July 3, 1897
Dr Armstrong talks about using the Salisbury meat and water treatment for gout patients and heartily recommends its use after three and a half years of experience.
The Value of an Exclusive Red Meat Diet in Certain Cases of Chronic Gout
ABOUT seven years ago I saw two patients, one suffering from severe chronic gouty arthritis and the other from recurrent uric acid calculi, in both of whom, after all routine treatment had failed, cure was effected by the so-called " Salisbury" treatment, prescribed and directed by a lady. Taking for many weeks nothing but red meat and hot water, these patients certainly made wonderful improvement, which, in spite of a gradual return to an ordinary dietary, persists to this day. It seemed to me that this treatment possessed some element of usefulness, but that it ought neither to be used indiscriminately nor without medical guidance. The only English book on the subject, which quickly obtained and still has a large circulation among the laity, was written in a tone and spirit which did not encourage the medical profession to give this method a thorough trial; but the patients whom I had tried in vain to help, and for whom I had sought the best special advice without good result, were so evidently benefited that I have since then given this diet a careful trial, more especially during the last three and a half years, when I have been afforded in Buxton exceptional opportunities for selecting suitable cases for its use and for watching its effects. The indefatigable and painstaking work of Dr. Alexander Haig and the careful and ingenious experiments of Dr. A. P. Luff, which latter, placed before us in the recent Goulstonian Lectures,” have excited so much interest, indicate that the red meats or their salts are in themselves harmful to the gouty. Having for the last three years been working on the subject of auto-poisoning in relation to the causation of out, some forms of rheumatoid arthritis, and allied ailments, had been led to doubt whether that is so, or whether it is not the admixture of food of other classes with the red meat which causes complex chemical changes leading to the formation (whether in the blood, tissues, or kindeys) of an excessive quantity of uric acid. The able and suggestive work of Dr. Lauder Brunton has done much to stimulate medical opinion on this subject, and has given us a better understanding regarding the chemical changes which take place during digestion and their clinical significance; while the researches of Gautier and Bouchard have added to our knowledge of “the self-poisoning of the individual."
The course of treatment, which lasts from four to twelve weeks in its strict form, is as follows—subject, of course, to such modifications as the condition of the patients and their progress demand. The bowels having been thoroughly relieved the patient begins to drink from three to five pints of hot water daily; the temperature of this should be from 100° to 120°F.; a little lemon juice may be added, and it should be drunk in sips. One pint should be taken at least one hour before each meal, and the same quantity at bedtime. The food should consist at first of beefsteak from which all fat, gristle, and connective tissue have been removed; this should be thoroughly minced, a little water being added, and then warmed through with gentle heat until it becomes brown in colour and perfectly soft and smooth; it can be eaten thus or else made up into cakes and cooked on the grill. On the minced meat may be put the poached whites of from two to four eggs per day. The only bread allowed is a half slice, cut very thin, and thoroughly torrified in the oven, with each meal. A little salt or pepper may be added to the meat, or a little mustard freshly mixed with lemon juice. As the treatment progresses a little of the steak may be given grilled, or a lean mutton chop; very little or no fluid should be given with the food. The quantity of the meat given is from one pound to four pounds in the twenty-four hours. During the latter part of the treatment a grilled cod-steak is often ordered Alcohol should be avoided; if absolutely necessary a little good whisky with cold water may be given with food; or a cup of weak tea with a slice of lemon, or a cup of black coffee may be taken. The immediate results experienced are a feeling of hunger and a difficulty in drinking so much hot water; these difficulties soon disappear, although the feeling of “emptiness” due to the stoppage of the carbohydrates often persists. There is also a marked diminution of the abdominal girth and a more or less rapid loss of flesh, especially in those who are fat and flabby; but walking is much easier and the breathing is often greatly relieved. The urine at first is often scanty and loaded with urates, which indicates either the necessity for adding some freshly prepared citrate of potash to the hot water given in the early morning and late evening, or else an increase in the quantity of water drunk. The bowels become constipated, the motions being scanty and dark coloured. An aperient is often necessary. After the first two or three weeks the patient begins to feel weak and easily tired, and it is wise at this stage to limit the amount of exercise taken, substituting in some cases a little massage; but before the conclusion of the course the strength returns, and stout patients especially feel the benefit of the diminished weight.
