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Sunday, 16 November 2014

Dr Wilhelm Ebstein (1836-1912); the Father of LCHF, on Gout, 1884

"It is difficult to label Wilhelm Ebstein because he was a clinician, pathologist, chemist, basic scientist, teacher, and writer. It is a mystery that so few know him because he was extremely productive and made many significant medical contributions.
Ebstein wrote 237 articles: 72 were about metabolic diseases, 38 dealt with gastrointestinal diseases, 16 were about infectious diseases, 12 were concerned with heart disease, 15 dealt with medical history, and the remainder were about various subjects that interested him.
He has been called the “forgotten founder of biochemical genetics” because he believed that obesity, gout, and diabetes mellitus were inheritable cellular metabolic diseases. 
His book discussing the use of a low-carbohydrate diet for obesity was popular, and several editions were published."

From J. Willis Hurst, M.D. 2009, Profiles in Cardiology – Portrait of a Contributor: Wilhelm Ebstein (1836-1912).

The history of low-carb diets can be said to begin with John Rollo’s Two Cases of the Diabetes Mellitus book (1779), Brillat Savarin’s Physiology of Taste (1825) and Banting’s Letter on Corpulence (1864). However none of these is really a high fat diet except perhaps Brillat Savarin’s, and all three, though good guesses from heuristic experiments, often self-experiments, do not draw on any great body of scientific research.
Dr Wilhelm Ebstein was a 19th century German physician who made considerable contributions to many branches of medicine, and whose research into the cause and treatment of metabolic diseases – corpulence, obesity and gout, as well as dyspepsia – developed, and supported with clinical and laboratory research, the argument for replacing starch with fat, and for keeping protein (albumen) moderate, in the treatment of these conditions. He does so persuasively and arrives, time after time, at judgments that remain relevant today. His dietary prescriptions are placed in a context of advice about exercise, sleep, and clothing that is also modern and conservative.
Ebstein was highly critical of Banting's diet, as being too low in fat and high in protein for anyone to want to consume long-term. He believed that restriction of fat was unnecessary, as fat in a carbohydrate-restricted diet did not contribute to adiposity and instead, by increasing satiety and supporting overall health, contributed to weight loss.
The Regimen to be Adopted in Cases of Gout, which appeared in 1884, two years after Ebstein’s work on the Treatment of Corpulence, sets out the scientific and clinical case for using a high-fat diet to treat a metabolic disease, gout, as well as the corpulence and dyspepsia associated with it.
I present below a series of excerpts from this work, which is available online.

     "According to Haughton's researches, the daily amount of uric acid secreted by flesh-eaters as contrasted with vegetarians is on an average 4.5 to 1.5. From Eanke's experiments we have, at the same time, the important fact that the nature of the diet has less influence on the elimination of uric acid than it has on that of urea. We must conclude from the experiments of H. Eanke that the secretion of uric acid is increased by the ingestion of food, apart from the nature of that food. Nevertheless, without reference to the fact that exclusive flesh diet increases the uric acid secretion, this diet has so many other inconveniences and dangers for the human organism, that it must be specially renounced when there is a disposition to gout independent of it.
On the other hand, purely vegetable foods, even though less uric acid may be secreted by their use, are unsuitable for many reasons as an exclusive means of support for persons in general, not to speak of gouty subjects in particular. Both animal and vegetable foods after all contain the same materials, although in different proportions, and experience shows us that it requires a perfectly healthy condition of the intestine to digest purely vegetable diet. For this reason vegetarians themselves, who should on principle reject any food of animal origin, do not, as a rule, reject the use of milk, cheese, and butter. The intestinal canal in gouty patients is very susceptible to functional disturbances, and if we select a purely vegetable diet, the actual quantity of nourishment to be taken will be so great as to overpower the efforts of the bowel to manage it.

     "Amongst those things which Cantani recognizes as absolutely prejudicial in gout are the carbohydrates and fats. I agree with Cantani in restricting the use of the carbohydrates as far as possible. Under certain circumstances I forbid some of them entirely. To begin with, I may say that such restriction is necessary, for experience shows us that it is precisely under the influence of the carbo-hydrates that most severe forms of dyspepsia arise. Be then the bond between gout and dyspepsia what it may, let gout be the cause or the consequence of dyspepsia (I believe that in by far the majority of cases we have to deal with the latter state of affairs), be these things as they may, the limitation of the carbohydrates in general forms a very important part of the treatment of one of the most important symptoms of gout ; a symptom which as often as not will disappear under an alteration of the regimen in this direction. The articles which it is of most importance to limit temporarily, or better still permanently, are those which are distinguished by excess of starch, which is ultimately converted into sugar.
As regards fats the case is quite different.


