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- Herausgeber: Hammersmith Health Books
- Kategorie: Ratgeber
- Sprache: Englisch
- Veröffentlichungsjahr: 2023
This is Dr Sarah Myhill's comprehensive guide to health care for health practitioners and motivated patients alike – armed with this knowledge, wellness and an optimal health-span should be within our grasp and the grasp of all those we care for.
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SM: ‘To my lovely patients, who have been willing guinea pigs, faithful to the cause and most forgiving when my suggestions have not worked. However, in doing so, they have pushed forward the frontiers of ecological medicine.’
CR: ‘To the Unknown ME Warrior. In the face of both untold abuse and neglect, the hurt of which is magnified by a cruel disbelief, you have shown in equal measure, a gentle grace and dignity, alongside a fortitude of unimaginable depth. I salute you.’
Small is beautiful – a study of medical science as if people matter – with apologies to EF Schumacher (19 August 1911 – 4 September 1977), German statistician and economist
Some people find the use of the word ‘patient’ derogatory. They prefer ‘clients’, but as Dr Adam Kay points out in his entertaining book This is Going to Hurt, it is prostitutes that have clients. The word ‘doctor’ comes from the Latin for ‘to teach’. Doctors should be teachers of health information. So that makes patients simply receivers of such. Not so derogatory after all!
To be a teacher in the right sense is to be a learner. Instruction begins when you, the teacher, learn from the learner, put yourself in his place so that you may understand what he understands and the way he understands it. Kierkegaard 1813–1855, Danish first existentialist philosopher
My education took off when I left medical school for the real world. Simply writing really makes me think further about my medical practice and how best to relay that information to my lovely patients. I so hope you enjoy reading this as much as I enjoyed writing it – these were happy days for me. (And me too! Craig)
My education was only interrupted by my schooling Sir Winston Churchill, 1874 – 1965
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ECOLOGICAL MEDICINE
The antidote to Big Pharma and Fast Food
SECOND EDITION
Dr Sarah Myhill mb bs andCraig Robinson ma (Oxon)
Contents
About the Authors
Dr Sarah Myhillmb bs qualified in medicine (with Honours) from Middlesex Hospital Medical School in 1981 and has since focused tirelessly on identifying and treating the underlying causes of health problems, especially the ‘diseases of civilisation’ with which we are beset in the West. She has worked in the NHS and private practice and now works as a Naturopathic Physician. She is the Clinical Director of the College of Naturopathic Medicine and for 17 years was the Hon. Secretary of the British Society for Ecological Medicine, which focuses on the causes of disease and treating through diet, supplements and avoiding toxic stress. She helps to run and lectures at the Society’s training courses and also lectures regularly on organophosphate poisoning, the problems of silicone, and chronic fatigue syndrome. Visit her website at www.drmyhill.co.uk
Craig Robinsonma took a first in Mathematics at Oxford University in 1985. He then joined Price Waterhouse and qualified as a Chartered Accountant in 1988, after which he worked as a lecturer in the private sector, and also in The City of London, primarily in Financial Sector Regulation roles. Craig first met Sarah in 2001, as a patient for the treatment of his ME, and since then they have developed a professional working relationship, where he helps with the maintenance of www.drmyhill.co.uk, the moderating of Dr Myhill’s Facebook groups and other ad hoc projects, as well as with the editing and writing of her books.
Stylistic note: Use of the first person singular in this book refers to me, Dr Sarah Myhill. One can assume that the medicine and biochemistry are mine, as edited by Craig Robinson, and that the classical and mathematical references are Craig’s.
You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete
Buckminster Fuller
Preface to the Second Edition
Medical practice should never stand still. It is called practice for a good reason – we are constantly learning. I have received so many new ideas and much interesting feedback from physicians and patients over the last two years that a second edition became essential. The principles remain the same: work out the mechanisms from the symptoms and signs and this leads to logical and effective treatment. These principles meant that we were able to effectively treat Covid-19 patients from the very start of this new disease – we simply applied Groundhog Acute. In consequence, none of my patients died. I only know of one who needed a brief hospital admission before recovering. For details of the treatment of Covid-19 see Chapter 52 (New killers of the 21st century).
Please continue to contact us with feedback and new ideas. The book is designed to be easily updated within individual chapters. If those changes are small we can make them simply when we reprint. When chapters need to be replaced or significantly extended we have to opt for a new edition, as now.
PART I
12Introduction
Chapter 1
The inquisitive doctor
Mankind is fucked*. Humans are to the World what cancer is to humans: growing uncontrollably, invading parts where they should never be, and destroying the very Being that nourishes them. Life expectancy in Westerners is falling,1 19% of UK working-age adults have a disability,2 infertility is rising with one in seven couples having difficulty conceiving,3 average IQs of children are falling,4 54% of us have a chronic disease (including obesity)5 and 10% of school children are now classified as SEND students (Special Educational Needs and Disability).6 We are accelerating towards self-destruction and extinction. Stephen Hawking (English theoretical physicist, cosmologist and author, 8 January 1942 – 14 March 2018) predicted the extinction of Homo sapiens within a thousand years – a blink of evolutionary time.