The changes due to the treatment are very marked. The swelling of the joints diminishes, the aching and soreness are greatly relieved, and the mobility is considerably in creased. The patient becomes brighter, and work, both mental and bodily, is done with pleasure instead of with trouble and effort; acidity, pyrosis, heaviness, distension, and oppressed feelings after food disappear, flatus is greatly diminished in quantity and becomes much less offensive, and the perspiration loses the disagreeable odour so frequently present in these cases. The urine becomes more copious and clearer, and does not give the reactions to nitric acid and ferric chloride mentioned later. and the oxalates and uric acid are materially decreased. The indications for the adoption of this treatment seem to me to be : (1) obstinate and refractory chronic gouty arthritis; (2) recurrent uric acid calculi; (3) frequent and intractable migraine; and (4) obstinate gouty dyspepsia. The treatment appears to be indicated more especially if any of the following symptoms are present : (a) amylaceous and intestinal dyspepsia; (b) acidity, pyrosis, and flatulence; (c) heaviness and irritability after food; (d) excessive formation of sulphuretted hydrogen in the large intestine, disagreeable smelling perspiration, and offensive breath; and the following conditions of the urine : (e) persistent lithiasis; (f) oxaluria; (q) excessive formation of indican ; (h) purple or red reaction with nitric acid; and (i) wine-red reaction with ferric chloride.
I am sure that where either damaged kidneys or a weakened heart are present exceptional care should be taken; in fact, many of these cases are quite unfit for the treatment. I do not say all, advisedly, as I have seen several cases in which both unsound kidneys and heart have been greatly relieved, but such patients require daily watching and the exhibition of great care, experience, and discretion. The above mentioned symptoms, I would venture to submit, bring us face to face with the great question of auto-poisoning. I have been greatly impressed by the sudden subsidence of severe chronic gouty arthritis in five cases. In three of these it followed what were described as “very severe bilious attacks”; and in two it came on after severe and spontaneous attacks of diarrhoea; the relief was immediate and complete, and for several weeks the patients kept better, but gradually the old symptoms began to return, and in three months after the sudden improvement they were as bad as ever. No doubt also many of us have observed how severe attacks of deltoid rheumatism of many weeks' standing have been at once removed by a mercurial purgative. These facts seem to me to point to the possibility of poisons generated in the alimentary canal setting up affections of the joints. Bouchard describes certain articular enlargements which he contends are almost always present, more or less, in cases of gastric dilatation. That a very considerable number of ptomaines, leucomaines, and toxins are formed in the ali mentary canal seems to be beyond doubt, as is also the fact that they are taken up by the blood and appear in the urine.
A most important discovery was made by Gautier in 1885, when he found that poisonous alkaloids were continuously being formed in healthy men and animals by decomposition in the intestinal canal during the process of digestion or in the blood and tissues generally by the metabolism which occurs during the functional activities of life. It seems to me that if we have either an excessive formation or a deficient elimination of these toxic products we get a con dition of self-poisoning, which may be either slight and transient, severe and lasting, or, what I believe to be more common still, a daily storage of small quantities of noxious matter which gradually undermines the health, leads to deterioration of the nervous system, and disturbance of the nutrition of some or all of the structures of the body; and it seems likely that vital action is much more quickly interfered with through the accumulation of waste products within the organs than by any want of nutriment of the organs themselves. Aitken, writing on gout and rheumatism, says: “They are such diseases as become developed under the influence of agents generated within the body itself through the continuous exercise of its functions in the daily course of nutrition, development, or growth.” That marked symptoms of poisoning do not more frequently occur is due to the physiological processes continually going on in our bodies: (a) the elimination of the poisons by the kidneys, liver, skin, lungs, and the lining mem brane of the bowels; and (b) their destruction by oxygenation, the leucomaines being burned up in the blood. That the urine contains toxic products was made clear by the researches of Mr. Reginald Harrison, our esteemed President, concerring so-called “catheter fever” when he gave his adhesion to the following important conclusions: (1) In health alkaloids exist in the living subject; (2) these arise in the intestinal canal through the action of putrefactive intestinal organisms; (3) the alkaloids of normal urine represent a practical part of these alkaloids absorbed by the intestinal mucous membrane and excreted by the kidneys; and (4) diseases augmenting intestinal alkaloids augment in consequence the urinary. Dr. Lauder Brunton suggests that one set of poisons is probably allied to uric acid, and includes guanidine, methyl-guanidine, xanthine, and other derivatives of urea. A very interesting statement has been made that while the greatest part of the products of albuminous waste is in health secreted by man in the form of urea with very little uric acid, in disturbance of nutrition (as by self poisoning, affections of the nervous system, &c.) the quantity of uric acid is enormously increased. It has also been suggested that as pyrocatechin, a body of the aromatic series frequently found in urine, is known to have a poisonous action on the