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Plus ça change, plus c’est la même chose

The more things change, the more they stay the same.

Not every post will be an in-depth, authoritative review of a topic like yesterday’s on Dr. Sears.  A change of pace can be nice, and I have always liked history.

JAMA likes to run articles called “JAMA 100 YEARS AGO” and the reprint from the July 24, 1909 issue is interesting. It is called  BUTTERMILK THERAPY.  They liked all caps at the turn of the century.

1909 was at the very beginning of the biologic sciences and the understanding of disease pathophysiology. Physicians had almost no useful, or more importantly, rigorously tested therapeutic interventions for diseases. So they relied on traditional method of determining what worked: expert opinion and anecdote. And that lead to buttermilk.

“Metchnikoff, Massol and several other authors have recommended fermented sour milk as prepared in Bulgaria, or a similar product, prepared according to Metchnikoff’s method from pure cultures of bacteria, as a panacea for many ills.”

Metchnikoff was a Russian microbiologist who won a Nobel prize in 1908 for discovering phagocytosis and was responsible for many early discoveries in the immune system and in host-bacterial interactions.  As a preeminent scientist of the time, his word was respected and carried weight.  As a side note, when he tried to commit suicide he did  so in a manner that would benefit science: he injected himself with the relapsing fever organisms and proved it could be blood borne, and while he evidently became very ill in the process, it failed to kill him.

Dr Massol was the discoverer of the Bacillus bulgaricus in buttermilk, now called Lactobacillus bulgaricus.  It was noted that childhood diarrhea responded to buttermilk, so Dr Massol investigated the microbiology of buttermilk to try and figure out why.
100 years later and they are still doing clinical trials to try and determine the effect of Lactobacilli on childhood diarrhea (2).

Under the pronouncements of a Nobel prize winner (where have we heard that before? Remember the Peter Principle (4)?  It was a book from the 1960’s.  The theory is that people rise in their profession until they reach a job at which they are incompetent, then they rise no further.  It explains why no one can do their job well.  A corollary is that if an individual masters an area, then they find another endeavor in which to become incompetent) buttermilk was suggested for many diseases:

 “Appendicitis, tropical dysentery, typhoid fever and other diseases are said to be cured or at least benefited by the treatment with sour milk or buttermilk. Intestinal putrefaction, intestinal autointoxication and some nervous and digestive derangement’s said to be brought about by these conditions are supposed to be favorably influenced by sour-milk therapy,”

In the early part of the century buttermilk became a fad and was widely consumed for its health benefits. Dr Kellogg, of Battle Creek and cereal fame, decried the hype of  buttermilk as a “panacea for nearly all human ill”, and of  “buttermilk germs in tablets and vials ..being dispensed by druggists and later by milk vendors thru out the civilized world (1)”.  I had no idea that the use of Lactobacillus was used therapeutically for over 100 years.  Probably the first cure of everything promoted by a Nobel laureate, but not to be the last.

 “According to Metchnikoff, the habitual use of sour milk prepared with the Bulgarian bacillus is conducive to long life. As support to this last suggestion it is stated that in Bulgaria there are relatively more centenarians than in other countries of Europe.”

Metchnikoff, who lived to be 71, was convinced on the basis of aging was due to intestinal putrefaction in the gut.  At the turn of the century there was a great deal of interest (in the case of Kellogg an obsession) with the bowels as a source of disease and especially intestinal putrefaction.  Metchnikoff considered the colon to be unimportant, feeling it served only as a place for putrefaction to occur, which could be, he thought, reversed by drinking buttermilk.  Others took his teaching to heart and a few surgeons did total colectomies on patients to reverse their ‘autointoxication’ from gastrointestinal putrefaction. Oddly, the colectomies were not effective.  Go figure.   Metchnikoff might have made whatstheharm.org if alive today.

At this distant remove, I cannot find the data to support the contention that Bulgaria and its population of the times had more people living to the age of 100.  I did  find some old information that suggested the life span of the average Bulgarian at the turn of the century was no greater than it’s neighbors. I will confess to suspicion as to the accuracy of longevity data from that time.  I remember, but cannot find, that the reason people in this part of the world lived to an advanced age was that they lied about their age.  I am sure the comments will confirm or deny this tidbit of (mis?)information.

I did not realize that the worry about the obsession with toxins brewing in the bowel had such a long, pseudoscientific history.  Today’s toxic colonic sludge that must be cleansed was yesterdays intestinal putrefaction.  The names may change, the obsession is eternal.

 “Other factors, however, such as race disposition, outdoor life and absence of effeminating luxuries, which might contribute to a similar result, have not been given due consideration. “

‘Absence of effeminating luxuries.’  I wonder what the Bulgarians lacked in  effeminating luxuries that lead to long life?  Clean water, flush toilets and vaccines I would wager. See? Vaccines are evil I tell you. Evil. There are effeminating luxuries.