     "I thought it would be useful to make some experiments myself as to how the secretion of uric acid was affected by moderate quantities of fat. A trustworthy healthy man, thirty years of age, was put under a diet containing fat in exactly known proportions. The urine was carefully collected and examined by Herr Jahns, apothecary to the university here. The determination of the uric acid was done in the usual way by treating the urine with muriatic acid, in the proportion of "0048 to every 100 c.c. of the mixture of urine and muriatic acid. The quantity of uric acid dissolved by the water used to wash the filtrate was put against the colouring- matter deposited, and not reckoned. The urea was determined by Liebig's method, as modified by Pfluger.

     "From these experiments this much may be gathered, that in a daily consumption of butter up to 120 grams, no increase of the secretion of uric acid takes place. If the prohibition of butter and fat in the regimen for gouty patients is based on the assumption that fat increases the production of uric acid, the statement cannot be justified as far as the secretion of the acid by the urine is concerned.

     "The butter was exceedingly well tolerated by the individual experimented on.

     "There is, then, no other ground for excluding fats from the mixed diet which we recommend in gout. All reasons which can be adduced against its allowance prove themselves weak ; and weighty indeed must be the reasons which would justify us in rejecting so important an article of diet as fat. But there are a number of circumstances which show us that fat is a very valuable food in gout, always within necessary bounds, and with adaptation to individual circumstances.

     "As regards Temple's recommendation that the individual experience of the patient should be taken into account, I grant at once that a certain amount of latitude should be allowed to him in the quantity and choice of different articles of diet. We can do this all the easier, inasmuch as amongst gouty patients we find a very great number of them to be highly intelligent, and (the two things are unfortunately not identical, as experienced physicians can ratify) relatively a goodly number of men who are both intelligent and amenable to scientific instruction. But a system of directions is not merely desirable, but also necessary, in order to keep the patient, for example, from lasting injury inflicted by a course of diet which an apparent success might delude him into thinking was a useful one. The essential point of these directions is to secure the due nourishment of the patient without overloading his highly sensitive stomach. In this respect fat is excellent. Its power of checking hunger, known to Hippocrates, plays an important part. In my book on "Corpulence and its Treatment" I have gone more fully into this point. In any case the use of fat does not allay the feeling of hunger by spoiling the patient's appetite, and causing nausea or other dyspeptic symptoms ; but, on the contrary, those forms of dyspepsia which are due to a diet over-rich in starchy foods are alleviated when part of the starch is replaced by fat. I have frequently, by this simple change in the bill of fare, seen obstinate dyspepsia, that had resisted every form of treatment, give way in the shortest time, and this, too, in gouty people. I grant that idiosyncrasies exist here as everywhere else, and that occasionally people are found who do not care for fat, or even good butter, to begin with, and who assert that they cannot bear these substances. In my experience such cases are very rare. I do not remember any such patient who for any length of time objected to good butter. But I may say that those persons who object to good fat as unbearable or unpleasant are very few compared with the great number of those who, in spite of their representations to the contrary, are forbidden fat by their medical attendants. Besides this, I have observed that where an idiosyncrasy against fat does exist, it is generally easily conquered in by far the majority of cases, especially if the patients observe that their prejudice was ill founded, and that their troubles get better under a diet in which fat has a place. I consider that fats are only really contra-indicated in those cases which are developed in consequence of mechanical insufficiency of the stomach (that is, where the muscular elements of the stomach are insufficient to empty its contents into the bowel in the normal fashion. That fat is advantageous in diseases of the stomach is asserted by earlier unprejudiced observers. I may state that so prominent a clinical teacher as C. Bartels, of Kiel, refused to eliminate fat from the diet of patients suffering from dilatation of the stomach, an affection which certainly forms a fruitful soil for the development of dyspeptic symptoms.
      "That fats of the best quality (and it is only such we should use both for the healthy and the sick) do not injure digestion is proved by physiological observations. The experiments of Frerichs in his classical work on digestion could only confirm the experiences of earlier observers, such as Tiedemann and Gmelin, Boucharclat and Sandras, Blondlot, Bernard and Barreswil, to the effect that fats suffer no actual change in the stomach, except that they are melted by the heat. C. A. Ewald has expressed himself in a like sense. Even though we accept as correct the statement of Ph. Cash, that the neutral fats are split up in the stomach into glycerine and fatty acids, yet physiological and pathological experience proves that no particular embarrassment arises from accepting the proposition.

     "In determining what fats are to be employed, regard must be had to individual circumstances. Furthermore, I may here remark that I have never seen disturbances of the alimentary canal arise from the introduction of an adequate quantity of fat into the diet of gouty patients ; on the contrary, fat suits them very well : and I may say this much, that the gouty process seems to be anything but unfavourable to the absorption of fat. The carbohydrates, although playing, according to Voit, a similar important part in keeping up the condition of the body as regards albumen, ought to be reduced to a relatively small quantity, on account of their greater indigestibility, in all cases where the gouty patient is inclined to dyspepsia. As a matter of fact, they may be unhesitatingly set aside in favour of that quantity of fat which is suitable to individual circumstances.

