit 19-20 November 1992, RCGP, London Further details from: (see entry for 18-19 September 1992) Transdermal Drug Delivery Systems 24-25 November 1992, Basel, Switzerland Further details from: (see entry for 22-23 October 1992)
Drug Dissolution and Bioavailability 26-27 November 1992, Basel, Switzerland Further details firom: (see entry for 22-23 October 1992)
Managing General Practice in the '90s 27-28 November 1992, RCGP, London Further details fiom: (see entry for 18-19 September 1992)
Colorectal Disease in 1993: An International Exchange of Medical and Surgical Concepts 18-20 February 1993, Fort Lauderdale, Florida Further details from: The Cleveland Clinic Educational Foundation, Dept of Continuing Education, 9500 Euclid Avenue Rm TT-31, Cleveland, OH 44195-5241, USA (Tel: 800 726 8173; Fax: 216 445 9406) Trace Elements and Free Radicals in Oxidative Diseases 5-9 April 1993, Chamonix, France Further details firom: Prof. A Favier/Mme A Alcaraz, Laboratoire de, Biochimie C, Hopital A Michallon, BP 217 X, 38043 Grenoble CEDEX 09, France (Tel: 76 76 54 07; Fax: 76 42 66 44) 6th International Conference on Behpet's Disease 30 June-1 July 1993, Paris, France Further details firom: Betrand Wechsler MD, Pitie-Salpetiere Hospital, 47/83 Bd de L'Hopital, 75013 Paris Cedex 13, France (Tel: 45 70 26 67; Fax: 45 70 20 45)
559
Journal of the Royal Society of Medicine Volume 85 September 1992
Empirical use of exclusion diets in chronic disorders: discussion paper
A H Hodson MRCS LRCP
Coleford Allergy Clinic, The Marshes, Coleford, Glos GL16 8BD
Keywords: environmental medicine; abnormal reactions; masking; challenge; withdrawal symptoms; physiological healing
Introduction In 1978 the Clinical Ecology Group was formed for the purpose of mutual discussion between doctors whose personal observations seemed to deviate from the conventional. My letter to the JRSM1 is an example. Ultimately the Group became the British Society for Allergy and Environmental Medicine (BSAEM) which co-operates with the American Academy of Environmental Medicine, the product of original pioneers like Albert Rowe2 and Shannon3.
Masking The British and American organizations are agreed that adverse immune reactions to environmental stimuli may become masked4. Masking means that the clinical consequences of adverse immune reactions are removed, but the adverse reactions continue underground, in so far as they are not yet detectable by conventional immunological methods. Children who are said to 'grow out of their allergies' are likely to represent early clinical advantages of masking. Apparent good health may continue for years, but ultimately an insidious process may lead to some form of degenerative disease of obscure aetiology. Masking may continue without any obvious relationship with illness, but if environmental stimuli are withheld from body contact for a short period, commonly assessed as 5-7 days, masking goes away5'6. Then by systematic re-introduction of abstained items, known as challenge, patients are commonly able to recognize and isolate individual offending items. As described by Mackarness7, Rinkel collapsed when, having abstained from eggs for 5 days, he consumed a piece of birthday cake, not knowing it contained egg. Withdrawal symptoms While the masking is going away withdrawal symptoms commonly occur. These consist of accentuation of present symptoms or resurrection of old symptoms which had resolved. The importance of withdrawal symptoms is (1) they are always temporary, usually 3 or 4 days, and (2) they represent precise evidence of the presence of hitherto masked
immune reactions. Hypothesis Although there are likely to be genetic variables, abnormal immune reactions are stimulated by overloading the immune processes beyond an acceptable capacity. The consequences include a variety of disorders, but, given the survival of the individual, masking occurs. The effect of masking is to remove symptoms. An affected individual is restored to good health, but the abnormal immune reactions continue,
and insidiously undermine the whole body. At some later stage morbidity of a degenerative nature presents, the precise aetiology being obscure. The simplest way to test this hypothesis is to select the dietary field. Masking of abnormal dietary reactions can be removed by abstention from selected items of diet, usually for 5-7 days, in the course of which withdrawal symptoms may occur. The items abstained from are then re-introduced systematically in order that, should a reaction occur, the patient can recognize which items have caused the reactions.
