Silas Weir Mitchell was a famous doctor that first learned about neurological disease during his service in the American Civil War. He is most well known for his views on hysteria and neurasthenia, but he was considered an expert on other neurological conditions as well. One area he was respected in was the treatment of epilepsy, for which he preferred to use drugs. “Despite the prevalent views on lifestyle modification as a treatment for epilepsy during this time period, as well as Mitchell’s own development of the “rest cure” for certain disease states, he was not a proponent of these types of interventions for epilepsy” (David B. Burkholder & Christopher J. Boes, Silas Weir Mitchell on Epilepsy Therapy in the Late 19th to Early 20th Centuries).
From his writings on neurasthenia, he had articulated a common view of this disease in terms of nerves and energy, libido and sexuality. And he applied a similar understanding to epilepsy: “Still, in Mitchell’s first discussion of amyl nitrite as an abortive therapy, he clearly agreed with a common thought of the day by attributing the patient’s epilepsy to sexual vices, stating he had partaken in “…great excess, and that the punishment was distinctly born of the offence” (Burkholder & Boes). But in 1912, he questioned his prior causal explanations, having had written that, “It is conceivable that in nerve centres normal or abnormal substances may accumulate until they result in irritative symptoms and discharges of neural energy. But how then could this sequence be arrested by a mere sensory stimulation, like a ligature on an arm, or by abruptly dilating the cerebral vessels with amyl? The explosions would only be put off for the minute; the activating poison would remain.” These doubts were expressed when in his early 80s, after a long career in medicine.
Still, he never suspected any role to be played by diet or lifestyle. This is strange, considering his professional expertise in his having used diet and lifestyle for those suffering from neurasthenia, a neurological disorder like epilepsy. Even in his theorizing, the factors he considered for both overlapped to some degree in specific details and through general framework. Yet for epilepsy, he couldn’t somehow make a connection in the same way between physical health and mental health. Meanwhile, others were attempting to make such connections. There was much experimentation going on with epilepsy, including dietary protocols.
William Spratling, in Epilepsy and Its Treatment (1904), partly shared Mitchell’s assessment in writing that, “have been unable to determine that different foods have any specific effect on epilepsy itself beyond that which they have on the organism in general.” That didn’t stop him from having suggested a mixed/balanced diet that, though not having excluded carbohydrates, did tell epileptics to eat moderately and slowly while avoiding pastries, alcohol and over-sweetened drinks. In certain extreme cases, he went even further by asserting that, “Foods should be in liquid form and highly nutritious from the start. Various preparations of milk, eggs, and beef extracts may be given; but plain peptonized milk is by far the best food of all. It should be given often and in small amounts.”
Spratling’s professional advice for treatment in some cases potentially could have been ketogenic, if not in a systematic manner. The same might’ve also been true of Sir J. Russell Reynolds’ even earlier 1862 epileptic protocol of avoiding “Salted meats, pastry, preserved vegetables, and cheese” (Epilepsy: Its Symptoms, Treatment, and Relation to Other Chronic Convulsive Diseases). Besides openly advocated low-carb diets like that of William Banting, many scientific experts, medical practitioners, public intellectuals and popular writers during that era flirted around the edges of restricting starches and sugar for various reason, though not to treat epilepsy. That is significant, since the average diet was already far lower in carbohydrates than what was seen in the following generations. Some patients would have found relief from seizures through ketosis without realizing what had helped them. The seeming randomness of who did and who did not experience improvements had to have been frustrating to doctors of the time.
In 1914, two years after having fallen into self-questioning, Mitchell would die without having learned of an effective treatment. Only a few years later in 1921, there was the discovery of dietary ketosis (Rollin Woodyatt) and the discovery of the medical use of a ketogenic diet for epileptic seizures (Russel Wilder), although ketosis was used for this purpose through fasting as far back as 500 BC. Despite this failure, like so many others, he approached the territory of a ketogenic diet while entirely missing it, such as in his recommendations of meat and dairy for neurasthenics which potentially could’ve put a patient into a state of ketosis. He came so close, though. After graduating from medical college in 1851, he moved to Paris and spent a year studying under Claude Bernard. About a decade later, the British Dr. William Harvey heard Bernard speak about the relationship between diet and diabetes, and this information he used to formulate a low-carb diet for his patient William Banting to lose weight. Banting then popularized this diet, but at that point it had already been in use by others going back to the 1790s.
During Mitchell’s lifetime, most Americans would have still followed a diet where carbohydrates were a small portion of meals and a small percentage of calories. It’s probable that the majority of the population during the 19th century was regularly in a state of ketosis, as the common diet back then consisted of mostly animal foods — what Nina Teicholz describes as the “meat-and-butter-gorging eighteenth and nineteenth centuries” (The Big Fat Surprise; see context of quote in Malnourished Americans). Mitchell himself might have experienced ketosis at different points in his life without realizing it. This wouldn’t have been an unusual thing for most of human existence, if not from a low-carb diet then from caloric restriction, intermittent eating, and fasting — ketosis isn’t exactly hard to achieve in a traditional setting. For example, it used to be standard for Americans to eat only one meal a day (Abigail Carroll, Three Squares) and that was in the context of a labor-intensive rural lifestyle. Sugary cereals, Pop-Tarts, etc were not available for breakfast. And snacking all day on crackers, chips, and cookies simply was not an option.
It’s interesting to note that meat-and-butter or rather meat-and-milk was what Mitchell, working as a doctor in the 19th century, told his neurasthenic patients to eat. But for unexplained reasons, he didn’t advise the same or a similar eating pattern to his epileptic patients. Low-carb and animal-based dieting was popular in his lifetime and was used by many doctors for various conditions, often for obesity but far from limited to that. It’s odd that no one made the connection of the ancient practice of fasting for epileptic seizures with the 19th century practice of potentially ketogenic diets. No one managed to figure this out until the 1920s and not for a lack of experimentation with diverse alimentary regimens. Then when it was finally discovered, after a short period of research, it was mostly forgotten about again for another three-quarters of a century. Yet even now drugs remain the primary treatment for epilepsy, despite ketosis being the most effective, not to mention safest, treatment; and, if ketosis is the normal state of physiological functioning, we might call it a cure for many people.