“The influence of sour milk on intestinal putrefaction and intestinal bacteria has been investigated by many observers. Thus Combe, Cohendy, Löbel and other French, German and English authors have published the results of experiments and clinical studies, from which they conclude that the extensive consumption of sour milk is decidedly beneficial. “

I cannot find the experiment of Combe, and Lobel’s studies are in German, which I cannot read. Cohendy (3) did an experiment on himself where he noted the amount of intestinal putrefaction (somehow testing the urine) on a regular diet then followed by a diet that included Lactobacillus and he noted a change for the better in the intestinal putrefaction.

“The success of the treatment is universally ascribed to the lactic acid in the milk or the lactic acid assumed to be produced by the bacteria in the digestive tract. The evidence, however, is by no means convincing. The work of many is characterized by lack of proper control and by neglect of the possibility that other factors might have influenced the results, and it is not altogether safe to accept the sanguine conclusions published. Metchnikoff, Massol and several other authors have recommended fermented sour milk as prepared in Bulgaria, or a similar product, prepared according to Metchnikoff’s method from pure cultures of bacteria, as a panacea for many ills.”

A true scientific thinker.  The author recognized the importance of controls in evaluating outcomes of therapies and the importance of eliminating confounding variables.  Cohendy’s ‘study ’was an anecdote, and while interesting, is useless in determining efficacy of a therapeutic intervention.  It is what makes clinical trials difficult and the problem with many of the trials of so called alternative therapies: no controls and an over reliance upon anecdotes.  Science based medicine has evolved since that time, I am not sanguine that the so called alternative therapies ever will.

There is an ongoing theme in this blog:  it is difficult to determine whether or not a therapy actually works unless you remove all the confounding variables and biases.  In 1909 this was beginning to be recognized, but not a common approach to the study of medicine.

He then moves on to another ongoing theme of this blog: biologic plausibility and of clinical relevance of the findings, issues that plague alternative medicine and some dietary therapies to this day.

“It has never been shown conclusively that lactic acid bacteria produce lactic acid in the digestive tract in sufficiently large quantity actually to inhibit putrefaction. The experiments of some observers, who have made deductions from the results of a sour-milk diet to the exclusion of all other food, are of little value, since it is not likely that any one would live on such a diet except for experimental purposes.

“Some rather absurd statements are found in the literature on the subject. For instance it is stated that milk should not be heated before using lactic ferments, since heating destroys the natural lactic acid bacteria present, and that consequently their restraining influence on injurious bacteria is lost.”

The naturalist fallacy was popular then and lives on today. I blame Rousseau, however,  for the reason we act like Clouseau.

“The inhibition exerted by the few lactic acid bacteria in fresh milk is negligible as compared with the antagonistic influence of the enormous numbers of lactic acid bacteria in artificial cultures which are used for inoculation of the heated milk. The bold assertion that the intestinal flora can be changed at will by introducing lactic acid bacteria seems to be without sufficient evidence. The reduction of putrefactive products when sour milk is taken is ascribed solely to the activity of lactic acid bacteria or the lactic acid produced by them.”

Of course, proponents ignore alternative explanations for why their theory may be in error.

“It has not been considered that sweet milk and carbohydrates with a simultaneous reduction of meat in the diet might possibly have a similar effect. In regard to buttermilk, it does not seem to have been taken into account that the precipitation and fine distribution of the casein, the reduction of the amount of fat and the partial conversion of the milk-sugar into acid may be factors largely responsible for beneficial results.”

Since buttermilk has no therapeutic benefits, except to make for delicious biscuits, in hindsight the facts of the argument are not valid, but the conceptual framework is: consider that your intervention is in error.  Do not try to prove it right,  and instead try and prove it wrong.

State of the art medicine of the day was full of experimental errors that rendered the results useless.  It still occurs in medicine, but not as often as the old days.

“Recently pure cultures of lactic acid bacteria, especially of the B. bulgaricus, have been recommended for reducing and curing abscesses, catarrh and other troubles caused by pyogenic bacteria. The principle involved is the antagonism of lactic acid bacteria to pyogenic bacteria, the acid produced by the former inhibiting the latter. This theory is attractive, but the evidence in its favor is, as yet at least, meager and unscientific, because of the absence of control observations. “

Again the emphasis upon relying on carefully controlled trials before embarking on therapeutic interventions. Going from diarrhea to abscesses and cararrh (snot from an ENT inflammation) is not reasonable as they have different etiologies.   If a single intervention of an unproven therapy can affect three diseases of widely varying pathophysiology and etiology, be wary as to its validity, in 1909 or 2009. In medicine, treatments of everything are usually treatments of nothing.

The importance of reproducibility from a variety of lines of evidence is then mentioned.

“More evidence and that, too, of varied nature is required before reliable conclusions can be drawn.”

Do not rely on a single study to make a decision if you can.  Like evolution or relativity, the validity of medical therapies should be verified from reproduced,  multiple independent sources of evidence.  All too often in alternative medicines the story is one of increasingly well done studies with decreasing efficacy until the best studies demonstrate no effect, but a continued reliance of earlier, poorer quality, studies to validate the intervention.

He then mentions the importance of using standard preparations of know potency.  Always an issue in the herbal world, where variability from lot to lot makes it impossible to know the ingredients and concentrations what you are taking.