James Lovelock (English scientist, born 26 July 1919), famed for his Gaia theory, has also predicted a bleak future. He has stated that humans behave like a pathogenic micro-organism, or like the cells of a tumour, as far as the Earth is concerned. Lovelock was a remarkable man; entirely on his own, he invented the electron capture detector in his barn-turned-laboratory, which he called his ‘experimental station’, and which was located in his back garden. In the late 1960s, he was the first to detect the widespread presence of CFCs in the atmosphere. He died on his 103rd birthday
Doctors should be providing the intellectual imperative to stop this terrible decline. They are supposed to be the brainy elite, caring for us individually and as a population. Instead, doctors are responsible for over-seeing this degenerative process because they have been corrupted by Big Pharma. They are doing this with kindness, gentleness and great humanity. They even claim an evidence-based approach. They daily reassure people that all will be well with their five-a-day fruit and vegetables, that vaccinations can only do good, that cocktails of drugs will prevent heart disease and that the cure for cancer is on the horizon. Doctors fail to tackle the 1.2root causes of disease because that is difficult. It means changing our comfortable, addictive and convenient lifestyles. Unpleasant symptoms that are the essential, early harbingers of pathology are suppressed with toxic drugs. The underlying pathology grumbles on unrecognised until the heart attack manifests, the tumour becomes palpable or the dementia irreversible. ‘What a shock! What a surprise! What bad luck,’ I hear them cry. Doctors are being kind to be cruel.
During my work as an NHS GP I had to wear two hats. With all my patients I would launch into my enthusiastic diatribe to try to identify symptom and disease, causation and mechanism. That was fine until I got on to the difficult stuff that involved self-discipline – changing diet, taking exercise and tackling addiction. If the eyes glazed over I knew I was dealing with a ‘Nah… don‘t do all that crap with me, just gimme the drugs’ type. Out came the prescription pad, on went the NICE† Guidelines hat and off trotted the patient, apparently satisfied with his/her quick fix. Thankfully my medical life was blessed by patients who thought as I did. They immediately saw the logic, grasped the difficult straws and started to put in place the troublesome interventions.
Through a panoply of natural approaches, such as diet, nutritional supplements, sleep and exercise, detoxification regimes and other such, I watched intractable arthritis resolve; migraines, irritable bowels and bladders melt away; fatigue syndromes, psychoses, autisms and asthmas disappear. Suddenly I thought I could change the World of Medicine. What would you do in my shoes? Being naturally gobby, I shouted it out so all could hear. And that is when my real troubles began.
Up until 2000 it never even crossed my mind that doctors could be interested in anything other than doing their best to cure their patients. It never occurred to me that doctors would not want to know about such safe, simple and effective medical interventions. It came as an intellectual tsunami to realise that not only did many doctors perceive me as a trouble-maker who undermined their authority, but so did the medical authorities themselves, from Health Boards right through to the General Medical Council (GMC), the UK regulator of doctors. They did not want their intellectually easy, drug-based, simple algorithms for management challenged. In their treatment of asthma, patients could be dismissed first with the blue inhaler, then with the brown inhaler and, for difficult cases, with both. Not only does this get patient out of the surgery in less than five minutes (a statistical triumph) but s/he also makes megabucks for Big Pharma. To my naïve amazement, the Establishment reacted furiously to the presumptuous, precocious, inquisitive doctor who was kicking the intellectual foundations of their ivory towers.
Since 2000 I have had to deal with 38 separate investigations from the GMC. The current score is Myhill 38, GMC. This makes me the most investigated doctor in its history. No complaints came from patients; all came from jealous doctors, local Health Boards or the GMC itself. After the first few investigations I was unable to get medical indemnity for GMC hearings and so I conducted my own legal defence. In October 2010 I was suspended from the Medical Register because I ‘lacked respect for my regulatory body, the General Medical Council’. In conducting my own defence, I demonstrated to the GMC that it was acting like a kangaroo court with the verdict having been decided upon before the hearing opened, with the GMC withholding evidence, with numerous GMC breaches of the Data Protection Act, and with the GMC denying me rights to call witnesses and refusing to tell me what allegations I faced. The last person to whom 1.3this applied was Ann Boleyn, decapitated under the orders of Henry VIII in 1536. At least I had some reason to be grateful that I was being tried after the enactment of the Abolition of Death Penalty Act 1965!
I took the GMC decision to suspend me to judicial review in the High Court. But before that hearing could be held, the GMC ran an emergency hearing of its own at which my licence to practice was restored. By 2012, all GMC action against me had been cancelled, with no case to answer. This may have had something to do with GMC legal opinion, discovered through a Freedom of Information Act search, which advised that:
‘…the problem with the Myhill cases is that all the patients are improved and refuse to give witness statements.’
It is a lesson in how the collective Medical Establishment views the World that the fact my patients were ‘improved’ was considered to be a ‘problem’.
Call me a slow learner. It has taken me 35 years to work out that I cannot change the World. But what I can do is to give those with the intelligence, discipline and determination, the Rules of the Game and the Tools of the Trade to diagnose, treat and cure themselves. In doing so they can slow the ageing process, prevent disease and live to their full potential.
But just as vital, when those who constitute the cancer of this world have succumbed to disease or degeneration, we shall be left with healthy human seeds who can repopulate the Earth with healthy stock. I want my family, my friends and my patients to survive the coming apocalypse. But to do so they must take control of their lives now. This too is part of Natural Selection. It means that those with minds that are sufficiently inquisitive to ask the right questions, intelligent brains to work out the answers and diligent determination to apply those, will survive.
This may sound rather like a manifesto for eugenics, but that is not my intention in writing this – this is just the way Natural Selection works. Thomas Robert Malthus (English scholar, 14 February 1766 – 23 December 1834) had similar ideas. Malthusian theory argues that a population will outgrow its resources, and that disease and other catastrophes will inevitably lead to ‘checks’ on human population growth.7
What follows is the blue-print for survival. You just must do it.
