the· antihistamines ·. ·. sal eosinophiles be- .. s were not statisti- ~ations on the Cyto- ons in Allergy of the :l Sinuses. J. Allergy and Kessler, W. R.: Practice, St. Louis: ompany, 1957, p. 119. r>uld be addr...ssed to: fl, U.S.AF. (M.C.) orce lospital (A.F.S.C.) f?, Texas 78236 . communication leSt, a slap on 1lish communi- means aJI one rhen one holds leed when one I had any, to lrder to make r between me [ give him, or nvolving a lot 'I .'I .. ,. JO UlC two or r way through cal about the 1se to develop ommunication put it forwani '-GEO:RGE H. NNALS OF ALLEJIGY I Sin<:~ many_ people have individual tolerances and intolerances to various foods, an allergy elimination diet may be a very ef!ective gallbuulder diet in gallb'/adder disease. ALLERGY ELIMINATION DIET AS THE MOST EFFECTIVE GALLBLADDER DIET FoR DECADES a standard "gall- bladder diet" has been routinely used in treating all forms of gallbladder dis- ease. This diet usually excludes cate- gorically fats, oils, greases, spices, con- diments, herbs, cabbage, "gas-forming vegetables," creams and gravies. This formidable list of "forbidden fruit" is casually handed out by the physician who is usually unaware of the severe dietary privation this really imposes on the patient. If these "forbidden fruits" are to be totally excluded from one's diet, most of the average American type diet would have to be withheld. Any patient who submits to such un- pleasant therapy is certainly entitled to exoect hiszhlv rewardin~ results. How- ever, the critical physician is aware that only a few patients receive significant benefits from such a regimen of man- agement. FrP-rment diet theranv failnr~ in .& . & ,I - spite of this severe regimen of priva- tion prompted this investigation to de- termine what role diet management should play in the care of the gallblad- der patient. Tne questions to be an- swered: 1. Is there a place for diet therapy in pDbladder disease? 2. If so, must the diet be so severely restrictive? VOLUME 26, FEBRUARY, 1968 J. C. BRENEMAN, M.D. 3. What is the best method for selecting an effective diet? There are three probable reasons why diet therapy in the gallbladder patient has yielded such equivocal results. ( 1) Patient noncompliance, ( 2) limited dietary efficacy, and ( 3) the nonspeci- ficity of the term gallbladder disease. , 1. To peruse the usual hospital diet used for gallbladder patients is to un- derstand that one outstanding reason for "equivocal results" is noncom- pliance. If the patient were to refrain from eating the "forbidden fruit,· scores of foods would be removed from his diet. A typical "gallbladder diet"• forbade 28 speciflc foods and 19 group- type foods: each group-type food, e.g. "spices," contained four to 20 individual foods. Strict compliance with this par- ticular diet example would make it necessarv for tbe tl.allbladder uatient to exclude ·a total of over 100 individual foods from hfr diet. Any patient who conscientiously adheres to such .a re- strictive regimen is certainly entitled to .. .. . ., " • , •. n oener untn ~u1vuciu rm.uu~. 2. A second variable is the individual patient who has individual tolerances and intolerances. Being afflicted with • Dietary Department, Borgen Hospital. Kalamazoo, Micfaigan. 83
Transcript
the· antihistamines ·. ·. sal eosinophiles be- .. s were not statisti-
~ations on the Cyto-ons in Allergy of the :l Sinuses. J. Allergy
and Kessler, W. R.: Practice, St. Louis:
ompany, 1957, p. 119. r>uld be addr...ssed to: fl, U.S.AF. (M.C.) orce lospital (A.F.S.C.) f?, Texas 78236 .
communication leSt, a slap on 1lish communi-means aJI one
rhen one holds leed when one I had any, to lrder to make
r between me [ give him, or nvolving a lot
'I .'I .. ,. JO UlC two or r way through
cal about the 1se to develop ommunication put it forwani '-GEO:RGE H.
NNALS OF ALLEJIGY
I
Sin<:~ many_ people have individual tolerances and intolerances to various foods, an allergy elimination diet may be a very ef!ective gallbuulder diet in gallb'/adder disease.
ALLERGY ELIMINATION DIET AS THE MOST EFFECTIVE GALLBLADDER DIET
FoR DECADES a standard "gall-bladder diet" has been routinely used in treating all forms of gallbladder dis-ease. This diet usually excludes cate-gorically fats, oils, greases, spices, con-diments, herbs, cabbage, "gas-forming vegetables," creams and gravies. This formidable list of "forbidden fruit" is casually handed out by the physician who is usually unaware of the severe dietary privation this really imposes on the patient. If these "forbidden fruits" are to be totally excluded from one's diet, most of the average American type diet would have to be withheld.