“When possible, it is better to obtain pure cultures from reliable laboratories where frequent transfers are made so that the purity and activity of the organisms are preserved. “

Buttermilk is no longer used as a natural cure, although a google will find the occasional suggestion it be used to gastrointestinal diseases.

The name of the author is not mentioned, whether because it was not known or because he wished to remain unknown. Perhaps the name Orac was already taken? But he could have been a blogger on SBM.

“Those who cannot remember the past are condemned to repeat it.”
George Santayana

“And those who do remember it are going repeat it anyway.”
Crislip’s addendum

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References

(1) http://books.google.com/books?id=dPEAAAAAYAAJ&pg=PA432&lpg=PA432&dq=Massol+buttermilk&source=bl&ots=j42Lli9FEy&sig=5PeWL9CL3Itd0w5eYBr_Kc5JrKI&hl=en&ei=j4lsSszRMI-eswOyzqmXBQ&sa=X&oi=book_result&ct=result&resnum=6

(2) http://www.bmj.com/cgi/content/full/335/7615/340?view=long&pmid=17690340

(3) http://books.google.com/books?id=yyre1C1wceoC&pg=PA185&lpg=PA185&dq=Cohendy+sour+milk&source=bl&ots=ac4WuszPBi&sig=8ieAQ0FqXX-opZOUlKt5Q4OXeD8&hl=en&ei=YpRsStnzBojCsQOksaWWBQ&sa=X&oi=book_result&ct=result&resnum=1

(4) http://en.wikipedia.org/wiki/Peter_Principle

Posted in: General, History, Science and Medicine

Leave a Comment (4) ↓

4 thoughts on “Plus ça change, plus c’est la même chose

  1. Nice post. The Santayana quote is fitting. Plus, I keep having this thought come up in my mind whenever I come across great posts like this one, or like this, from the LastPsychiatrist:
    http://thelastpsychiatrist.com/2009/05/ramachandrans_mirror.html

    http://thelastpsychiatrist.com/2008/11/how_to_treat_vertigo.html

    What does it take for us to benefit from someone else’s discoveries, or insight, or knowledge?

    As noted, medicine (and CAMWOO) draws strongly upon clinical observation, and training. But medicine (and CAMWOO) could benefit from so much more.

    Consider this: the old testament book of Daniel starts with a controlled trial of diet for fitness/preventing illness. Whether a true story or not, and whether the effective ingredient was or was not God are points for discussion, but the power of the controlle trial should have, nonetheless, been apparent to at least one of the thousands exposed to this writing. “Daniel” has been fairly broadly known for 2300+ years, yet we have been slow to capitalize on the concept of the controlled trial.

    A thousand years later, Avicenna again introduced the power of the controlled trial. Again, this powerful piece of methodology went over like a lead balloon.

    Then, 700 years after Avicenna, James Lind conducts a controlled trial, with a resulting history of influence contiguous through to the present day.

    What if we humans had recognized the power of a controlled trial in 500BC, rather than 1750 AD? This was not an idea one guy had, and kept to himself.

    SBM is doing a good job of getting us all on the same intellectual page, so we can benefit from helpful stuff, such as the superiority of controlled trials over observational case studies, and put the kookiness to an end. I appreciate the posts, SBM.

  2. Calli Arcale says:

    Concern about bowel health as the source of all illness is very old indeed. You can find some rather hilarious references to it in the play “La malade imaginaire” (The Imaginary Invalid) by the French playwrite Moliere, first performed in 1673. The title character is obsessed with his health and is quite definitely hypochondriac. Doctors have been milking his hypochondria for all its worth, and now he’s pressuring his daughter to marry a doctor so he can get free medical care. Of course, “medical care” in those days was almost entirely quackery, and Moliere makes this opinion abundantly clear. ;-) One of the most commonly mentioned interventions in the play is the enema. The invalid is obsessed with enemas.

    I think the reason why colon health has always been big in unscientific medicine is simple because it’s easy to influence it. You know you’re achieving *something*, even if it’s not an actual cure, and that would make it easy to think it had actually worked.

  3. daedalus2u says:

    Elie Metchnikoff is quite an interesting character.

    http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=14321564

    Interesting that he chose relapsing fever to try and kill himself. This was ~1880. He lived until 1916, without mention of further depressive episodes. Relapsing fever was used to treat neurosyphilis by Wagner-Jauregg in Fever Therapy (for which he was awarded the Nobel Prize in 1927). Fever Therapy was also used to treat a number of other neuropsychiatric disorders, all of them now known to be characterized by reduced cerebral blood flow.

    Neurosyphilis is characterized by reduced cerebral blood flow and reduced cerebral O2 consumption. These are restored acutely during Fever Therapy (induced by malaria or typhoid pyrogens)

    http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=14778896

    Depression is also characterized by reduced cerebral blood flow and reduced cerebral O2 consumption which increases as the depression improves. I wonder if there was a resolution of his depression following his “self-medication” with relapsing fever? If so, I attribute it to NO from iNOS.

  4. David Gorski says:

    This post reminds me of a topic I had been meaning to take on for a long time now. Suffice it to say that it involves toxins. (Oh, no!) I’ll leave it at that for now.

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