Clinical observations The following describes my personal experience as a general practitioner. I was able to receive instruction from Dr Richard Mackarness at his clinic at Park Prewett Hospital in general terms, but I had no practical experience when, in 1982, I introduced the new methods into my NHS general practice. In spite of inexperience, significant inroads were made into the hard core of patients, presumably present in all general practices, who appeared to defy the endeavours of general practitioners and consultants. These were the patients who were invited to attend for 'food allergy' management outside surgery hours. They were introduced as a group to the Stone Age Diet (Table 1). This diet was first composed by Mackarness7. It excludes completely those items which, because we consume them daily for years, are most likely to overload immune systems. Mackarness permitted fructose, but this sugar activates candida (a yeast) as do other sugars. His original Stone Age Diet was used in my early endeavours, whereas Table 1 which I use now limits fructose. The diet also tries to exclude chemical dietary contaminants. What is left is a 'dull' diet, but it is fully balanced. In spite of an initial fall out of about 50% in patients not prepared to undertake the prescribed diet, the extra time was repaid in due course by reduction in out of hours and emergency calls, the major stress factors of general practice. Of those who attended a second session a week later to tell me their experiences, an encouraging number had had withdrawal symptoms and then felt better, while others felt better without detectable withdrawal symptoms. Comments like 'I haven't felt so well for years' encouraged others in the group. This is the stage which follows 'unmasking' of abnormal immune processes. It is a clear signal that whatever the prior diagnosis, there is dietary involvement in the aetiology. Of particular interest were patients who said they felt so happy. One said she had felt unhappy for her whole life, but had never said anything about it because she thought that unhappiness must be normal and everyone else was like her.
0141-0768/92
090556-04/$02.00/0 ( 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 September 1992 Table 1. The Stone Age Diet (modified from Mackarness by limitation of fructose)
Allowed Fresh meat Fresh fish Fresh vegetables Fresh fruit Drinks
Seasoning Olive oil/ sunflower oil Fresh nuts
Animal or bird and offal Preferably free swimmers. Flat fish and shellfish being less mobile, if contaminated may remain so All vegetables including potato. No factory frozen products But limit to equivalent of two items, eg an apple and orange a day No dried fruit. These concentrate fructose Pure fruit juices have a high fructose content Spring water - do not accept 'mineral' water Tap water (a) if boiled enough (2 or 3 min), kettles with automatic switch-off do not boil for long enough (b) if filtered, cheap filters seem adequate 'Herbal teas' are permitted because herbs are vegetables. The word 'teas' should correctly be applied only to products of tea plant. Factory mixed herbal 'teas' should be avoided because cereals may be included Fresh pepper ground with own pepper mill. Factory ground products are suspect Sea salt (table salt and many cooking salts contain a chemical drying agent) For cooking and salad dressing. Sunflower oil is perhaps less safe now it is sold in quantity
Avoid mixtures. Most nuts are from different plant families. Excessive nuts can lead to excessive lectin consumption
Forbidden All items in tins, bottles or packets All cereals: common cereals include wheat, rye, barley, oat, rice, millet, corn and corn oil. Pure vegetable oil is made from cereals. Cereal produce (eg bread, biscuits, cakes) Sugar, sweets, chocolate, fizzy drinks, fruit squashes Milk, cream, butter, margarine, eggs, cheese All preserved meat or fish (eg bacon, ham, kippers, smoked fish) Crisps, packaged nuts, packaged flavourings, gravy powder Yeasts and mushrooms Coffee, tea, alcohol
I next instructed them in the art of challenge, to seek out dietary culprits. In this first experience I failed to impress on patients the need to challenge with primary ingredients like wheat, milk and egg, before embarking on 'cocktails' like biscuits, cake, wine and supermarket own brands. The result was confusion, but patients who had had their first taste of good health for years were prepared to cooperate by returning to the Stone Age Diet. Further discussions were a unique experience of co-operation between doctor and the sort of patient who had hitherto represented doctor's despair or even hostility.
Prescribed drugs Most patients had been prescribed drugs for years. These could be gradually reduced and commonly stopped altogether. Further clinical observations In the course of management of a number of groups in the NHS according to the methods already described, the introduction of intra-cutaneous testing9 led to success in some previous failures. They eventually proved too time consuming for NHS general practice but are mentioned because they were used for statistics following retirement into private practice. From 1984 the first 200 private patients, except those who attended once only, were entered on punch cards which were collated in 1987 for statistical purposes. Motivation Patients who were prepared to accept the diet were usually well motivated, but many private patients had already experienced acupuncture, homoeopathy or other complementary medicine. They were somewhat demoralized yet had a greater determination to
'try anything'. They represented a challenge when it became clear that the successful results achieved in NHS patients, using simpler methods only, must have represented the 'easy' cases. At least the initial fall out among private patients was small, compared with NHS patients. The Stone Age Diet was continued, slightly modified (Table 1). Because it is relatively extensive it is less 'efficient' from the point of view of inducing withdrawal symptoms, but, with the help of intracutaneous testing methods, abnormal reactions to items on the diet could in due course be isolated. The diet was extended to 2 weeks when it was found that for dermatological, arthritic and bowel problems the withdrawal symptoms which appeared to be settling after a week were liable to be supplanted by different withdrawal symptoms in the second week, and the patient did not reach the phase of feeling well until the end of the second week. 'Eccentricity of dieting'0 refers to the frequent loss of weight of a half stone after 2 weeks, even though the Stone Age Diet is fully balanced.