Any patient who submits to such un-pleasant therapy is certainly entitled to exoect hiszhlv rewardin~ results. How-ever, the critical physician is aware that only a few patients receive significant benefits from such a regimen of man-agement.
FrP-rment diet theranv failnr~ in .& . & ,I -
spite of this severe regimen of priva-tion prompted this investigation to de-termine what role diet management should play in the care of the gallblad-der patient. Tne questions to be an-swered:
1. Is there a place for diet therapy in pDbladder disease?
2. If so, must the diet be so severely restrictive? VOLUME 26, FEBRUARY, 1968
J. C. BRENEMAN, M.D.
3. What is the best method for selecting an effective diet?
There are three probable reasons why diet therapy in the gallbladder patient has yielded such equivocal results. ( 1) Patient noncompliance, ( 2) limited dietary efficacy, and ( 3) the nonspeci-ficity of the term gallbladder disease. ,
1. To peruse the usual hospital diet used for gallbladder patients is to un-derstand that one outstanding reason for "equivocal results" is noncom-pliance. If the patient were to refrain from eating the "forbidden fruit,· scores of foods would be removed from his diet. A typical "gallbladder diet"• forbade 28 speciflc foods and 19 group-type foods: each group-type food, e.g. "spices," contained four to 20 individual foods. Strict compliance with this par-ticular diet example would make it necessarv for tbe tl.allbladder uatient to exclude ·a total of over 100 individual foods from hfr diet. Any patient who conscientiously adheres to such . a re-strictive regimen is certainly entitled to .. .. . ., " • , •. n oener untn ~u1vuciu rm.uu~.
2. A second variable is the individual patient who has individual tolerances and intolerances. Being afflicted with
Medications of Post-Type of Cholecystectomy Causing
Sex _-'nne Syndrome Guilty Foods" Symptoms --- ------·--- -·--
1 F 1.3,15,16, Novocain 63 2 F multiple 1.2.3, 17 64 3 F multiple 1.8.9.20 65 4 F multiple 1 ,4,9 Tetrazets 66 5 F multiple 1961 1.3. 7.8,20 67 6 F single 1950 1.3.12.21 68 7 M multiple 1.3 69 8 F multiple 1954 1.3.4,9.12 Tetrazets 9 F multiple 1,3,4. 7,9.13.16.21 Aspirin
10 F multiple 1961 1.3.4.5, 14 11 F multiple 1.2.3.4.19.21 morphine sulfate 12 F multiple 1958 2,3,11,21 13 F 1,9 14 F multiple 1.9 15 F multiple 1.2.3.4.12.14.15 16 F multiple 1.3 17 F multiple 3 l8 F multiple 1962 1,2,3 19 F multiple 1.4 20 M single 1.3.4 21 F multiple 1958 1.8 22 F 1954 1.3.4.8,9.11 sulfa 23 F 1954 _1.6.7 gall 24 F 1,3.4.7.8.13 25 F 1953 1.3 fact 26 F 1,3,4,7,13 pati 27 F 1,7,9 28 M multiple 1.3.7,14,21 reru 29 F 1.12 forr 30 F 1.2.3 31 F 1.5.9,12.20 mig 32 F 1,8 fooc 33 M multiple 1.4,7.9 Cm 34 F 3.4.13 35 F 1.12.13,21 be 36 F multiple 1960 1 tiet1 37 F multiple 1.3 .4.9.16.21 38 F multiple 1.3,4 3 39 F multiple 1.2.3.4,9 dist 40 F 1,3.4.8.14 se i 41 F 1.3.4,21 sulfa 42 F multiple 1,3.4,9 spe 43 F 1 .2.4:8,9, 12,21 blac 44 F 1 A,9.12.16 45 F mu•tiple 2.3.4, 11, 14.21 ver! 46 F multiple 1,3,4, 7,8,9, 13 the1 11"'1 C muftip~a 1,3,4,9,21 I .. , . ofa 48 F single 1,2.3,9,13.16,21 49 F multiple 1,3,4,7,14,16,18 50 F multiple 1 ,2,3,4,9,20,21 penicillin Seli 51 F multiple 1948 1.2.4.21 52 F 1,4,8,9, 13.16.18 (
i: L2.4.13 bla< 54 F 1,2,3.12,21 55 M 1.3,9.12,21 sulfa bee 56 F 1.3.4.9 penicillin. per1 57 M multiple 1,2,3.4,8 58 M multiple 1964 1.3.4 ger; 59 F multiple 1.2.3.13,12 penicillin, aspirin this 60 F multiple 1 lNa 61 F multiple 1.3.4,9.11 62 F multiple 1,4.16,21 dut 84 ANNALS OF ALLED.4.ff VOL
gallstones certainly doesn't change this fact. Past efforts to pigeonhole these patients, diet-wise, certainly is another reason for "equivocal results." Even the formidable list of "forbidden foods" might not exclude all the off ending foods from all gallbladder patients. Conversely, most foods excluded might be absolutely tolerable in a given pa-tient.