References
1. Pasha-Robinson. Life expectancy plummets in parts of UK, data reveals. The Independent 17 January 2018. www.independent.co.uk/news/uk/home-news/life-expectancy-uk-plumments-ons-data-hartlepool-torridge-amber-valley-barnsley-a8164171.html (accessed 15 July 2019)
2. Panjwani A. How many people have a disability? Full Fact 3 May 2018. https://fullfact.org/health/how-many-people-have-disability/ (accessed 15 July 2019)
3. Infertility. NHS, 14 February 2017. www.nhs.uk/conditions/infertility/ (accessed 15 July 2019)
4. Dockrill P. IQ scores are falling in ‘worrying’ reversal of 20th Century intelligence boom. Science Alert 13 June 2018. www.sciencealert.com/iq-scores-falling-in-worrying-reversal-20th-century-intelligence-boom-flynn-effect-intelligence (accessed 15 July 2019)
5. 54% have chronic disease – CDC – ‘Chronic Disease in America’ - www.cdc.gov/chronicdisease/re-sources/infographic/chronic-diseases.htm
6. 10% of children now classified as SEND – ‘afasic website’ - https://www.afasic.org.uk/about-talking/what-are-speech-language-and-communication-needs-slcn/
7. Malthus. Essay on the Principle of Population - www.esp.org/books/malthus/population/malthus.pdf
1.4
*Linguistic note: The etymology of ‘fuck’ is not known with certainty, but it is probably cognate with the Germanic word ficken. It is an ‘old’ word but again the scholars are divided upon actual dates. What is certain is that it is a versatile word – it is both a transitive and intransitive verb, and an adjective, adverb and noun. This quality is admirably demonstrated by a story from Craig’s past at a time during his ‘Gap Year’, when he was working as an odd-job porter at Stoke Mandeville Hospital, with his colleague, a Polish immigrant, ‘Wodge’. Craig and Wodge were called in front of a hospital bigwig after dropping an expensive fridge. They were asked to explain themselves and here is how the conversation went:
Bigwig – So, Wodge, what happened? Wodge – Some fucking fucker fucking fucked the fucking fucker. Bigwig [head in hands] – And Robinson, what do you have to say? Craig – I am impressed by Wodge’s last sentence, Sir, it was 75% ‘fuck’.
†Footnote: NICE is the UK ‘health’ regulator, the National Institute for Health and Care Excellence, and provides national guidance and advice on health and social care.
Chapter 2
The roadmap from symptoms to mechanisms to diagnosis and treatment
Since we can no longer rely on the medical profession to guide us to a healthy lifestyle, we must do it ourselves. This can only be achieved by a true understanding of the underlying mechanisms by which Western diets and lifestyles negatively affect health and create disease.
The idea of this book is to empower people to heal themselves through addressing the root causes of their diseases. I hope that what follows is a logical progression from symptoms to identifying the underlying mechanisms, to the relevant interventions, tests and tools with which to tackle the root cause of those symptoms. This is how any garage mechanic would fix a car – first ask the driver why the car was not working (symptoms) and then have a look at the vehicle for tell-tale signs to obtain a working hypothesis of a diagnosis. Having established the mechanisms by which things are going wrong the mechanic is in a position to cure. Once the car is functioning normally the hypothesis becomes the diagnosis.
The expectations of life depend upon diligence; the mechanic that would perfect his work must first sharpen his tools.
Confucius, Chinese teacher and philosopher, 551 – 479 BC
So, first, this book discusses symptoms, not as something to be immediately squashed with powerful prescription drugs, but rather as signposts as to what might be going wrong. Symptoms are the early warning system of the body that all is not right. We must listen to them.
The next step along this logical path is an exposition of what mechanisms may be causing these symptoms and how one can identify which particular mechanisms are at play in this patient. The identification of these mechanisms is achieved through clinical symptoms, signs and tests.
At this point along the logical path, the reader will have identified their symptoms and also will have isolated the mechanisms causing those symptoms. The next step is to lay out the ‘tools of the trade’ – that is, the interventions that can be put in place to treat those mechanisms, as 2.2identified. These interventions are ‘sustainable’ in that they reverse, not escalate, disease processes. By contrast, symptom-supressing medication accelerates the underlying disease process.
The logical path is now complete:
Back to our broken-down car analogy, the responsible driver does not wait for something to go wrong. By feeding his car the best possible clean fuel and oil, ensuring it undergoes regular servicing and by driving with due care and attention, his car will motor on for hundreds of thousands of miles. This is disease prevention. My job as a doctor is to be the interface between the good science and the art of healing. My duty is to provide the necessary information to allow people to live to their full potential through identifying root causes of disease and treating them with logical interventions. In practice, there is a basic protocol that we should all be doing in order to be that ‘responsible driver’ and this I have called, ‘Groundhog Basic’. In the film Groundhog Day, this refers to a time loop – this too is another sort of loop that bears constant repetition.
Groundhog Basic
Initially we have to identify and correct those aspects of contemporary Western lifestyles that are so damaging to health. The big issues are:
diet and nutrition
sleep
exercise
pollution and
infection avoidance.
Ideally, we should all put in place interventions now, before symptoms appear and before these problems trigger pathology. As mentioned, I call this set of interventions Groundhog Basic. It is the starting point to prevent and treat all disease. Do not be tempted to skip what is difficult. Done well, this may be all that is required.
These interventions are covered in the following chapters:
Chapter 20 – Groundhog Basic: what we should all be doing all the time to function at our full potential and prevent disease
Chapter 21 – The paleo-ketogenic (PK) diet plus essential micronutrients: multivitamins, minerals and essential fatty acids – what to eat, which supplements to take.