Normal physiological processes Environmental medicine accepts the presence of physiological healing provided that such processes have the opportunity to operate normally. Methods are therefore aimed at analysis of environmental stimuli which obstruct normal healing by the creation of abnormal immune responses. Co-operation The essential requirement of co-operation between patient and doctor leads to individual patient knowledge of those environmental stimuli which are specifically harmful to the individual. This gives each patient, who has achieved complete remission,
557
558
Journal of the Royal Society of Medicine Volume 85 September 1992
Table 2. Irritable bowel (n=47; 21% male, 79% female)
Age (years) Results
0-20 2% Good 42%
20-39 28%
Improved 30%
40-59 60% Poor 17%
60+ 11% Not known 11%
Most patients with irritable bowel had been previously diagnosed either by general practitioners or consultants Table 3. Arthritis: Definition by translation, arthron (joint) -itis (inflammation) (n=75; 22% male, 77% female) Age (years) M F 0-20 1 10 0 *Osteo- (n=11) 5 12 1 *Rheumatoid (n=17) All others (n=47) 11 36 2
Results OsteoRheumatoid All others Total
Good 45% 35% 45% 42%
20-39 40-59 60+ 0 1
5 6
6 9
11
24
10
Improved Poor Not known 18% 18% 18% 24% 6% 35% 28% 19% 8% 28% 20% 9%
Many patients were taking anti-inflammatory drugs, sometimes for years. Relatively few had seen consultants. Rheumatoid figures showed fewer good results than others, but the overall total results were singularly similar to those of irritable bowel *Diagnosis by consultant a
knowledge of personal preventive medicine for the of maintaining good health.
purpose
Outcome Statistics derived from punch cards were originally intended for self-information. They do not represent a formal trial, but the results seemed likely to be of wider interest (Tables 2-5). The results were classified as follows: Good This represents a complete remission of all symptoms with a clinical and psychological return to good health, expected to continue. Improved There was an initial promise of good result, but though patients were generally better, recovery was incomplete. Poor The results were disappointing in spite of good follow up. Not known This applied to patients who did not follow up. Worse There were patients who did not improve and ceased to attend, but there was no positive evidence that any became worse. Reasons for other than good results may be either (1) incomplete removal of processes which inhibit physiological healing; or (2) physiological healing processes vary with the individual. There are probably hereditary determinations should this be so, but more detailed analysis represents a potential for fascinating
research.
Table 4. Comparison of results (n=200)
Irritable bowel (n=47) All arthritis (n=75) Non-infective skins (n=77) Asthma (n=35) Migraine (n=24) Depression (n=55)
Good
Improved
Poor
42% 42% 42% 43% 42% 30%
30% 28% 31% 26% 13% 40%
17% 20% 14% 23% 29% 16%
The numbers indicate that many patients had more than one of the syndromes selected to represent a short list of common but essentially different presentations. The singular similarity of good results persisted with the exception ofthe psychological presentation (depression) where the confident assessment of complete remission expected to continue is more difficult. Even a 30% freedom from depression without the use of drugs is important
Table 5. Withdrawal symptoms Irritable bowel All arthritis Non-infective skins Asthma Migraine Depression
25% 28% 29% 26% 26% 33%
Withdrawal symptoms indicate the presence of a dietary influence in the aetiology of widely differing presentations. The timing of symptoms followed by release from them does not suggest a psychological involvement. These figures show a degree of similarity. They would be expected to be generally higher in the course of a more 'efficient' exclusion diet, such as lamb, pears and spring water. The most reliable restriction is complete starvation for 5 days, but this usually means hospital admission
Discussion The trend among members of the BSAEM inclines increasingly towards environmental medicine, and the word 'allergy' has been avoided in this paper. It is a mistake to dismiss, with a word like 'alternate', the empirical evidence of environmental medicine which is commonly also disregarded by 'holistic' organizations. Members of the BSAEM are all conventionally qualified doctors who, in the manner of scientists, are interested in finding answers to what is not understood. This article has indicated how any general practitioner who is so inclined may significantly reduce the stress of general practice. In the past 40 years the increasing success of pharmaceutical products has led to decreasing interest in the physiological potential within the body which, if given a chance, has powers of healing. Environmental medicine depends on successful analysis, with minimal positive management except to maintain patients' morale until the resumption of normal physiological processes. These appear to be common to syndromes conventionally managed as separate entities. Consistent co-operation between patient and doctor provides the patient with essential knowledge for extending successful remission by individual preventive medicine, in order to avoid the re-introduction of adverse immune reactions which inhibit the physiological processes responsible for healing. In most of the conditions named in the statistical tables, there is commonly some degree of concomitant
Journal of the Royal Society of Medicine Volume 85 September 1992
psychological imbalance, but it is unsafe to conclude a primary psychological diagnosis in the absence of a prior programme of restricted diet. Acknowledgments: I thank Dr K K Eaton, Dr George Hearn and Dr D L J Freed for their help and advice.