3. The third wriable involved is the disease itself. Ga11bladder disease per se is very nonspecific. To evaluate any specific therapy a specific type of gall-bladder disease must be treated. Con-versely, one cannot expect one form of therapy to he effective for all discas:::s of a particular organ.
Selection of Materials Cho)elithiasis was thP ctv>PiA.n nalL - -..- - ---- c,-·-
bladder disease chosen for this study because its diagnosis is virtually 100 percent accurate by either x-ray or sur· gery, or both. In the patients selected this evidence consisted of unquestioned X·ray evidence, palpation of gallstones during exploratory surgery, or the surgi-Vot.u:r.n: 26, FEBRUARY, 1968
cal confirmation of cholelithiasis. Pa-tients were not excluded from this study after· the gallbladder had been surgically removed if they had a post cholecystectomy syndrome~ It was thought that continued intolerance to the same foods might .explain the post cholecystectomy syndrome on the basis of continued food sensitivity, Sixty-two female and seven male patients were randomly selected who satisfied the above criteria. They ranged in age from 31 to 79 years.
The second selection was an appro-priate dietary regimen to test these var-iables. The one that best fulfilled the requirements of the study was a stand-ard elimination diet plan similar to that used in food allergy study.
Procedure Each patient was placed on a basic
allergy elimination diet which in this case consisted of beef, rye, soybean, rice, cherry, peach, ap'icot, bset and ,pmach. Since a food intolerance might represent a food allergy, antihistamine therapy was used to exclude this possi-
M
ALLERGY ELIMINATION DIET-BRENEMAN
TABLE II. INCIDENCE Of FOODS INDICTED ------· Food Number of Food Number of
36 or 52% 24 or 34.8% 17or24.7% 15 or 21.7% 13 or 19% 10 or 14.5% 10 or 14.5% 10 or 14.5%
bility. This was given in the form of a long-acting antihistamine capsule twice a day during the first week. 0 At the end of the first week the antihistamine was stopped and additional test foods were added to the diet. No fat restric-tions were imposed. When a patient experienced gastrointestinal symptoms comparable to his previous "gallbladder attacks,., or "spells" this food was dis-continued and not retested for several weeks. Severe and prolonged reactions seemed to respond more quickly to re-use of antihistamines. This process was carried out until all the regular com-ponents of his usual diet had been test-ed. Retesting of questionable and in-criminated foods was done several times to be sure that each offending food was, indeed, guilty of producing the "gallbladder syndrome."
Results A'it-h· tiPnt '' , ftn' . • • !. __ t;: pa ___ -· .s were reuevea o err
symptoms at the end of one week's use of tl,e basic elimination diet. H usually took three to five days for the symptoms to disappear. It is interesting to note that this is the same time ini:erval re-quired to show results in food allergy tests. ( See Tables I and II.)
• The capsule used contained pyrilamine maleate 30 mg, methapyrilene hydrochloride 20 mg, prophenPYfidamine maleate 10 mg in time released form. 86
Apple Tn..w,.of'n ·-··-·-Peas Cabbage Spices Peanut Fish Rye Medications Other
6 6 4 4 3 3 2 1
14 29
Sixty-three of the 69 patients could not tolerate egg. This high incide~ of egg sensitivity was unexpected. Without previous evidence of egg in-tolerance in gallbladder patients, it isn't surprising that eggs have not been ex-cluded from previous types of gallblad-der diets. The ubiquity of egg in the American diet and its usual inclusion in the typical gallbladder diet could well explain many of the aforementioned "equivocal results" obtained from diet therapy.
It was further observed that by the elimination dietary method only an average of 4.43 foods were eventually excluded from the patient's diet-the range being from 1 to 9. This is in con-trast to the usual hospital "gallbladder diet" wherein all gallbladder patients must exclude several scores of foods. Thus, the temptation of noncompliance is reduced.