Chapter 22 – Sleep: common reasons for poor sleep and how to fix them
Chapter 23 Exercise– this must be the right sort to afford overall gains
Chapter 24 – Sunshine and light – why you should get as much of this as you can
Chapter 25 – Reduce the chemical burden: we are all poisoned – what you can do to minimise the effects
Chapter 26 – To love and be loved – sufficient physical and mental security to satisfy our universal need to love and care, and be loved and cared for
Chapter 27 – Avoid infections and treat them aggressively – be prepared so you can do this and get rid of them quickly
Chapter 28 – Diet, detox and die-off reactions – expect to get worse at first and see this as a good sign! Why this happens. What to do about it.
Without these difficult but vital foundations 2.3in place, other interventions will be to little avail. These interventions should be applied in all cases regardless of time, regardless of current state of health and regardless of current pathology. There is no excuse not to start now and, believe you me, I have heard all possible excuses under the sun. Groundhog Basic is non-negotiable.
None of us lives the perfect life. It is like the old Irish joke – when the traveller asked the way to Dublin, he was told by the local, ‘If I were you, I would not be starting from here.’ People do not seek medical help until they have a problem. For those that come to this book with established pathology, you may start with the specialty chapters, see what you have to do to recover and use the tools of the trade in addition to the Groundhog regimes to do so as quickly as possible. If you want to know the reason why, then plough your way through the early chapters.
In practice, with age and illness, we slowly have to move to the Groundhog Chronic strategies. Part VII of this book starts from a disease perspective, revises what has gone before and details the tricks of trade that have evolved proven and safe techniques.
This book is an introduction, a starting place, and, perhaps most importantly, a signpost for those patients who wish to take control of their own health. To do otherwise than this, and to try and write a book which covered every situation for every patient, would make for a dull old read. Furthermore, with experience, my ideas and advice will not stand still and so the fine detail of such a book would need constant updating. I make no apology for this state of affairs as, being old and female, I’m allowed to change my mind!
I’m not young enough to know it all.
Oscar Wilde, writer, 1854 – 1900
There is much more detail in our other books, namely:
Prevent and Cure Diabetes – delicious diets not dangerous drugs supplies the WHY of the PK dietThe PK Cookbook – go paleo-ketogenic and get the best of both worlds supplies the HOW of the PK dietDiagnosis and Treatment of Chronic Fatigue Syndrome and Myalgic Encephalitis – it’s mitochondria not hypochondria takes a detailed look at energy delivery mechanisms and how they apply in practical realityThe Infection Game – life is an arms race takes a detailed look at the role of infection as a driver of disease and what can be done to prevent and treat it.Applying the principles of this book does take courage as well as determination. In the words of Earl Nightingale (12 March 1921 – 25 March 1989), American radio speaker and author, whose works focused on the issues of human character development, motivation and meaningful existence:
All you need is the plan, the road map and the courage to press on to your destination.2.4
Chapter 3
Stumbling and fumbling my way to the right questions
It’s all about asking the question ‘why?’
I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who
Joseph Rudyard Kipling, 30 December 1865 – 18 January 1936
Let’s start with the bleeding obvious – when all else fails, use your brain.
Dr Ada Marion Dansie, Medical Consultant to George Bernard Shaw, and my grandmother
Five years at medical school followed by one year in hospital jobs does little to prepare a doctor for the real world. I had no answers to the early questions thrown up by NHS General Practice:
‘Why do I have high blood pressure?’
‘Why do I get such awful headaches?’
‘Why am I depressed?’
Correct conventional answers to these questions are deficiency of, respectively, anti-hypertensive drugs, painkillers and SSRIs (selective serotonin reuptake inhibitors – antidepressants such as Prozac). But this is not the ‘why’ of the matter. Indeed, it is hardly even the ‘what’ of the matter. Masking the symptoms does not explain them. The clues, which the symptoms represent, have been missed and the investigative detective work, which should have resulted from those clues, has been left undone.
The world is full of obvious things which nobody by any chance ever observes.
Sherlock Holmes inThe Hound of the Baskervilles by Sir Arthur Conan Doyle, 22 May 1859 – 7 July 1930
One year on and I was breast-feeding my daughter, Ruth. She had terrible ‘three-month’ colic and all I could do to lessen the screams was to walk round the house, all night, with her in my arms. My husband Nick’s reaction was ‘You’re the effing doctor – you sort it out.’ He was right. It was not until I stumbled across advice for me to give up all dairy products that the problem was resolved. So too was my chronic sinusitis and rhinitis. At the time this was a momentous and life-changing discovery – but this information was nowhere to be found in the medical textbooks. Thirty-seven years later, this common cause and effect is still absent from conventional medical literature.
This made me worry about not knowing causation. I had been trained to elicit clinical 3.2symptoms and signs and recognise clinical pictures, but actually what patients wanted to know was, Why? What did they need to do to put things right? My standard line had been, ‘Well, let’s do a blood test and come back next week.’ This gave me time to fumble anxiously through my lecture notes and textbooks, looking for answers. The answers my patients wanted were not there. It came as a great relief to me to find out that my patients really did not mind me telling them I did not know. Thankfully, they rated my ability to care higher than my ability to know. Thankfully, they were happy to help me with my researches and act as willing guinea pigs with the dietary and lifestyle experiments that actually addressed the root causes of their problems.
The investigation of a patient should be like a detective story – 90% of the clues come from the history and 10% from the examination and tests. Listen carefully and your patient will not only tell you the diagnosis but, most likely, also the causes. In my final practice medical exams in 1981 I had a darling patient with primary biliary cirrhosis. She told me exactly what was wrong with her and coached me through the questions that my examiners would ask!
Just listen to your patient, he is telling you the diagnosis.