     "Another point to notice is this : We know that when hard work is required, a dietary into which fat enters is absolutely necessary. We shall see that we can give no better advice even to the gouty, and all of the gouty disposition, than to exercise their natural strength. A suitable ingestion of fat is by far the most appropriate and convenient method of enabling the patient to do that. The consumption, then, of a suitable quantity of fat being a point which was known, even in antiquity, to have a beneficial effect in satisfying the appetite of gouty patients, and in counteracting the tendency to excess, the next thing that is worthy of observation is, that there should be but scant choice in the details of the dietary. The danger which the variatio delectat brings with it is a specially great one in the case of the gouty, for if they take in any degree too much even of the kind of food which is allowed them, they run against the principle of limitation which is of such importance in the treatment. The gouty individual stands in the first rank of those who must eat merely to live. If ever he found any pleasure in living to eat he must wean himself from it as soon as possible. Sweets apart, our gouty friend may be as ticklish as he likes, but he must never be a glutton. He must cease to eat as soon as the first feeling of satisfaction comes on ; nor must he give way to the false appetite which comes on after this, and which if gratified brings him to the non possumus stage.

     "The reader will see that these principles agree in general with those which I have prescribed for the corpulent ; and as corpulence and gout go very often hand and hand, there is no difficulty in carrying out the treatment, but the same regimen will meet both indications. As a matter of course, gouty persons with a tendency to corpulence must be refused many things which a healthy fat man would be allowed to take. Amongst these things we may reckon many sorts of vegetables, such as cabbages and so forth. Whatever diet is used, it must be so adjusted and prepared as to give as little trouble to the stomach as possible, and so be best adapted to the nutrition of the individual. Potatoes, in so far as they are allowed in general, and leguminous vegetables had better be prepared as purees; and meat must be scraped or grated, and lightly fried in butter, for those who have bad teeth. Patients must be strictly enjoined to eat slowly and chew well, and if their teeth are defective should provide themselves with artificial sets. By acting on these principles and prescribing certain changes, both quantitative and qualitative, adapted to individual cases, we shall be able to limit corpulence in those patients who are inclined to it. We shall also find this to be the best means of supporting gouty patients who are not corpulent, and of keeping up their bodily condition so far as the gout will allow. Unfortunately, gout often enough causes severe derangements of nutrition, and it is specially incumbent on the medical attendant to limit and avert such derangements by means of dietetic prescriptions, never, however, allowing himself to give any impetus to the gout by denying the patient what is absolutely necessary. I consider it to be a thing not at all permissible, and very bad practice, to attempt to subdue gout by starvation cures and such like methods of treatment, which simply lower the strength of a patient, who has dangers enough to combat without this. Every case must be treated according to its own individual merits, within the framework of the principles laid down here, and no attempt must be made to cut the treatment to a uniform pattern throughout. Where corpulence has to be reduced it must be done slowly. Those cures for corpulence which act quickly are particularly unsuitable in the case of gout.

     "As regards relishes, such as condiments in general, vinegar, &c., only that quantity should be taken which is absolutely necessary to make the food palatable. Dishes which require much condiment to make them acceptable ought, as a rule, to be entirely avoided. Apart from many other disadvantages which the unrestricted use of condiments entails, they produce direct irritation of the mucous membrane of the intestinal canal if they are taken in any quantity ; and it is a primary indication with us to irritate the intestines as little as possible in cases of gout. Fruit, on the contrary, we may freely recommend to the gouty and those who have a tendency to gout.

     "Wohler, relying on facts observed by himself, has taught us that the vegetable acids with alkaline bases become changed into carbonates in the animal economy, and in view of the disadvantages which are entailed by a prolonged use of the alkaline carbonates, he recommends as a substitute the vegetable acids. The use of these is justified by the fact that they are not only pleasant, but can be continued for a long time without injury to digestion. Such fruits, therefore, as cherries and strawberries, which contain an organic acid, can be taken with good results, and are less injurious to digestion than the alkaline carbonates. Wohler mentions the so-called cherry cure, which enjoyed a special reputation in gout. He also takes notice of the strawberry cure, which was the means by which Linnaeus cured himself of a long-standing gout. Similarly, other fruits may be employed with advantage. I recommend them as far as possible as an integral portion of the diet. But when the cure is confined exclusively to the use of fruits, as, for example, in the grape cure, we must be very cautious. Dyspeptic troubles are easily induced by such means, and the mischief thus wrought counterbalances any good that may be derived from the fruit.

      "As regards the question of drink, pure water is in general the best drink for anyone, and gouty people are no exception."


Spittin'chips said...

Nice journey into history, George.


George G said...

Very interesting.
I didn't realise the LCHF diet had such a well documented history going so far back in the 19th century.
By the way there was an interesting episode on the Australian ABC science show this week, positively featuring LCHF diets.

George Henderson said...

That would have to be the best LCHF TV show yet, everyone came across as measured and responsible - goes to show what a difference sympathetic editing makes to a scientific discussion.

Lekkoduch said...

Thank you, thank you, thank you! I was looking for this for a long time!

Betsy said...

Very good article, George.