It is of further interest to note that the incidence of reaciious to individual foods is different both from a standard list of food allergy ( which usually places milk in the position of most frl.:'q11Pnt offender) as well as the list of "gallbladder diets" ( which usually implicates "fats," "greases," and "rich foods").
Discussion Since 1948 this therapeutic regimen
has been found to be efficacious in a ANNALS OF ALUUIGY
I '
group o ence wj unrewai iergy e] tients VI strictioIJ spirits < spoke t1 ness of gram. 1 study: I ly the i ficient 1 dividua'.
.· syncrasi intimab toms of lecystec is stimu ories.
Summai On tl:
apy is
tht' mo wi1 aft, drn of SUI om wh pat Un . wil anc an seU Oli Ptll Ne
umber of 'atients
6 6 4 4 3 3 2 1
14 29
69 patients could his high incide~ ·· · was unexpected. · ddence of egg i!i- . ··. der patients, it isn't have not been ex-
!. types of gallblad-uity of egg in the s usual inclusion :in ler diet could well 1e aforementioned 1btained from diet
:erved that by the method only an
ls were eventually [>atient's diet-the > 9. This is in con-spital "gallbladder L1Ib1adder patients I scores of foods. of noncompliance
:erest to note that iions to irrdividual h from a standard · ( which usually position of most s well as the list " ( which usually ·eases," and "rich
~apeutic regimen e efficacious in a ~NN .. _ ~..5 OF All.EAGY
ALLERGY ELIMINATION DIET-BRENEMAN
· · group of patients whose earlier experi-.. ence with diet therapy has been most unrewarding. Not until the use of al-iergy eiimination <liets were these pa-tients willin~ to cJ .,}ply with food re-strictions. Thereafter the cooperative
· spirits displayed by these patients be-·. spoke the degree of relief and effective-
ness of the allergy elimination diet pro-gram. Two questions are rctised by this study: ( 1) Are elimination diets mere-ly the instrument to provide more ef-ficient mecha~ics for coping with in-dividual patient's intolerances and idio-syncrasies, and ( 2) is true food allergy intimately involved in producing symp-
. toms of cholelithiasis and the post cho-lecystectomy syndrome? Further study is stimulated by these unanswered the-ories.
Summary On the basis of this study, diet ther-
apy is indeed a valuable adjunct to
treatment of symptoms due to two forms of gallbladder disease, cholelithi-asis and post cholecystectomy syn-drome.
This study further suggests that the physician cannot · simpiy tell · the gall-stone patient to avoid "fats, greases and rich foods" and expect to achieve satis-factory results. Instead, as in most fields of 111edicine, we find that each patient has individual tolerances and intoler-ances-even to various foods. The most efficient method for finding these food sensitivities and idiosyncrasies is to em-ploy an allergy elimination diet~
The troublesome post-cbolecystec-tomy syndrome responds· very well to this type of therapy which might well represent the most effective regimen of management. The fact that antihis-tamine therapy hastened recovery fr001 food reactions suggest that the post-cholecystectomy syndrome has an aller-gic component in its etiology.
WHEN DOCTORS ARE PATIENTS ''The physician who has himself beer. sick is alert to detect the Ouctuations in
the well-being of the patient which accompany changes in physical state and mood, each of which is reffected in the other. Such a physician is endowed also with the rare quality beaer described as understanding than as sympathy. It is, after all, for understanding rather than pity that the average patien• seeks a. doctor, yet this important talent is far harder to acquire than the facile ha1f-virtue of sympathy; both the praise and scorn of the public for the latter are well summarized in the phrase 'bedside manner: This sensiiivii.y is 11ugii1eiitoo whiln one is oneself most ilJ; although the sick physician is never guilty of the coldness which sometimes blemishes his healthy colleague, his own understanding of patients is greatly enhanced when he is himself moi.i: in need of understanding Under these ctrcumstances a sort of grace may illume the physician in his work.
"The !!,;,-k phy'!kfrm ~~m,.,. 11w1trP. also of the avidity with which a patient will dutch and possess every word uttered by the doctor. So great is the ignor-ance of the laymen in medical matters that his doctor's statements have for him an oracular signiRcant.-e which the physician rarely appreciates-until he has him-sell been dejected by a gesture or enmuraged by a smile."-IAN S't'EVENSON: Observations on ilJness from the inside ( bronciuectasfs), in When Doctors Are Patients, ed. by Pinner, M., and Miller, B. F., W. W. Norton and Company, Inc., New York, l&o2, Ch. 21.