Sir William Osler, 1st Baronet, FRS FRCP, Canadian physician, 12 July 1849 – 29 December 1919
Tests may confirm or refute the hypothesis, because every diagnosis is just a hypothesis. Then, once the diagnosis is further corroborated by test results, it has to be put to the ultimate test. The ultimate test is response to treatment. Is the patient better? If not, then the diagnosis is wrong.
exitus acta probat – the result validates the deeds.
Ovid 43 BC – AD 17/18
Doctors routinely confuse the making of diagnoses with merely the descriptions of symptoms and clinical pictures, neither of which constitutes a diagnosis. Examples include hypertension, asthma, irritable bowel syndrome and arthritis, all of which are descriptions of symptoms and none of which is an actual diagnosis. Clinical pictures include Parkinson’s disease, heart failure and colitis. But these are convenient titles simply to slot patients into symptom-relieving categories which do little to reverse the disease process or afford a permanent cure. Symptom-relieving medication postpones the day when major organ failures result. Many patients are duped into believing that the drugs are addressing underlying pathology and will result in a cure. This is dishonest, wicked and unsustainable medicine.
My early days in NHS General Practice were exciting. I learned to expect miracles as the norm. I watched a child’s ‘congenital’ deafness resolve on a dairy-free diet (see case history, Chapter 77); I saw patients with years of headaches find relief by cutting out gluten-containing grains; I saw women with chronic cystitis gain relief by cutting yeast and sugar out of their diets. A proper diagnosis establishing causation has obvious implications for management and the potential for cure. What was so astonishing to me was that when I tried to communicate my excitement and experiences to fellow doctors, they could not have been less interested and dismissed me as a ‘flaky quack’.*
However, the greatest challenge came from seeing and treating patients with myalgic encephalitis (ME)/chronic fatigue syndrome (CFS). 3.3This was the elephant in the room. There was absolutely no doubt that these patients were seriously physically unwell. I saw Olympic athletes, England footballers and cricketers, university lecturers, airline pilots, tough farmers, fire fighters and Gulf War veterans reduced to a life of dependency by debilitating pathological fatigue.
I concluded that I would never be able to write a book because it would be out of date as soon as it had been written. However, I now believe that, although I do not know, and will never know, all the answers, I do at least have sight of enough of the elephant to make a start. At least I am asking the right questions and so have a chance of recognising some of the answers when they present.
…dans les champs de l’observation, le hasard ne favorise que les esprits préparés (In the field of observation, chance favours only the prepared mind).
Louis Pasteur, French microbiologist, 27 December 1822 – 28 September 1895
In this book I hope to paint a recognisable picture that will deliver both the intellectual imperative and the reasoning behind my ideas and also inspire readers to make the difficult lifestyle changes that will result in long-term good health. But the devil is in the detail – read on.
What has been so unexpected is that the answers to treating ME/CFS have shed a whole new light on other common medical problems, such as cancer, heart disease, dementia and other such degenerative conditions. What follows is a blueprint for good health for all, for life.
This book is the end result of 37 years of trial and error, largely the latter. At first, I really did not know what I was doing but being a cocky little sod…
I couldn’t wait for success, so I went ahead without it.
Jonathan Winters, American comedian, 11 November 1925 – 11 April 2013
I hope I am working towards the ‘bleedin’ obvious’. 3.4
*Historical note: Why ‘quack’? Quack is a shortening of the ‘old’ Dutch ‘quacksalver’ (spelled kwakzalver in the modern Dutch), which originally meant a person who cures with home remedies, and then came to mean one using false cures or knowledge.
PART II
26Symptoms and clinical pictures
Chapter 4
Symptoms – our vital early warning system
Symptoms are our early warning systems, which protect us from foreigners and from ourselves. Do not suppress symptoms. They guide us back to health. And remember, the detective work starts with symptoms. The best clinical clues come from them – 90% of the diagnosis comes from the history, the patient’s account of their illness.
Symptoms are desirable and therapeutic
The two commonest symptoms, pain and fatigue, are essential to protect us from ourselves. We all experience these symptoms on a daily basis – they tell us what we can and cannot do. Without these warning signs we would keep going until we dropped, either because the energy delivery ran out (so the heart and brain would stop) or wore out (healing and repair occur during sleep and rest). We ignore or suppress these symptoms at our peril.
Many other symptoms arise downstream of these two, the most common. This happens because we ignore the early warning signs that pain and fatigue represent, or interfere with them, or try to suppress them. Often pathology arises as a result of adopting this ‘ignore, interfere and suppress’ type of medicine. Therefore, symptoms should always prompt us to ask the question ‘Why?’ Collections of symptoms may provide further clues as to causation.
We are too much accustomed to attribute to a single cause that which is the product of several, and the majority of our controversies come from that.
Baron Justus Von Liebig, German chemist, 12 May 1803 –18 April 1873 Attrib.
‘Evidence-based medicine’
Conventional medical treatments are based on ‘randomised controlled trials’ (RCTs). These are considered to be the ‘gold standard’ for evidence-based medicine, but there are many reasons why they are inadequate:
Most, if not all, diseases have multiple causes and are not amenable to single interventions. However, the people participating in such trials are randomly allocated to either the group receiving the treatment under investigation or to a group receiving standard treatment (or placebo treatment) known as the ‘control’. Already we can see that these trials effectively look at ‘either/or’ choices and so exclude the possibility of 4.2multi-causal illness. For such multi-causal complex illnesses, the RCT fails at the first hurdle. This is part of what is called ‘confounding’ and is badly mitigated against. (Confounding is where the experimental controls do not allow the experimenter to eliminate plausible alternative explanations for the illness.)The RCT can be set up and the statistics manipulated in such a way as to get a positive outcome that promotes drug prescribing when in fact no such positive result has been achieved.Any drug trial that does not give a positive result is not published. This was the subject of a campaign run by Richard Smith, former Editor of the British Medical Journal, who advised that all drugs trials, regardless of outcome, should be published. He failed. Why? Follow the money – he who pays the piper calls the tune.As Angus Deaton and Nancy Cartwright conclude in their article ‘Understanding and misunderstanding randomized controlled trials’:1
RCT results are…weak ground for inferring “what works”.