spinal cord it may probably interfere with the joint centres, an thus set up reflex trouble in the articulations. To those who entertain the opinion, so generally held, that the various toxins are formed from the decomposition of animal food it will not be at all clear how a meat dietary, even with the aid of hot water, can alter this condition ; but Brunton and Macfadyen have shown that “the same bacteria which form a peptonising enzyme on proteid soil can also produce a diastatic enzyme on carbohydrate soil”; and, further, that “the same bacilli, when grown in starch paste instead of in gelatin or in beef-tea, produced a different ferment, which would convert starch into sugar, but which would not act upon gelatin.” Bouchard, again, strongly condemns bread, with the exception of the outer crust, on the ground that the process of baking, although it has interrupted the fermentation, has not stopped it altogether, and that this fermentation re-appears when moisture and temperature are again favourable to it, and from this are formed acetic and butyric acids, leucin, tyrosin, and phenol in large and poisonous quantities. The difficulties of a mixed diet of meat and carbo-hydrates in the gouty state are that the latter are so much more easily oxidised, and are therefore more readily consumed in the system than the albuminous compounds, and thus prevent the disintegration and oxidation of the latter; and also that vegetable albumin less easily undergoes disintegration than animal albumin. In gout disintegrative changes in the albuminates are arrested, and insufficiently oxidized substances remain in the blood; and in this connexion it is of importance to note that under a diet of animal food more oxygen is retained in the system than when starchy foods are taken in excess. The microbes subsisting on starchy food, milk, and cheese may be got rid of by a purely meat diet and vice versá, the offending microbes being starved out.
I would now ask the question whether, from the foregoing facts and theories, it is possible to suggest any scientifically satisfying reason for using this dietary. And in reply I would submit that meat taken as suggested is easily and readily digested; that the process of digestion is more com plete and perfect, and is almost entirely free both from the processes of fermentation and putrefaction, and from the toxic products thereof; and also that there is a more complete oxidation of the food taken, and therefore less waste and morbid material remaining in the system. Whatever poison does remain is more promptly eliminated by diuretics than by any other means, and no diuretic is more efficient than a free supply of water, especially when taken into a comparatively empty stomach. The exceptional power of water as an eliminator has been well shown by the researches of Sanquirico into the lethal doses of various drugs. There can be no doubt also that water has a direct flushing effect on the stomach, kidneys, and liver. It has been suggested to me that, while a very much improved condition of the general health might be brought about by the stimulating effects of a diet of red meat, the uric acid in the system would be driven into the joints to their great detriment, and that when this diet was discontinued most serious relapse would occur, the last state of the patient being much worse than the first. I have watched this point most carefully, and in a number of cases I have gradually brought the patient down from a meat diet to a carefully arranged mixed dietary, and in eight cases still further to the meat-free dietary recommended by Dr. Alexander Haig, without any such result being observed. Had space permitted I should like to have submitted the detailed notes of cases of chronic gout and recurrent renal calculi treated by this method. In some respects the latter cases are the more interesting, for in spite of the continuous taking of solvents they were, up to the time of taking this dietary, frequently passing uric acid calculi. With the exception of a few small stones passed shortly after the commencement of the treatment (in less than half the cases only) no further formation took place, although the use of all solvents was discontinued. My experience of the sc-called “Salisbury” dietary has led me to form the following conclusions, which I venture to submit for consideration and criticism: (1) that a certain number of cases of chronic gouty arthritis, recurrent uric acid calculi, and gouty dyspepsia, with fermentative changes, which have proved refractory to ordinary methods of treat ment and dietary, may be treated by means of an exclusively red meat dietary, plus hot water drinking, with excellent results; (2) that this method of treatment is irksome and trying, and as, unless it is carried out strictly in the first instance, it is apt to do harm it should only be used in those cases where other methods have failed or are thought likely to do so; (3) that the cases require careful selection and close medical supervision, the details being modified according to the needs of each individual patient; (4) that those who suffer from persistent albuminuria or organic heart disease are in most instances unfit for this treatment— when, however, it is prescribed for them its course should be watched daily; (5) that certain cases of chronic gouty arthritis which fail to improve while on a mixed diet recover equally well whether on this dietary or on the meat-free dietary suggested by Dr. Alexander Haig; (6) that it is of the utmost importance that no addition, however small, of carbohydrates, saccharine matters, or fruit be made to the dietary during the first few weeks of treatment, very slight acts of carelessness in this respect having often caused disappointment and failure; and (7) that used with due care and discretion this method is a most efficient, and sometimes even a brilliant, addition to our therapeutic resources, but that it is only necessary in some 3 or 4 per cent of gouty cases treated.