4 Rinkel HJ. Role offood allergy in internal medicine. Ann Allergy 1944;2:115-24 5 Coca AF. Familia nonreaginic fiood-alergy. Springfield, Illinois: Charles C. Thomas, Oxford: Blackwell Scientific Publications, 1942 6 Rowe AH. Elimination diets and the patient's allergies. London: Henry Kimpton, 1944 7 Mackarness R. NOT ALL in the mind. London: Pan Books, 1976:59 8 Mackarness R. Chemical victims. London: Pan Books, 1980:167-9 9 Miller J. Provocative testing and injection therapy. Springfield, Illinois: Charles C Thomas, 1972 10 Hodson AH. Eccentricity of dieting. J R Soc Med 1990;83:478
References 1 Hodson AH. Immunology of the tonsils. J R Soc Med 1991;84:58 2 Rowe AH. Food allergy. Its manifestations, diagnosis and treatment, with a general discussion of bronchial asthma. Philadelphia: Lee & Febiger, 1931 3 Shannon WR. Neuropathic manifestations in infants and children as a result of anaphylactic reaction to foods contained in their diet. Am J Dis Child 1922;24: 154-65
(Accepted 30 October 1991)
Forthcoming events
Teaching the Medical Audit Teachers 1-3 December 1992, RGCP, London Further details from: (see entry for 18-19 September 1992)
(continued from p 555)
Quality Assurance and its Implications for Clinical Research 11 November 1992, London Further details from: (see entry for 26-28 October 1992)
Pharmacokinetics in New Drug Research 12 November 1992, London Further details from: (see entry for 26-28 October 1992)
Glaucoma Management 10-11 December 1992, San Francisco, USA Further details from: (see entry for 5-7 November 1992) Techniques & Applications of Molecular Biology: A Course for Medical Practitioners 14-17 December 1992, University of Warwick Further details from: Dr Stephen Hicks, Department of Biological Sciences, University of Warwick, Coventry CV4 7AL (Tel: 0203 523540; Fax: 0203 523701)
New Horizons-General Practice at the Forefront 13 November 1992, Regent's College, London Further details from: (see entry for 18-19 September 1992)
Performance Appraisal 17-18 December 1992, RCGP, London Further details firom: (see entry for 18-19 September 1992)
38th Annual Group Therapy Symposium 13-15 November 1992, San Francisco, California Further details from: (see entry for 5-7 November 1992)
MRCP Part II Course 8-12 February 1992, Royal Free Hospital, London Further details from: Dr D Geraint James, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG (Tel: 071 794 0500)
One Day Course: Advances in Practical Arthroscopic Surgery 14 November 1992 (also 15 November), Droitwich Further details from: Mrs F Warren, Droitwich Knee Clinic, St Andrews Road, Droitwich WR9 8AE (Tel: 0905 795916; Fax: 0905 723371)
Data Handling for Medical Audit 19-20 November 1992, RCGP, London Further details from: (see entry for 18-19 September 1992) Transdermal Drug Delivery Systems 24-25 November 1992, Basel, Switzerland Further details from: (see entry for 22-23 October 1992)
Drug Dissolution and Bioavailability 26-27 November 1992, Basel, Switzerland Further details firom: (see entry for 22-23 October 1992)
Managing General Practice in the '90s 27-28 November 1992, RCGP, London Further details fiom: (see entry for 18-19 September 1992)
Colorectal Disease in 1993: An International Exchange of Medical and Surgical Concepts 18-20 February 1993, Fort Lauderdale, Florida Further details from: The Cleveland Clinic Educational Foundation, Dept of Continuing Education, 9500 Euclid Avenue Rm TT-31, Cleveland, OH 44195-5241, USA (Tel: 800 726 8173; Fax: 216 445 9406) Trace Elements and Free Radicals in Oxidative Diseases 5-9 April 1993, Chamonix, France Further details firom: Prof. A Favier/Mme A Alcaraz, Laboratoire de, Biochimie C, Hopital A Michallon, BP 217 X, 38043 Grenoble CEDEX 09, France (Tel: 76 76 54 07; Fax: 76 42 66 44) 6th International Conference on Behpet's Disease 30 June-1 July 1993, Paris, France Further details firom: Betrand Wechsler MD, Pitie-Salpetiere Hospital, 47/83 Bd de L'Hopital, 75013 Paris Cedex 13, France (Tel: 45 70 26 67; Fax: 45 70 20 45)
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