The art of medicine should follow the long-established tradition of case studies. The best doctors are patient, patient watchers.
The good physician treats the disease; the great physician treats the patient who has the disease.
Sir William Osler, 1st Baronet, FRS FRCP, Canadian physician, 12 July 1849 – 29 December 1919
So, what follows in this book is not a list of RCTs giving quick-fix, symptom-suppressing, ‘single’ interventions, but rather a tool box of many interventions to address the many mechanisms at play that place the patient at the centre of the action. First, and in order to identify those mechanisms, we must investigate the symptoms… Read on!
Reference
1. Deaton A, Cartwright N. Understanding and misunderstanding randomized controlled trials. Social Science & Medicine 2018; 210: 2-21. www.sciencedirect.com/science/article/pii/S0277953617307359
Chapter 5
Fatigue: tired all the time
– how we know when we are running out of energy
Fatigue is the symptom that arises when energy demand exceeds energy delivery. If we think of energy as money, then so it is with energy:
Annual income twenty pounds, annual expenditure nineteen pounds nineteen and six, result happiness.
Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery.
Mr Micawber from David Copperfield by Charles Dickens, 7 February 1812 – 9 June 1870
This means there is a two-pronged approach to treating fatigue – improve energy delivery systems and identify mechanisms by which energy is wasted. As I have said, I think of energy as money – it is hard work earning it and great fun spending it. In this chapter I look at energy delivery. How energy is wasted is discussed in Chapters 7 and 8.
Energy delivery
Energy delivery is all about the collective function of:
the dietary fuel in the tank
the mitochondrial engine and its controllers: the thyroid accelerator pedal and the adrenal gearbox.
Together these are responsible for producing the energy molecule adenosine triphosphate, or ATP. ATP is the currency of energy in the body and a molecule of ATP can buy any job, from muscle contraction to a nerve impulse, hormone synthesis to immune activity. Without ATP none of these things is possible. This explains the multiplicity of symptoms experienced when energy delivery mechanisms are impaired, because every cell and every organ of the body may be affected.
The symptoms may be described as ‘mild’ or ‘severe’, and the following checklists can be used as a rule of thumb* to decide whether energy delivery mechanisms are starting to fail.
5.2
Mild symptoms of poor energy delivery mechanism
When symptoms are mild, the patient will:
become an owl – s/he won’t be able to get up in the mornings, will sleep in at weekends (this may be a symptom peculiar to the underactive thyroid)start to use addictions to cope with fatigue – especially caffeine, sugar and refined carbohydrateshave to consciously pace activity – and look forward to rest time and sleepdread Monday mornings, if in employmentlose the ability (or it will become an effort) to enjoy him/herselftreasure ‘chill out’ time in the eveningslose his/her usual stamina – s/he will not be able to achieve normal levels of fitnessexperience a decline in muscular strengthbecome irritable, experience mild anxiety and low mood – these symptoms are imposed by the brain to prevent the person spending energy frivolously; having fun means spending energyfeel mildly stressed – I think this symptom of stress arises when the brain knows it does not have the energy reserves to deal with physical, emotional and mental demandsexperience joint and muscle stiffness – for tissues to slide over each other with minimal friction requires them to be at just the right temperature; poor energy delivery means the body runs colder.These symptoms are often seen as part of the ageing process. This is because mitochondria, which are the engines of cells that generate energy, are also responsible for the ageing process. Numbers of mitochondria fall with age. So, as we age, we have to pace our activities. This is because our body’s ability to generate energy reduces hand in hand with the falling numbers of mitochondria. The obvious corollary is: ‘Look after the mitochondria and slow down the ageing process.’
Severe symptoms of poor energy delivery and the molecular mechanism for such
At medical school one of the most dreaded subjects was biochemistry. The usual survival strategy was to mug up for the exam at the last minute, usually on caffeine and chocolate biscuits, sit the exam on an addictive high, adrenalin-fuelled by fear of failure, then forget those nasty biochemical formulae. This was permissible because biochemistry was given scant clinical application – energy delivery mechanisms, ATP and mitochondria were never mentioned on the wards. Now I find myself explaining much of Life in terms of energy and biochemistry. Like money, you don’t know you’ve got it until you’ve lost it. Both bring fun and security. Energy is my most precious possession.
So, a little biochemistry must follow. The central player is one of Nature’s most ancient molecules – namely, adenosine triphosphate, or ATP, as mentioned at the start of this chapter. The business of making energy focuses around the synthesis of its sister molecule, adenosine diphosphate (ADP). Spending energy involves ATP cycling back to ADP. ATP is a battery to deliver a bolt of energy and this powers nearly all tasks in the body, from conducting a nerve impulse to making a hormone. All living things need ATP and this molecule makes the difference between Life and Death.
As your ATP battery discharges and as energy reserves slip away, you will experience:
Poor stamina. One molecule of ATP is converted to ADP and recycled back to ATP via mitochondria every 10 seconds. If this recycling is slow, then poor stamina (mental 5.3and physical) and muscle weakness will result very quickly.Pain. If you run out of ATP because mitochondria cannot keep up with demand, then there is a switch into anaerobic metabolism with the production of lactic acid. One molecule of glucose, burned aerobically in mitochondria, can produce 32-36 molecules of ATP (depending on efficiency). Anaerobic production generates just two molecules of ATP, together with one molecule of lactic acid. It is horribly inefficient. Furthermore, to clear the lactic acid requires six molecules of ATP. This is a particular problem for my severely fatigued patients who simply do not have the energy reserves to clear the lactic acid and therefore the lactic acid burn is prolonged. When this occurs in the heart, patients are told they have ‘atypical chest pain’, whereas what the patient is actually experiencing is angina.Slow recovery from exertion and delayed fatigue. As ATP is drained, the body can employ another metabolic trick. Two molecules of ADP (two phosphates) combine to form one molecule of ATP (three phosphates) and one of adenosine monophosphate, or AMP (one phosphate) – this is called the adenylate kinase reaction. The good news is that we have another molecule of ATP, but the bad news is that AMP is poorly recycled and drains out of the system. The body then has to make brand new ATP. This it can do from a sugar molecule, but this involves a complex and time-consuming piece of biochemistry – namely, the pentose phosphate shunt. Thus, there is delayed fatigue. This symptom is one that characterises the clinical picture of pathological fatigue because more severe tissue damage starts to occur at this point of very poor energy delivery.Foggy brain. The brain is greatly demanding of energy. At rest it consumes 20% of the total energy generated in the body. Poor energy delivery results in foggy brain, poor shortterm memory and difficulty multi-tasking and problem-solving. These are the early symptoms of dementia and, indeed, much dementia is about poor energy delivery.Dizzy spells as if about to lose consciousness. These too are symptomatic of the brain running out of energy. This is commonly due to low blood pressure or blood sugar levels suddenly dropping (but the answer is NOT to eat more sugar – read on).Very low mood and depression, ATP multi-tasks. It is not just the energy molecule; it is also a neurotransmitter in its own right. To be precise, it is a co-transmitter – neurotransmitters such as dopamine, GABA, serotonin and acetylcholine do not work unless ATP is present. Disorders of mood, such as anxiety and depression, could be much better treated if energy delivery issues were tackled.Anxiety and the feeling of severe stress. This arises because sufferers know that they do not have the energy to deal with expected and unexpected demands. Anxiety creates another vicious cycle because it ‘kicks’ what I call an ‘emotional hole’ in the ‘energy bucket’ and interferes with sleep, thereby sending the energy balance further into deficit, and thereby increasing anxiety…Procrastination. This has the positive effect of postponing the moment when we have to spend energy.I love deadlines. I love the whooshing sound as they go by.
Douglas Adams, English author, 11 March 1952 – 11 May 2001
Figure 5.1: The vicious cycle of low energy
5.5
Intolerance of heat. We lose heat by pumping blood to the skin so it can cool. The skin is the largest organ of the body and pumping blood round the skin increases cardiac output by 20%. This explains why we all fatigue more quickly on hot days and this can be unsustainable for my severe pathologically fatigued patients.Variable blurred vision. The muscles of the eye demand energy and so, if energy delivery is poor, then the pathologically fatigued will be unable to contract their eye muscles to allow the lens to focus.Light intolerance. The retina, weight for weight, is the most energy demanding organ of the body. It consumes energy 100 times faster than the rest of the body. This is because the business of converting a light signal into an electrical signal requires massive amounts of ATP. Light intolerance is a feature of severe CFS/ME. It is also a feature of migraine which, I suspect, also has energy delivery as one possible cause. One cannot generate energy without the production of free radicals and these damage tissues. I suspect this explains the high incidence of eye pathology with ageing, such as cataracts, glaucoma and macular degeneration.Noise intolerance. Again, the business of converting vibrations of air and bone molecules into an electrical signal for the brain to interpret is greatly demanding of energy.Shortness of breath. If energy delivery at the cellular level is impaired, the brain may misinterpret this as poor oxygen delivery and stimulate the respiratory centre to breathe harder. This may result in hyperventilation, which actually makes the situation worse. Hyperventilation changes the acidity of the blood and so oxygen sticks more avidly to haemoglobin, so worsening oxygen delivery. Shortness of breath may also result from heart failure, respiratory failure and anaemia.Susceptibility to infection. The immune system is greatly demanding of energy and raw materials.Loss of libido. This makes perfect biological sense – procreation and raising children require large amounts of energy.Readers of George Orwell’s 1984 will recognise many of these symptoms of fatigue in the protagonist, Winston Smith. This is not surprising as Winston’s diet was appalling, often non-existent, and the demands of his work as a clerk in the Records Department of the Ministry of Truth, where he re-wrote the past, were emotionally, intellectually and physically exhausting. In short, Winston had very poor energy delivery and overwhelming energy demands. Orwell sums up the effect of this energy imbalance with characteristic succinctness and genius:
Winston was gelatinous with fatigue.
George Orwell (Eric Arthur Blair), 25 June 1903 – 21 January 1950
Signs of poor energy delivery
Ut imago est animi voltus sic indices oculi. The face is a picture of the mind as the eyes are its interpreter.
Cicero, 106 – 43 BC
The muscles of the face are largely unconsciously controlled and reflect not just thoughts but also energy. The brain that has a large energy bucket produces an ‘attractive’ mobile face that engages and smiles with shining eyes. No energy and even the most ‘beautiful’ face is rendered ‘ugly’, with flat unresponsive features and dull eyes that do not focus. Again, this makes perfect 5.6evolutionary sense – for obvious reasons we need to be able to assess the energy available to friends and foe.
‘Attractive’, ‘beautiful’ and ‘ugly’ may seem unusual words to find in a description of the signs of illness. But I use these terms because they are universally ‘understood’, not in any ‘judgemental or ‘discriminatory’ way. The fact is that we ‘look different’ when we are ill, and evolution has ‘taught’ us to recognise these outward signs of illness as ‘unattractive’ – dark circles under the eyes, for example. Many of my most ill patients have become, as they have got better, the most attractive human beings.
Movement is another giveaway. When working, I always like to watch my patients coming into the surgery. So much can be learnt about energy and pain from gait, balance and poise.
Pathology that arises if poor energy balance symptoms are ignored or masked
Organ damage and organ failure arise as a result of ignoring or masking poor energy balance symptoms. The masking comes from suppressing symptoms with either prescription drugs or addictions, or both.
Heart failure. Symptoms usually come before organ damage, but not always. The kidneys, for example, suffer in silence. However, if symptoms are ignored, then organ damage will result. As I have said, fatigue is the symptom that arises when energy demand exceeds energy delivery; when this occurs at the cellular level, levels of ATP, the energy molecule, within cells will fall. If levels of ATP fall below a critical amount, this triggers cell apoptosis – ‘programmed cell death’, or cell suicide in other words. Indeed, this is part of the ageing process – we literally lose cells and our organs slowly shrink. If the situation becomes critical, either because total energy delivery fails, or the number of cells declines, we develop organ failure and ultimately die. Indeed, it is this process which prevents us from living for ever. A common organ failure that results in death is heart failure. We are currently seeing an epidemic of heart failure, which I believe partly stems from the prescription of statins. One of the side effects of statins is that they inhibit the body’s own production of co-enzyme Q10, which is essential for mitochondrial function. (Interestingly, the benefits of statins seem to have little to do with their effect on cholesterol levels. Any benefit seems to arise because biochemically they look like vitamin D. Vitamin D is highly protective against heart disease, cancer and degenerative conditions. Statins are a particular hate of mine. See Chapter 58 for the statin story.)Dementia. This is brain organ failure – essentially it arises when the speed at which nerves process electrical signals slows down. That process is enormously demanding of energy. My CFS/ME patients exhibit early symptoms of dementia – happily reversible through improving energy delivery mechanisms (see Chapter 30). Another major cause of dementia is arteriosclerosis (arterial damage from metabolic syndrome), resulting in poor oxygen and fuel delivery to the brain. I suspect statins are also partly responsible for our epidemics of dementia. Another cause is the prion disorder of Alzheimer’s associated with chronic infection and chemical poisoning.Immune system failure. The immune system is enormously demanding of energy and this probably explains why elderly people are much more likely to die from infection than younger people, simply because they do not have the energy to power their immune system to fight infections effectively. Infection 5.7has been, and continues to be, the single greatest killer of humans (see our book The Infection Game – life is an arms race).Cancer. The risk of this too increases as energy delivery mechanisms fail. It has always intrigued me that primary cancers of the heart are so rare. The heart is abundantly supplied with energy; it cannot stop beating for a second.Pain. This too may be a symptom of poor energy delivery because when aerobic metabolism cannot keep up with demand there is a switch into anaerobic metabolism with the production of lactic acid, as described earlier in this chapter – and this is painful. (In Chapter 6, we consider pain in detail.)Of pain you could wish only one thing: that it should stop.
George Orwell in 1984, 25 June 1903 – 21 January 1950
Here, we depart from Orwell’s immediacy – one should not just wish to make pain stop, but rather one should wish to understand why one has pain, address the causes and make the pain stop that way.
The forgetting curve
Earlier in this chapter, I noted how my fellow medical students learnt biochemistry in order to pass the exam and then forgot it as quickly as they could. This book is large, and you may find yourself thinking that you cannot possibly remember it all. Thankfully, you don’t have to recall all of it in detail – you can refer to it as often as you like, and in fact doing this will cement the contents in your memory.
The ‘forgetting curve’ hypothesises the decline of memory retention in time. It is an imperfect model but worth dwelling on. This curve shows how information is lost over time when there is no attempt to retain it. In 1885, Hermann Ebbinghaus collected data to plot a forgetting curve; it approximates an exponential curve as shown in Figure 5.2.
All is not lost. With regular sessions of ‘remembering’ – either by ‘doing it’ (here, following the advice daily) or ‘re-reading it’, we can readjust the ‘forgetting curve’ to look more like Figure 5.3.
So, do not despair. Just do it – maybe re-read parts, and you will remember it, or at least pick out those essential to your health. 5.8
Figure 5.2: The ‘forgetting curve’ plotted by Hermann Ebbinghaus, German psychologist, 25 January 1850 – 26 February 1909
Figure 5.3: The effect on the ‘forgetting curve’ of regular ‘remembering’ sessions
*Linguistic note: ‘Rule of thumb’ is often said to derive from a law that allowed a man to beat his wife with a stick so long as it is were no thicker than his thumb. The story goes that in 1782, Judge Sir Francis Buller made this legal ruling. In the following year, James Gillray published a satirical cartoon of Buller, caricaturing him as ‘Judge Thumb’. Perhaps Buller has been mis-reported – the phrase was in use before 1782. He was known for being harsh in his punishments, but there is no evidence that he made this ruling. Edward Foss, author of The Judges of England, 1870, wrote that, despite investigation, ‘no substantial evidence has been found that he ever expressed so ungallant an opinion’. (Craig’s note: A little more than ungallant, I would say!)
†Linguistic note: ‘Torpid’ means a state of being mentally or physically inactive or lethargic. ‘Torpids’ is the name given to a series of boat races at Oxford University – the name derives from the event’s origins as a race for the second boats of the colleges, which were of course slower than the first boats.
